结核病实验室诊断技术及其进展 - 结核病防治网

诊 断 Diagnosis
标准 4. 所有胸部影象学检查可疑肺结核的病人，应该对其痰标本进行微生 物学检查。 Standard 4. All persons with chest radiographic findings suggestive of tuberculosis should have sputum specimens submitted for microbiological examination.
15人/年 • 如果不给予治疗涂阳病人更容易死亡
Rouillon A. Tubercle 1976;57:275-99
结核病变在体内的演变和播散
TB和HIV 双重感染 TB and HIV co-infection
• 在没有HIV感染的人群中，结核杆菌感染者在其一生中 大约有10%的人会发病
In the absence of HIV, about 10% of people infected with TB will develop TB disease. • 在TB/HIV双重感染者中约50%的感染者会成为结核病患者
In people co-infected with HIV and TB, about 50 % may develop TB disease • TB 加速和恶化 HIV/AIDS的疾病进展 TB accelerates the progression of HIV disease
TB和HIV 双重感染 TB and HIV co-infection (cont’)
卫星DNA、小卫星DNA、微卫星DNA VNTR 2. 散在重复序列 Interpersed Repeats
GC富含重复序列和主要的串联重复序列 Polymorphic GC-Rich Repetitive Sequence & Major
Polymorphic Tandem Repeats
PGRS & MPTS PE\PPE
International standards for
Tuberculosis care
结核病关怀----国际标准
Diagnosis:
诊 断 Diagnosis
标准 1. 所有不能解释的进行性、持续咳嗽2-3周的可以症状者都 应该进行结核病相关检查 STANDARD 1. All persons with otherwise unexplained productive cough lasting two–three weeks or more should be evaluated for tuberculosis.
问题 Problems
低治愈率 Low cure rate 高死亡率 High mortality rates during treatment 高复发率 High rates of TB recurrence
问题 Problems （cont’)
涂阴肺结核的过诊 Over-diagnosis of sputum smear-negative PTB 涂阳肺结核的漏诊 Under-diagnosis of sputum smear-positive PTB 肺外结核病的误诊 Missed diagnosis of extra-pulmonary TB
NTI, Ind J Tuberc, 1974
过诊
Actual cases
HIV/AIDS中涂阳肺结核病人的比例
AFB positivity in
70
HIV
Negative
TB patients
60
Early HIV
50
40
Late HIV
30
20
10
0
积极治疗传染源可以减少结核病的传播
• 涂阳病人的传染性是涂阴病人的 4-20 倍 • 如果不给予治疗一个涂阳病人可以传染10-
诊 断 Diagnosis
标准 5. 涂阴肺结核的诊断标准：至少3个痰涂片检查阴性；胸部影象学检 查可疑肺结核；对广谱抗生素试验性治疗无效（除外喹诺酮类）。对这 样的病人如果条件允许，应该做培养；对已知或疑似HIV感染者，应加快 对其的诊断进程。
STANDARD 5. The diagnosis of sputum smear-negative pulmonary tuberculosis should be based on the following criteria: at least three negative sputum smears (including at least one early morning specimen); chest radiography findings consistent with tuberculosis; and lack of response to a trial of broad-spectrum antimicrobial agents. (NOTE: Because the fl uoroquinolones are active against M. tuberculosis complex and, thus, may cause transient improvement in persons with tuberculosis, they should be avoided.) For such patients, if facilities for culture are available, sputum cultures should be obtained. In persons with known or suspected HIV infection, the diagnostic evaluation should be expedited.
非结核分枝杆菌
• Ⅰ 缓慢生长 光产色 堪萨斯、海、猿分枝杆菌
• Ⅱ 缓慢生长 暗产色 瘰疬、苏加
• Ⅲ 缓慢生长 不产色 鸟胞内 蟾分枝杆菌
• Ⅳ 快速生长
偶发、龟
非结核分枝杆菌不能使豚鼠致病
1886年Lenman和Neaman命名
结核分枝杆菌
生物标本
生物样本成分千差万别 合格的标本 如果每毫升灌洗液中超过105 个集落形成单位，某一 微生物存在，且有该微生物感染的其他临床表现，则 该微生物可能就是病原菌
诊 断 Diagnosis
标准 2. 所有肺结核的可疑症状者都应该进行痰涂片显微镜检查（至 少两次痰涂片检查，至少包含一份晨痰） STANDARD 2. All patients (adults, adolescents, and children who are capable of producing sputum) suspected of having pulmonary tuberculosis should have at least two, and preferably three, sputum specimens obtained for microscopic examination.When possible, at least one early morning specimen should be obtained.
98% 100
80 60
40 20
0
AFB 显微镜涂片检 查
专家组一直同意诊断
70%
X-线
显微镜涂片检查的特异性 较 X-线检查好
100
98%
80
特异性
60
50%
40
20
0
AFB Microscopy
X-ray
X-线诊断结核病的过诊问题
100 80 60 40 20 0 Diagnosed by Xray alone
范围：
散在重复序列
基因复制 短的序列重复
移动的遗传元件
IS Elements REP13E12 Family Prophage CRISPR Sequences(spoligotyping)
clustered regularly interspaced short palindromic repeats
predicted protein-coding genes)
• 65.6 % GC 含量
Cole ST et al. Nature 1998; 393: 537.
重复DNA
Repetitive DNA in the Mycobacterium tuberculosis Complex
分类： 1.串联重复序列 Tandem Repeats(TRs）
诊 断 Diagnosis
标准 3. 所有的肺结核可疑症状者，都应该对其病变部位来源的合格标本 进行显微镜涂片检查，如果条件允许可以做培养和组织病理学检查。 STANDARD 3. For all patients (adults, adolescents, and children) suspected of having extrapulmonary tuberculosis, appropriate specimens from the suspected sites of involvement should be obtained for microscopy and, where facilities and resources are available, for culture and histopathological examination.
流感病毒和呼吸道合胞体病毒正常情况下不存在于呼 吸道。
结核免疫
• 经典免疫学认为，结核的免疫属于传染免疫（infection immunity),又称有菌免疫，即只有当结核菌在体内存在时才 有免疫力，一旦体内的细菌被杀灭，免疫力随即消失。机体 对结核分枝杆菌能产生抗体，但无免疫保护作用。 • TB accelerates the progression of HIV disease