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Infectiousdisease
傳染病病因:病原微生物(Pathogen)
引起疾病有傳染性,流行性 地方性,季節(jié)性入侵門戶:特定病原體—特定的入侵門戶—
特定播散方式—特定組織和器官和力—特定病變定位發(fā)病機(jī)理:細(xì)菌:內(nèi)/外毒素 病毒:細(xì)胞/體液免疫傳染病
共同特點(diǎn)
傳染病
共同特點(diǎn)
基本病理變化 炎癥(急/慢性) 宿主——病原致病力,兩者決定疾病過程臨床經(jīng)過,典型: 潛伏期:感染—出現(xiàn)癥狀 前驅(qū)期:出現(xiàn)非特異性癥狀 發(fā)病期:出現(xiàn)疾病的典型癥狀 愈復(fù)期:病情漸趨緩解轉(zhuǎn)歸痊愈:永久或暫時(shí)性免疫慢性復(fù)發(fā)死亡自然動(dòng)物病三類病毒性動(dòng)物病:出血熱、鸚鵡熱、狂犬病、SARS、
birdflu.立克次體病細(xì)菌病、螺旋體病、萊什曼病、布魯氏病舉例20世紀(jì)30年代蘇聯(lián)大規(guī)模森林腦炎森林腦炎病毒森林修鐵路工人
80年代上海食用毛蚶38.5萬甲肝病人野鹿、狼自然動(dòng)物病90年代耐藥性結(jié)核(美國)從野猴、血貂、海龜身上傳來21世紀(jì)初
SARS:動(dòng)物源性冠狀病毒(RNA病毒)Birdflu:H5N1型其它著名的病例有:中世紀(jì)鼠疫大流行blackdeath
艾滋病、口蹄疫、炭疽、埃博拉病毒、瘋牛病美國12變種香港6變種授課內(nèi)容結(jié)核神經(jīng)系統(tǒng)傳染病
流行性乙型腦炎
流行性腦膜炎麻風(fēng)梅毒傷寒細(xì)菌性痢疾Tuberculosis
結(jié)核IntroductionAchronicinfectiousdiseaseMycobacteriumTuberculosis☆PulmonaryTBisthemostcommontype.involveallorgans(rareinthyroid,pancreasandmyocardium)Characteristicchanges:
tuberculousgranuloma+caseousnecrosis結(jié)核結(jié)節(jié)干酪樣壞死TuberculosisEpidemiologyHistory☆“癆病”Worldwide
1.7billioninfected8-10millionnewcases3milliondeathsChina0.55billioninfected0.13milliondeathsTuberculosisPredisposingfactorssocialfactors:poverty,crowding,agingchronicdebilitatingdisease:diabetesmellitus,Hodgkindisease,pulmonarysilicosis,alcoholism,etalimmunitydeficiency:HIV
TuberculosisEtiologyRobertKoch24th,March“世界防治結(jié)核病日”Pathogenspecies:
M.hominis(人型)M.bovine(牛型)M.avium(鳥型)M.piscium(魚型)M.murium(鼠型)
humanTuberculosisHIVinfectedhostEtiologyPathogenicity
Lipid:mycolicacid(分枝菌酸)cordfactor(索狀因子)WaxD(蠟質(zhì)D)phospholipid(磷脂)mycosides(分枝菌糖苷脂)
Protein:Tuberculin結(jié)核菌素/純蛋白衍生物(PPD)GlycogenTuberculosis分支菌酸(mycolicacid)--抗酸染色TransmissionRespiratorytract(pulmonaryT.B):inhaletheairborneorganismsexposetocontaminatedsecretionsDigestivetract(intestinalT.B):
drinkinginfectedmilkSkininjury:
CongenitalBCG:nonpathogenic,livingT.B,undergoing230passages,13yrs)
mother PlacentaAmnioticfluidFetusTuberculosisPathogenesis
infection≠disease★Onlyasmallfractionofthosewhocontractaninfectiondevelopactivedisease.
TuberculosisPrimaryinfection(non-specificimmunity)hyperemia,edema,neutrophils,TandBcells,MΦphagocytosed,butnotkilledN-RAMP1:naturalresistance-associatedmacrophageprotein1MostpatientsatthisstageareasymptomaticorhaveamildflulikeillnessTuberculosisPathogenesis2–3wkslaterspecificimmunityandallergyoccursOT/PPDSecondaryinfection:(specificimmunity)Kochphenomena:immunityaccompaniedwithallergyTuberculosisPathogenesisPPDtest
false-negativefalse-positiveTuberculosisPathogenesisKochphenomenon:cellmediatedimmunity(CMI)accompaniedwithdelayedtissuehypersensitivity(DTH)TuberculosisCMIandDTHaredifferentimmunoreactionsDifferentantigensDifferentTcellsubtypesTheamountoforganismsorantigenandTh1/Th2excursionDifferentCKsDifferentmethodstokillorganismsPathologicalchangesExudationdominantchanges滲出病變happenedinearlystageofinfectionordeteriorationofDis.
Predisposingfactors:
suppressedimmunity,plentyofmycobacteriumT.BhighvirulenceandstrongDTHchanges:serousinflammation,serous-fibrinousinflammationlocation:pleura,meninges,peritoneumTuberculosisTuberculosisPathologicalchangesExudationdominantchanges:
development:unstableabsorbedwithoutanychangeschangeintoproliferationdominantornecrosisdominantchangeseasytofindorganismsTuberculosisPathologicalchangesProliferationdominantchange(Tubercleformation,granuloma)肉芽腫性病變
Predisposingconditions:strongimmunityfewmycobacteriumlowvirulence
TuberculosisPathologicalchangesProliferationdominantchange(Tubercleformation,granuloma)
Changes:EpithelioidcellsLanghan’sgiantcellsLymphocytesdifficulttofindorganismsTuberculosisTubercle結(jié)核結(jié)節(jié)PathologicalchangesNecrosisdominantchangePredisposingfactors:weakenedimmunity,severehypersensitivitylargeamountofmycobacteriumT.B.highvirulenceChanges:caseousnecrosis(干酪樣壞死)
Gross:granular,cheesyappearance(richinlipid)
LM:acidophiliagranularmaterialswithoutstructure
TuberculosiscaseousnecrosisPathologicalchangesNecrosisdominantchangeeasytofindorganismsDevelopment:
Existforlong→timingbombTheamountofmycobacteriumwillincreasesharplywhenthediseasedeteriorateFibrosisTuberculosisPathologicalchangesexudationchangesgranulomalesioncaseousnecrosisTuberculosisBasicchangesHostBacterialImmunityAllergyAmountpathogenexudationlowstrongerlargestronggranulomahigherweakerfewlownecrosislowstrongestlargestrongTuberculosis愈合
病灶?。簼B出性病灶吸收消散 增生性病灶纖維化 干酪壞死灶,吸收消散,纖維化-------------"吸收好轉(zhuǎn)期" 病灶大:
纖維化 鈣化(20%鈣化灶內(nèi)有活菌)
-------------"硬結(jié)鈣化期"ConsequenceTuberculosis惡化
1.病灶擴(kuò)大病灶周圍滲出
結(jié)核結(jié)節(jié)及干酪樣壞死模糊的云絮狀陰影陰影密度增高"浸潤進(jìn)展期"ConsequenceTuberculosis惡化2、溶解、播散與空洞形成壞死、液化——天然腔道排出----空洞“開放性肺結(jié)核”播散
天然腔道:支氣管---肺
“溶解播散期”
消化道——腸
輸尿管——膀胱淋巴道:淋巴結(jié)血道:遠(yuǎn)處器官ConsequenceTuberculosisPulmonaryTuberculosis
肺結(jié)核
PrimarypulmonaryT.B.SecondarypulmonaryT.B.TuberculosisPreviouslyunexposedMostinchildren,agedorimmunosuppressdpersons(HIV)ExogenousorganismPathologicalchange:
GhonComplex(原發(fā)復(fù)合征)1-1.5-cmareaofgray-whiteinflammatoryconsolidation(lowerpartofupperlobeorupperpartoflowerlobe)TuberculouslymphatitisRegionalnodeinvolvement,oftenwithcaseatePrimaryPulmonaryTuberculosisTuberculosisGhonComplexTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosis
絕大多數(shù)無明顯的癥狀
5%患者有倦怠,盜汗,消瘦等1、98%好轉(zhuǎn),機(jī)體產(chǎn)生免疫力,病灶吸收,纖維化,鈣化
Ranke復(fù)合征(Rankecomplex)2、惡化進(jìn)展血道播散淋巴道播散支氣管播散Consequence轉(zhuǎn)歸TuberculosisPrimaryPulmonaryTuberculosis血道播散acutemiliaryT.B.
(急性粟粒性結(jié)核)大量細(xì)菌一次進(jìn)入肺靜脈
全身(肝、脾、腦膜、腎、骨髓)肺動(dòng)脈
肺抵抗力極差或用大量激素、免疫抑制劑或細(xì)胞毒藥后TuberculosisPrimaryPulmonaryTuberculosis粟粒性肺結(jié)核大小一致、分布均勻、灰白色圓形鏡下:結(jié)核結(jié)節(jié)TuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosissubacuteorchronicmiliaryT.B.(亞急性或慢性全身粟粒性結(jié)核病) 少量多次進(jìn)入血循環(huán),病灶大小、新舊和性質(zhì)不一致secondaryorextrapulmonaryT.B.
(繼發(fā)性肺結(jié)核或肺外器官結(jié)核?。┓?、骨關(guān)節(jié)、腦、腎、輸卵管、附睪等處痊愈或潛伏下來日后復(fù)發(fā)血道播散TuberculosisPrimaryPulmonaryTuberculosis
鎖骨上下LN頸LN肺門LN 支氣管、氣管LN
縱隔LN
腹膜后LN
結(jié)核結(jié)節(jié)形成伴淋巴組織增生干酪樣壞死與軟組織粘連,甚至經(jīng)久不愈的竇道
淋巴道播散TuberculosisPrimaryPulmonaryTuberculosis支氣管播散少見。LN腫大將小兒薄壁氣管壓癟
TuberculosisPrimaryPulmonaryTuberculosisSecondaryPulmonaryT.B.
繼發(fā)性肺結(jié)核PreviouslyinfectedAdulttypePathogenesis<5%exogenous>95%endogenousseedingTuberculosis1.Location:apexoflobelowarterialbloodpressure,lessMΦ,lessventilation,highO2pressure2.Changes:caseousnecrosis---proliferationfocuslocalizationlesslymphaticandvascularspreadingmorebronchialdissemination3.Longcourseofdisease,complexchangesTuberculosisSecondaryPulmonaryTuberculosisPrimaryPT.BSecondaryPT.B
InfectionpreviouslyuninfectedpreviouslyinfectedPatientchildrenadultSpecialCMIandDTHoccurinthecoursepreviouslyhadPathologicalchangesGhoncomplexvariouschanges,localization,cavityBeginningfocuslowerpartofupperlobeapexoflobeupperpartoflowerlobeCharacterofchangesexudation,necrosisproliferation,necrosisDisseminationlymphaticandbloodvesselbronchialCourseofdiseaseshort,self-controllong,fluctuant,clinicaltreatmentcomparisonTuberculosis原發(fā)性肺結(jié)核繼發(fā)性肺結(jié)核結(jié)核桿菌感染初染再染發(fā)病人群兒童成人特異性免疫力和過敏性先無,在病程中發(fā)生有病理特征原發(fā)復(fù)合征病變多樣,新舊病灶并存起始病灶下葉上部、上葉下部近胸膜處肺尖病變性質(zhì)滲出壞死為主肉芽腫形成和壞死為主播散方式淋巴道、血道播散多為支氣管,趨于肺內(nèi)演變病程短,大多自愈長,波動(dòng)性,需治療PathologicalchangesFocallesion:(局灶型)1.location:1~2cmbeneathapexoflobe2.modality:lessthan2cmindiametersingleormultiplefocusesproliferationdominantcaseousnecrosisincentralandfibrosisaround3.development:healingbyfibrosisorcalcificationfewbecomeinfiltrativelesionTuberculosisSecondaryPulmonaryTuberculosisTuberculosisSecondaryPulmonaryTuberculosisPathologicalchangesInfiltrativelesion(浸潤型):1.source:focallesion2.location:apexorsubclavicalarea(subclavicularinfiltration)3.modality:exudationdominant,caseousnecrosisincentral4.clinicalsymptoms
TuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisPathologicalchangesInfiltrativelesion(浸潤型):5.development:healingbyabsorb,fibrosis,calcificationdiseaseprogresses,acutecavitationmayoccurcaseouspneumoniaspontaneouspneumothoraxtuberculouspyopneumothoraxchronicfibro-cavitativetypeTuberculosisPrimaryPulmonaryTuberculosisChronicfibro-cavitativelesion(慢性纖維空洞型)1.source:infiltrativetypewithacutecavity2.Characters:☆singleormultiplechroniccavitiesthreelayers----inner:caseousnecroticmaterialsmid:tuberculousgranulationtissueouter:fibrousscar☆diversefoci☆fibrosis(cirrhoticpulmonarytuberculosis)PathologicalchangesTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisChronicfibro-cavitativelesion(慢性纖維空洞型)
3.clinicalsymptoms
openT.B.(mycobacteriuminsputum)emptysis,laryngealT.B.,IntestinalT.B.,corpulmonale4.developmenthealing:smallcavity→scarhealinglargecavity→openhealingPathologicalchangesTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisCaseousPneumonia(干酪樣肺炎)
1.source:infiltrativelesionbronchialspreadingofacuteorchroniccavity2.modality:lobularorlobarcaseouspneumoniaacutecavity(localliquefaction).LM:caseousnecrosiswithserous-fibrinousexudate3.Poorprognosis(百日癆or奔馬癆)PathologicalchangesTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisTuberculoma(結(jié)核球)1.source:fibrosisofcaseousnecrosisininfiltrativetypebronchiaclosureleadstocaseousmaterialsfillinthecavitycombinationofseveraltubercular2.modality:caseouslesionwithfibrouscapsule2-5cmindiameter3.prognosis:stabledeteriorationPathologicalchangesTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisTuberculouspleuritis:wetanddrywettype----Exudativepleuritis:MostinyoungpeopleSource:mycobacteriadisseminationfromprimaryfocusorhilarlymphnodsDTHinducedbyproteinofmycobacteriainpleuraPathologicalchanges:serous-fibrinousinflammationClinicalsymptomsPrognosis:1.absorb2.richinfibrinmaycauseadhesionofpleuraPathologicalchangesTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisdrytype----proliferativepleuritis:T.B.focusbeneathpleuraextendtopleuraMostinapexoflobe,localpleuraadhesionandthickeningCaseouspleuritisrare
PathologicalchangesTuberculosisPrimaryPulmonaryTuberculosisSystemicsymptoms
responsetoT.B.“toxic”components
Localmanifestations:
coughhemoptysischestpainlowerrespiratoryfunctionCPCmalaise,weary,nightsweat,lowfeverintheafternoon,hecticrosycheeks,lossofappetiteTuberculosisPrimaryPulmonaryTuberculosisHematogenictuberculosisResultfromPrimarytuberculosisorSecondarytuberculosisTuberculosisTuberculosisPrimaryPulmonaryTuberculosisExtrapulmonaryTuberculosisInvolveallorgansReactivationoflatentfociPathologicalchangesandcharacteroforgansarecorrelativeTuberculosisIntestinalTuberculosisSourceofMycobacterium
primary:drinkinginfectedmilksecondary:
swollenmycobacteriumcontainedsputumLocation:
anysegmentofintestinemostcommonatileocecalsegment:1.richinlymphtissue,easytoinvade2.longtimeforfoodtostayinthissegmentTuberculosisUlcerativeintestinalT.B.
TuberclesinlymphtissuefusednecrosisulcerationFeaturesofulcer:
1.longaxisoftheulcerisverticaltolongaxisofintestine,becauseofthecircularlymphaticsofintestine
2.irregularmarginoftheulcer(rat-bite-like),caseousbaseandtuberculargranulationtissuebeneath,fibrinexudateandmiliarytuberclesinserosaIntestinalTuberculosisTuberculosisUlcerativeintestinalT.B.3.IntestinalstraitnessafterulcerhealingFibrosisleadstoaadhesionamongserosaandadjacenttissuesHemorrhageandperforationareuncommonClinicalsymptoms:
chronicabdominalpain,intermittentdiarrheaandconstipation,tubuculartoxicsymptomsTuberculosisIntestinalUlcerativeT.B.TuberculosisProliferativeintestinalT.B.
proliferativechangesdominant,causingthickeningofintestine,polyposis,leadingtoabdominalmassand/orileus※※※※※※※※IntestinalT.B.MesenteryT.B.Tuberculousperitonitiswettypeperitonealtuberclegreenishyelloworhematicascitesdrytype
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