泌尿生殖系結(jié)核

1、泌尿生殖系結(jié)核泌尿生殖系結(jié)核第1頁Urinary TBA disease of young adults. 60% between 2040y.Infecting organism Mycobacterium tuberculosis (結(jié)核分支桿菌，結(jié)核桿菌), Tubercle bacilli 泌尿生殖系結(jié)核第2頁Infecting Route(感染路徑)Hematogenous route(血行路徑) from the lungs.Primary sites(初發(fā)部位): Kidney, Prostate (前列腺)Other organs involved: direct extens

2、ion 泌尿生殖系結(jié)核第3頁P(yáng)athogenesis(發(fā)病機(jī)理)Tubercle bacilli hit the renal cortex(腎皮質(zhì)):Normal resistance(抵抗力): organism destroyedSufficient virulence(致病力): clinical infection established.泌尿生殖系結(jié)核第4頁P(yáng)athogenesisTB of kidney: progresses slowly, 1520y to destroy a kidney with good resistance.No clinical disturbance

3、 until the calyces / pelvis(腎盞/腎盂) involved.泌尿生殖系結(jié)核第5頁P(yáng)athology(病理)泌尿生殖系結(jié)核第6頁Kidney & Ureter (輸尿管)Grossly: a soft, yellowish localized bulge (隆起).On section: involved area filled with cheesy material (caseation, 干酪樣物質(zhì)).泌尿生殖系結(jié)核第7頁Kidney & UreterWalls of pelvis, calyces and ureter thickened. Ulceratio

4、n(潰瘍形成) in calyces.Complete ureteral stenosis(輸尿管狹窄) Autonephrectomy(腎自截). Bladder urine normal and symptom absent.泌尿生殖系結(jié)核第8頁Kidney & UreterBasic lesionTubercle foci(結(jié)核結(jié)節(jié)) Epithelioid reticulum(上皮樣網(wǎng)) Peripheral giant cellsHeal by fibrosis(纖維化).泌尿生殖系結(jié)核第9頁Kidney & UreterTB is a combination of caseatio

5、n(干酪樣變), cavitation(空洞形成) and healing by fibrosis &scarring(纖維化和疤痕愈合).Depending on virulence vs resistance.Calcification(鈣化): strongly suggestive of TB. Secondary renal stones in 10%.泌尿生殖系結(jié)核第10頁Left kidney: autonephrectomyRight Kidney: hydronephrosis & ureteral reflux (腎積水&輸尿管返流)Contraction of the b

6、ladder (膀胱孿縮) 泌尿生殖系結(jié)核第11頁左腎萎縮泌尿生殖系結(jié)核第12頁萎縮腎外觀泌尿生殖系結(jié)核第13頁Caseation & Fibrosis泌尿生殖系結(jié)核第14頁Lt Renal Dysfunction on Radioisotope Scan(同位素掃描)泌尿生殖系結(jié)核第15頁Calcification (鈣化)泌尿生殖系結(jié)核第16頁BladderTubercle form: white/yellow raised nodules(結(jié)節(jié)) surrounded by a halo of hyperremia(充血).Tubercles break downdeep ragged

7、ulcers bladder irritable. 泌尿生殖系結(jié)核第17頁膀胱結(jié)核，多個(gè)粟粒樣黃色小結(jié)節(jié)泌尿生殖系結(jié)核第18頁膀胱結(jié)核，結(jié)核性潰瘍泌尿生殖系結(jié)核第19頁Diagnosis(診療)泌尿生殖系結(jié)核第20頁Just saying you had turned a corner doesnt make it so.Just saying there is massive destruction doesnt make it so. _John KerryJust saying there is TB also doesnt make it so.We must provideDemon

8、stration of tubercle bacilli in urine by culture.泌尿生殖系結(jié)核第21頁Diagnosis: Symptoms(癥狀)No classic clinical picture of renal TB.Most are vesical in-origin(膀胱起源): burning, frequency(尿頻) & nocturia(夜尿), hematuria(血尿)泌尿生殖系結(jié)核第22頁Diagnosis: Signs(體征)Kidneyno enlargement / tenderness(觸痛)External genitalia(外生殖器

9、): thickened, nontender epididymis(附睪) chronic scrotal draining sinus(陰囊竇道) Induration/nodulationof prostate & seminal vesicles(前列腺/精囊硬結(jié)) 泌尿生殖系結(jié)核第23頁Diagnosis: Lab FindingsPersistent pyuria(膿尿) without organism on culture. But acid-fast stains: 60%(+). Culture for TB (1st morning urine): (+) percent

10、age very high.Tuberculin test(結(jié)核菌素試驗(yàn)): (-) against TB.泌尿生殖系結(jié)核第24頁Diagnosis: X-ray FindingsChest filmPlain film(平片): Enlargement of 1 kidney Obliteration(消失) of the renal & psoas (腰大肌) shadow Renal stones(腎結(jié)石) 10%泌尿生殖系結(jié)核第25頁Diagnosis: X-ray FindingsExcretory urograms(排泄性尿路造影): “Moth-eaten”(蚤咬) appear

11、ance of ulcerated calyces. Obliteration of 1/more calyces. Dilation of calyces. Abscess cavities connecting with calyces.泌尿生殖系結(jié)核第26頁Excretory urograms: Ureteral stricture with secondary dilatation. Absence of function of the kidney.Retrograde Urography泌尿生殖系結(jié)核第27頁泌尿生殖系結(jié)核第28頁泌尿生殖系結(jié)核第29頁MRU or CT泌尿生殖系結(jié)

12、核第30頁泌尿生殖系結(jié)核第31頁Diagnosis: Instrumental ExamsCystoscope(膀胱鏡): Tubercles & ulcers, contraction(孿縮)Cystogram(膀胱造影): Ureteral reflux(輸尿管返流)泌尿生殖系結(jié)核第32頁Differential Diagnosis判別診療Chronic nonspecific cystitis 慢性膀胱炎Epididymitis 附睪炎Multiple small renal stones and medullary sponge kidneys(海綿腎)Urinary bilharzi

13、asis(血吸蟲病)Bladder stones or cancer. 泌尿生殖系結(jié)核第33頁Treatment (治療)TB must be treated as a generalized disease!泌尿生殖系結(jié)核第34頁Basic treatmentMedical 藥品Surgical excision(外科切除) merely adjunct泌尿生殖系結(jié)核第35頁Treatment: Renal TBCombination of drugs(1st line):1. Isoniazid (INH, 異煙肼) 200300mg/d2. Rifapin (RFP, 利福平) 4506

14、00mg/d3. Ethambutol (EMB, 乙胺丁醇) 15mg/kg/d4. Streptomycin (STM, 鏈霉素) 1g/d im5. Pyrazinamide (PZA, 吡嗪酰胺) 1.52g/d泌尿生殖系結(jié)核第36頁Treatment: Renal TBPrefer INH + RFP + EMBResistance to 1st line drugs:Aminosalicylic acid (氨基水楊酸)Capreomycin (卷須霉素)Cycloserine (環(huán)絲氨酸)Ethionamide (乙硫異煙胺)Viomycin (紫霉素)泌尿生殖系結(jié)核第37頁Tr

15、eatment: Renal TBNephrectomy(腎切除) :1. After 3 m, urine culture still (+) and gross involvement radiologically evident.2. Severe sepsis(膿毒癥), pain or bleeding from 1 kidney.3. Marked advanced on 1 side and minimal damage on the other. 泌尿生殖系結(jié)核第38頁Treatment: Vesical TBTends to heal when treatment for t

16、he “primary” infection is given.Ulcers : trans-urethral electrocoagulation (經(jīng)尿道電凝)Extreme bladder contraction: urinary diversion(尿流改道); augmentation cystoplasty(節(jié)段性膀胱成形術(shù))泌尿生殖系結(jié)核第39頁Treatment: General MeasuresOptimal nutrition: importantIrritable bladder: bladder sedatives(鎮(zhèn)靜劑) tolterodine, oxybutyni

17、n泌尿生殖系結(jié)核第40頁P(yáng)rognosis(預(yù)后)Relapse(復(fù)發(fā)): Ureteral stenosis; Vesical contraction 泌尿生殖系結(jié)核第41頁P(yáng)rognosisOverall control rate: 98% at 5 yearsUrine study: every 6 m during treatment; every year for 10 years.泌尿生殖系結(jié)核第42頁Case ReportA 56y male with left abdominal mass & anemia(貧血).X-ray showed a large stone in Lt kidney with severe h