Introduction to tuberculosis

Introduction:

TuberculosisIt is a chronic infectious disease caused by Mycobacterium tuberculosis, which can invade many organs, and it is most common to form pulmonary tuberculosis (pulrnonary tuberculosis). Excreted patients are an important source of infection. Human infection with tuberculosis does not necessarily occur, and when the resistance is reduced or the cell-mediated allergic reaction is increased, it may cause clinical disease. The basic pathological features of the disease are exudation, caseous necrosis and other proliferative tissue reactions, which can form voids. If diagnosed in time and treated reasonably, most of them will be cured. The most common surgical method for surgical treatment of pulmonary tuberculosis is still pneumonectomy, which is an effective means of eliminating chronic infectious diseases, preventing recurrence and treating various serious complications.

Cause:

【Causes】

Mycobacterium tuberculosis belongs to the actinomycetes, mycobacteria of the mycobacteria family, and is a pathogenic acid-fast bacteria. Mainly divided into human, cattle, birds, mice and other types. People who are pathogenic to humans are mainly human bacteria, and bovine bacteria are rarely infected. The tuberculosis form is slender and curved, with rounded ends, no spores or capsules, no flagella, about 1 to 5 μm in length and 0.2 to 0.5 μm in width. In the specimen, they are dispersed or piled up or arranged in a chain. Mycobacterium tuberculosis is an aerobic bacterium that does not multiply in the absence of oxygen, but can still survive for a long time. Under good conditions, about 18 to 24 hours of breeding, the bacterial lipid component accounts for about 1/4 of its weight, and it is acid resistant when dyed. Tuberculosis is highly resistant to dryness and strong acid and alkali, and can exist in the external environment for a long time. It can survive for 20 to 30 hours in the sputum and 6 to 8 months in the septic area. However, the resistance to damp heat is very low, and it can be killed by boiling for 5 minutes or directly in the sun for 2 hours. UV disinfection is better. Both human and bovine tuberculosis strains are obligate parasites, with human and bovine as natural storage hosts, respectively. Both have the same level of virulence to humans, monkeys and guinea pigs. The resistance of tuberculosis to drugs can be formed by the development of congenital drug-resistant bacteria in the flora, or it can be quickly developed due to the use of an anti-tuberculosis drug alone in the human body. bacteria. Drug-resistant bacteria can cause treatment difficulties and affect the efficacy. Long-term exposure to streptomycin by Mycobacterium tuberculosis can also produce dependence, the so-called Lai drug, but Lai medicine is rare in the clinic.

Tuberculosis

It belongs to the actinomycetes, Mycobacterium genus of Mycobacterium, and the main cause of human tuberculosis is human tuberculosis, and bovine infection is rare. Tuberculosis is an aerobic bacteria, which is not easy to stain. After dyeing with magenta, it can not be decolorized by washing with acidic alcohol, so it is called acid-fast bacillus; the microscopic examination is slender and slightly curved. Strong resistance to the outside world, can survive for more than 5 months in the damp area; but in the sun exposure for 2 hours, 5% ~ 12% cresol soap (Lasu) solution for 2 to 12 hours, 70% alcohol exposure for 2 minutes , or boil for 1 minute, you can be killed. The easiest way to sterilize is to directly burn the crepe paper with germs. Mycobacterium tuberculosis grows slowly, and it takes 15 to 20 hours to proliferate. It takes 4 to 6 weeks to grow into visible colonies, and it takes at least 3 weeks.

Mycobacterium tuberculosis is a complex composed of high molecular weight fatty acids, lipids, proteins and polysaccharides, which is related to its pathogenicity and immune response. In the human body, lipids can cause mononuclear cells, epithelioid cells and lymphocytes to infiltrate to form tuberculous nodules; proteins can cause allergic reactions, neutrophils and monocytes infiltrate; polysaccharides are involved in certain immune responses (such as agglutination reaction). Tuberculosis is divided into human, bovine and mouse types. The first two types (especially human type, standard strain H37Rv) are the main pathogens of human tuberculosis. The human form is similar to the bovine type, and has strong pathogenicity to guinea pigs. However, the human pathogenic bacteria have immunogenicity to rabbits. It is far stronger than bovine bacteria. Human bacteria can produce niacin, while niacin tests for bovine bacteria are mostly negative. Drinking unsterilized cow clothes with bovine tuberculosis may cause intestinal tuberculosis infection.

Group A: strong growth and reproduction, existing outside the cell, strong pathogenicity, infectious, mostly in the early active lesions of the disease, in the cavity wall or in the human cavity, easy to be killed by anti-tuberculosis drugs, especially Isoniazid has the best effect and plays a major bactericidal effect. Streptomycin and rifampicin are also effective, but not as good as the former. Group B: It is an intracellular bacteria, which is present in macrophages. The bacteria are protected by acidic cytoplasm and can grow, but the reproduction is slow. Pyrazinamide has a better bactericidal effect at pH <5.5. Group C: Occasionally, the breeding bacteria are present in the necrotic foci of the cheese. The growth environment is unfavorable to the bacteria. The tuberculosis is often dormant, and only occasionally occurs for short-term growth and reproduction, and is sensitive only to a few drugs such as rifampicin. Group B and group C are persistent bacteria, which are often the source of future recurrence. They only temporarily dormant and may survive for several months or years. Also known as "sustained bacteria." Group D: It is a dormant mushroom. A small amount of tuberculosis in the lesion is completely in a dormant state, and it is not pathogenic and infectious, and is harmless to the human body. Any drug that acts on it, most naturally dies or is swallowed and killed, rarely relapses.

The above grouping according to bacterial growth and reproduction has certain guiding significance for drug selection.

During the breeding process, tuberculosis develops resistance due to mutations in the chromosomal gene. Drug resistance is an important biological property of tuberculosis, which is related to the success or failure of treatment. The natural resistant bacteria continue to grow and multiply. In the final flora, the resistant bacteria are the main ones (the sensitive bacteria are eliminated by the drugs), and the anti-tuberculosis drugs are ineffective. This kind of natural resistant bacteria (natural variation) occurs due to gene mutation. , usually without causing serious consequences. Another mechanism for developing drug resistance is that after the drug is contacted with tuberculosis, some bacteria undergo induced mutation and gradually adapt to survive in the drug-containing environment (secondary drug resistance). 1 μg of isoniazid (INH) per ml in solid medium, streptomycin (SM) 10 μg orRifampin(RFP) 50 μg of growable tuberculosis bacteria are called drug-resistant bacteria of each drug. The pathogenicity of INH-resistant strains to animals is significantly weakened, the pathogenicity of SM-resistant bacteria is generally not reduced, the resistance to RFP bacteria is reduced to varying degrees, and the pathogenicity of tuberculosis bacteria resistant to both RFP and INH is reduced. More significant than a single INH-resistant person.

The patient has not used a drug in the past, but the sputum is resistant to the drug, and the original drug-resistant bacteria are infected. Long-term irrational use of drugs, emergence of drug-resistant bacteria through elimination or induction mechanism, said secondary drug resistance. Many of the patients who were treated were secondary drug-resistant cases. In recent years, the number of drug-resistant tuberculosis bacteria has increased, making it a clinically difficult case to cure. Any combination of drugs, inadequate drug doses, irregular medications, discontinuation of treatment, or premature withdrawal may lead to bacterial resistance. The consequences of drug resistance must be recent treatment failure or long-term recurrence. Therefore, avoiding and overcoming bacterial resistance is the key to the success of TB chemotherapy.

About 5% of clinically positive sputum cultures are non-tuberculous mycobacteria (except for Mycobacterium tuberculosis and mycobacteria other than Mycobacterium leprae), and are also acid-fast bacilli, which are widely found in nature, when the body is immune. When damaged, it can cause intrapulmonary and extrapulmonary infections. Its clinical manifestations resemble tuberculosis, but most of them are resistant to tuberculosis drugs. The biological characteristics of such non-tuberculous mycobacteria are different from those of tuberculosis. For example, it can grow at 28 ° C, the colony is smooth, the niacin test is negative, the drug-resistant contact test is positive, and the guinea pig is not pathogenic.

Route of infection

Respiratory infections are the main route of infection for tuberculosis, and droplet infection is the most common form of infection. The source of infection is mainly the sputum of tuberculosis patients (especially those with sputum smear positive and untreated). Healthy people are infected by inhaling droplets ejected from coughing and sneezing. A drip of less than 10 μg can enter the alveolar cavity, or float in the air for a long time due to its light weight, and the droplets in the indoor ventilation environment can also be inhaled to cause infection. The secondary route of infection is through the digestive tract into the body. A small amount of virulence tuberculosis can be killed by the body's immune defense mechanism. Only when a large number of virulence tuberculosis is invaded and the body's immunity is insufficient, can it occur after infection. Other routes of infection, such as transdermal and genitourinary systems, are rare.

Basic pathological changes in tuberculosis

The human immunity and allergic reaction, the number and virulence of tuberculosis invasion, and the nature and extent of tuberculosis lesions are closely related to the possibility and speed of changing from one pathological type to another. Therefore, the pathological process is quite complicated, and the basic pathological changes may not all appear in the lungs of tuberculosis patients.

(1) Exudation-based lesions

It is characterized by congestion, edema and leukocyte infiltration. Neutrophils are found in early exudative lesions and are gradually replaced by monocytes (phagocytic cells). Intubated tuberculosis is seen in large mononuclear cells. Exudative lesions usually occur in the early stages of tuberculosis inflammation or when the lesions worsen, as well as in serosal tuberculosis. When the condition improves, the exudative lesions can be completely dissipated and absorbed.

(2) Proliferative lesions

There can be a brief exudation phase at the beginning. When large mononuclear cells phagocytose and digest tuberculosis, the phospholipid component of the bacteria makes the large mononuclear cells larger and flatter, similar to epithelial cells, called "epithelial cells." Epithelial cells aggregate into clusters, and Langhans giant cells can appear in the center. The latter can transmit information of tuberculosis antigen to lymphocytes, and there are often more lymphocytes on the periphery, forming a typical tuberculous nodule, which is a characteristic lesion of tuberculosis, and "tuberculosis" is also named. Tuberculosis is often difficult to find in tuberculous nodules. Hyperplasia-based lesions occur in cases where the amount of bacteria is small and human cell-mediated immunity predominates.

(3) Metamorphism-based lesions (cheese-like necrosis)

Often occurs on the basis of exudation or proliferative lesions. If the body's resistance is reduced, the amount of bacteria is too much, and the allergic reaction is strong, the tuberculosis bacteria in the exudative lesions will continue to multiply after the macrophages are beaten, so that the cells become turbid and swollen, and then the fat degeneration occurs, and the fragments are broken until the cells are necrotic. After the inflammatory cells die, the proteolytic enzyme is released, and the tissue is dissolved and necrotic, forming coagulative necrosis. Due to the presence of a large amount of lipids, the lesions were yellow-grey under the naked eye, and the texture was loose and brittle, resembling cheese, hence the name of cheese-like necrosis. Microscopic examination revealed a solidified, red-colored, tuberculous necrotic tissue.

The above three lesions can exist simultaneously in a history of lung lesions, but usually one is dominant. For example, in the center of exudative and proliferative lesions, a small amount of caseous necrosis may occur; and lesions dominated by metamorphism are often accompanied by varying degrees of exudation and tuberculous nodules.

[Pathogenesis]

In 1891, koch injected TB into the skin of healthy guinea pigs. After 2 to 3 weeks, local redness, ulceration, local lymphadenopathy, and necrosis and hematogenous dissemination of the lesions occurred. Most of the guinea pigs died due to blood circulation. However, after the infection, the guinea pigs that had not died after the infection were injected with the same amount of tuberculosis, and the local reaction occurred violently after 2 to 3 days. The injection site showed redness and induration, and ulcers formed rapidly, but the ulcer soon became scarred and the lesion was limited. The local lymph nodes are not swollen. The severe local focal reaction after reinfection indicates the allergic reaction of the body, and the lesion tends to be limited without dissemination, which is evidence of immunity. This so-called koch phenomenon of different primary and secondary infections has been used to explain the different pathogenesis of primary and secondary tuberculosis in humans.

1. Immunization of human body immunity to tuberculosis is mainly based on cellular immunity. The cellular immunity of Mycobacterium tuberculosis mainly depends on the cellular active substance released by the sensitized lymphocytes (T cells) combined with specific antigens. For example, chemokines attract general lymphocytes to accumulate at the antigen site; macrophage activating factor enhances phagocytosis and destroys tuberculosis, and transfer factor converts the attracted lymphocytes into sensitized lymphocytes. This specific immunity is:

1 control the reproduction of tuberculosis

2 increase the body's ability to destroy tuberculosis, reducing bacteria

3 control the three effects of tuberculosis in the body

2. Allergic reaction to tuberculosis-sensitized organisms, localized redness and induration 24 to 72 hours after local injection of tuberculosis antigen, histologically showed a large number of lymphocytic infiltration, which is a type IV delayed type allergic reaction expressed by the body on tuberculosis antigen. . Allergic reactions produce a mass that has a localized effect on tuberculosis. Parallel and consistent with immunity. On the other hand, allergic reactions, especially when they are too strong, can cause significant tissue damage directly or indirectly, and become an important part of the immune pathogenesis of tuberculosis.

The basic pathological changes of tuberculosis The basic pathological condition of tuberculosis is an inflammatory reaction that can simultaneously cause histological changes such as hyperemia, exudation, necrosis and hyperplasia.

Human reactivity

(1) Immunity and allergy

The natural immunity (innate immunity) of the human body to tuberculosis is non-specific. The immunity (acquired immunity) obtained after inoculation with BCG or after infection with tuberculosis is specific, and it can kill or closely surround the invading tuberculosis, stop its spread, and heal the lesion. Acquired immunity is significantly stronger than natural immunity, but their protection against tuberculosis is relative. After the human body is infected with tuberculosis, it does not develop into tuberculosis because of its immunity. Exercise can help boost immunity; on the contrary, measles, diabetes, silicosis, AIDS and other chronic diseases, malnutrition or the use of glucocorticoids, immunosuppressive agents, etc., reduce the body's immune function, susceptible to tuberculosis infection, or the original Stable lesions are reactivated. Age can affect people's natural resistance to tuberculosis infection, and the elderly and children are susceptible, related to the low cellular immunity in old age and the imperfect cellular immune system of young children.

The immunity of tuberculosis is mainly cellular immunity, which is manifested by the sensitization of lymphocytes and the enhancement of phagocytic function. The invaded tuberculosis is phagocytosed by phagocytic cells, processed and processed to transmit antigen information to T lymphocytes to make them sensitized. When the T lymphocytes are exposed to tuberculosis again, a variety of lymphokines (including chemokines, macrophage migration inhibitors, macrophage activating factors, etc.) can be released, allowing macrophages to accumulate around the bacteria, phagocytosis and Kill the bacteria, then become epithelial cells and giant cells of Langhans, eventually forming tuberculous nodules, limiting the lesions.

4 to 8 weeks after tuberculosis invades the human body, the sensitive reaction of body tissues to tuberculosis and its metabolites is called allergic reaction, and the inflammatory mediators, skin reaction factors and lymphocyte toxins released by another subset of T lymphocytes. And so on. Local inflammatory exudation, even cheese necrosis, often accompanied by systemic symptoms such as fever, fatigue and loss of appetite. At this time, if tuberculin is used as a skin test (see below), it can be positive. Local tissue congestion and edema were injected and a large number of sensitized T lymphocytes were infiltrated. This cellular immune response to tuberculosis and its metabolites belongs to type IV (late-type) allergic reactions. After infection with tuberculosis, skin nodular erythema, polyarthritis or herpetic conjunctivitis can occur, which are all manifestations of tuberculosis, often occurring in patients with primary tuberculosis infection.

The peptides and polysaccharide complexes of tuberculosis are related to the reaction, while the waxy and tuberculosis proteins are related to allergies. The antigen components of the two are different, but the immune and allergic reactions often coexist. For example, after vaccination with BCG, immunity can be produced, and tuberculin reaction (allergy) is also positive. The appearance of both may also be related to the lymphokines produced by different T lymphocyte subsets in the body. Immunization protects the human body, while allergic reactions are often accompanied by tissue damage and are also detrimental to bacteria. Serious illness, malnutrition or the use of immunosuppressive drugs can weaken immunity, and allergic reactions are also inhibited, showing no response to tuberculosis test. When the systemic condition improves or stops the drug that suppresses the immune response, the tuberculin reaction becomes positive as the immune and allergic reactions recover. Immune and allergic reactions are sometimes not parallel, and are related to the complex internal and external environment of the human body, the effects of drugs, and the amount of bacteria and virulence. In short, the number, virulence, human immunity and allergic reaction of invading tuberculosis determine the occurrence, development and outcome of tuberculosis after infection. When the body's resistance is at a disadvantage, tuberculosis is often easy to develop; on the contrary, it is not easy to develop after infection, even if the disease is mild and easy to cure.

(2) Primary infection and reinfection

The guinea pig was inoculated with a certain amount of tuberculosis, and there was no obvious reaction in the first few days. After about 10 to 14 days, the local injection of redness and swelling gradually formed ulcers. After a long period of time, the tuberculosis bacteria multiplied and reached the local lymph nodes. Lymph nodes and blood circulation spread to the whole body, and guinea pigs are prone to death, indicating that guinea pigs are not immune to tuberculosis.

If the same amount of tuberculosis is injected into a guinea pig that has been infected with a small amount of tuberculosis 4 to 6 weeks ago, the reaction that occurs is obviously different from the above. After the injection, the animal is hyperthermia. After 2 to 3 days, the injection has localized redness, ulceration, necrosis and other violent reactions, but soon it can heal, scarring, local lymph nodes are not swollen, and no systemic tuberculosis spreads. Nor will it die. This local severe allergic reaction caused by reinfection is usually easy to heal and has no systemic dissemination, which is the result of guinea pigs having immunity against tuberculosis. The phenomenon that the body responds differently to the reinfection of tuberculosis and the initial infection is called the Koch phenomenon.

After the first (usually pediatric) infection of the lungs (initial infection), the bacteria are carried by the phagocytic cells to the hilar lymph nodes (swelled lymph nodes), and can be spread throughout the body (recessive bacteremia), if the body immunity Low, may develop into primary progressive tuberculosis. However, in adults (often infected with mild tuberculosis in childhood, or have been vaccinated with BCG), the body has established immunity, and reinfection at this time does not cause local lymphadenopathy, and is not prone to systemic dissemination. In the reinfection, local violent tissue reaction occurs, and the lesions are exudative, and even the cheese-like necrosis and melting form a cavity.

The outcome of tuberculosis

The proliferation of tuberculosis in the case of necrotic lesions caused liquefaction, which is related to the infiltration of neutrophils and macromonocytes. The liquefied caseous necrotic part can be absorbed, partially formed by the bronchus to form a cavity, or cause bronchial dissemination in the lung. When the body's immunity is enhanced and treated with anti-tuberculosis drugs, the lesions can gradually heal. Exudative lesions are absorbed and dissipated by phagocytosis of the mononuclear-phagocytic system, even without scarring. Smaller caseous necrotic or proliferative lesions can also be reduced and absorbed after treatment, leaving only slight fibrous scars. In the healing process, the lesion is often accompanied by fibrous tissue hyperplasia, forming a cord-like scar. Cheese-like lesions can also heal due to loss of water, contraction, and calcium deposition, eventually forming a calcification.

Spread and deterioration of tuberculosis

When the human body is infected with tuberculosis for the first time, the tuberculosis can be swallowed by the cells and transported to the hilar lymph nodes via lymphatic vessels. A small amount of tuberculosis bacteria can enter the blood circulation and spread to the whole body, but there may be no significant clinical symptoms (hidden bacteremia). If necrotic lesions erode blood vessels, tuberculosis can pass through the blood circulation, causing systemic miliary tuberculosis including the lungs, such as meninges, bones, and kidney tuberculosis. Tuberculosis in the lungs can be spread along the bronchus, forming new tuberculosis lesions in other parts of the lung. Ingestion of a large number of sputum containing tuberculosis into the gastrointestinal tract can also cause intestinal tuberculosis and peritoneal tuberculosis. Tuberculosis can be directly extended to the pleura causing tuberculous pleurisy.

The evolution of tuberculosis pathological changes is related to the body's systemic immune function and the strength of local lung immunity. Fibrosis is a manifestation of immunity, and the formation of voids often indicates low immunity.

symptom:

痰 Tuberculosis examination is not only the main basis for the diagnosis of tuberculosis, but also an important indicator for assessing the efficacy and follow-up of the disease. The sputum of patients with pulmonary tuberculosis can be intermittently sterilized, so it should be checked several times in succession. X-ray examination is a necessary means to diagnose tuberculosis, and it is of great value for early diagnosis, determination of lesion location, extent, nature, understanding of its evolution and treatment selection.

In clinical diagnosis, the current classification method in China includes four parts, namely tuberculosis type, lesion range and cavity part, sputum examination, activity and outcome.

1. Tuberculosis is divided into five types (the new clinical type 5 of tuberculosis adopted by the Chinese Medical Association Tuberculosis Branch in 1998)

Type I: primary tuberculosis; type II: hematogenous disseminated tuberculosis; type III: secondary tuberculosis (including invasive, fibrous cavity and caseous pneumonia); type IV: tuberculous pleurisy (including tuberculous dryness) Pleuritis, tuberculous exudative pleurisy, tuberculous empyema.); V type: other extrapulmonary tuberculosis.

Second, the extent of the lesion and the cavity

Press right, left, and divide the upper, middle, and lower lung fields. The lesion on the right side is recorded above the horizontal line, and the lesion on the left side is recorded below the horizontal line. Those with no lesions on the side are indicated by "(-)". The lungs were divided into upper, middle and lower lung fields with the inner ends of the lower edges of the 2nd and 4th front ribs. If there is a hole, add a "0" to the corresponding lung field.

Third, tuberculosis test

The sputum is positive or negative, which is represented by (+) or (-), respectively, and the smear, collection or culture method is represented by "coating", "collection" or "cultivation", respectively. Patients who are innocent or unexamined are marked as “innocent” or not investigated.

Fourth, activity and outcomes

In determining the activity and outcome of tuberculosis, the patient's clinical manifestations, lung lesions, cavities and sputum should be integrated. According to the degree of activity of tuberculosis lesions, it can be divided into three phases:

(1) Progress period

Should have one of the following: newly discovered active lesions; lesions worsen than before, increase; new voids or voids increase; sputum positive.

(2) The period of improvement

One of the following is better: the lesion is absorbed earlier; the cavity is closed or reduced; the bacillus is turned negative.

(3) Stability period

There was no activity change in the lesion, the cavity was closed, and the sputum was continuously negative (at least once a month) for more than 6 months. If the cavity is still present, the bacteriocin should be continuously negative for more than 1 year.

Open tuberculosis refers to patients with advanced and partially improved stage of tuberculosis. The tuberculosis is often excreted in the sputum, which is highly contagious and must be treated in isolation.

Active tuberculosis refers to exudative infiltrative lesions or metamorphic lesions such as caseous necrosis, cavity formation, bronchial dissemination, and disseminated miliary tuberculosis. The clinical symptoms are more prominent. Both active and improved periods are active tuberculosis, and among the advanced patients, except for a few (such as acute hematogenous disseminated miliary tuberculosis), almost all of them are sterilized. Patients with partial improvement are still vaccinated, all of which are open tuberculosis. In another part of the improvement period, the sputum negative is not open. Active tuberculosis should be treated in isolation for all bacteria in the sputum.

Patients in stable phase are inactive tuberculosis, which is classified as a preliminary clinical cure; if observed for two years, the lesion remains stable and the sputum remains negative, which can be regarded as clinical cure; if there are still cavities, it should be observed for more than 3 years, such as No change can be considered a clinical cure.

Diagnostic example: invasive pulmonary tuberculosis = upper 0 middle / middle coating (+) advanced

Typical pulmonary tuberculosis is slow onset, with a long course of illness, low fever, burnout, loss of appetite, cough and a small amount of hemoptysis. However, most patients had mild lesions with no significant symptoms and were found by X-ray health examination. It is also diagnosed with empty hemoptysis, and traces of his medical history may have mild systemic symptoms. A small number of patients were diagnosed as acute miliary tuberculosis or caseous pneumonia by X-ray because of sudden onset and prominent toxic and respiratory symptoms. Elderly patients with tuberculosis are easily covered by the symptoms of chronic bronchitis. Occasionally, undetected severe tuberculosis, because of secondary infection, has high fever, and even has developed to sepsis or respiratory failure before going to the doctor. In view of the fact that the clinical manifestations of tuberculosis are often diversified, in areas where the tuberculosis epidemic has been basically controlled and the incidence rate is low, medical personnel should especially recognize their atypical performance in daily medical treatment.

symptom

(a) systemic symptoms

It is characterized by low fever, fatigue, loss of appetite, weight loss, night sweats, etc. If the lung lesions progress and spread, they are often irregularly hot. Women may have menstrual disorders or amenorrhea.

(two) respiratory symptoms

Usually dry cough or a small amount of mucus sputum, secondary infection, sputum mucus purulent. About one-third of patients have varying degrees of hemoptysis, and blood in the sputum is mostly caused by telangiectasia of inflammatory lesions; moderate hemoptysis is associated with small vessel injury or rupture of the tumor due to cavities. After hemoptysis, there is often low fever, which may be caused by residual blood clots in the bronchioles or obstruction of bronchial infection; if fever continues to retreat, tuberculosis lesions should be considered. Sometimes indurated calcified tuberculosis lesions can be hemoptysis due to mechanical damage to blood vessels, or combined with bronchiectasis. Hemorrhagic shock can occur when hemoptysis occurs; occasionally, blood clots block the airway and cause suffocation. At this time, the patient is extremely irritated, nervous, struggling to sit up, chest tightness, shortness of breath, and convulsions, and should be rescued immediately.

When the inflammation of the lesion involves the parietal layer and the pleura, the corresponding chest wall has a tingling pain, which is generally not severe, and is aggravated by breathing and coughing. In chronic severe pulmonary tuberculosis, respiratory function is reduced, and progressive dyspnea and even hypoxia and cyanosis often occur. If you have a pneumothorax or a large amount of pleural effusion, the symptoms of dyspnea are particularly serious.

Sign

Early lesions are small or located deep in the lung tissue, and there are no abnormal signs. If the lesion is large, the respiratory movement of the affected side is weakened, the percussion is voiced, the breath sound is reduced during auscultation, or the bronchoalveolar breath sounds. Because tuberculosis occurs in the posterior segment of the upper lobe of the lung and the dorsal segment of the lower lobe, the upper and lower clavicle area is slightly turbid, and the sputum can be heard after coughing, which has reference significance for diagnosis. When extensive pulmonary fibrosis or pleural adhesions are thickened in the lung lesions, the affected thoracic cage is often depressed, the intercostal space is narrowed, the trachea is displaced and turbid, and the contralateral side may have compensatory emphysema sign.

Tuberculosis infection and the occurrence and development of tuberculosis

Tuberculosis is divided into two major categories: primary and continuing. The so-called primary tuberculosis refers to the lesions that occur in the lungs when the tuberculosis is first infected, and is common in children. At this time, the human body is less reactive, and the local reaction of the lesion is also mild, and the tuberculosis often reaches the lymph nodes along the lymphatic vessels. Secondary tuberculosis usually occurs in adults who have been infected with tuberculosis. At this time, the human body has certain immune and allergic reactions to tuberculosis. The bacteria are active in the lungs, and the lesions are mostly near the lung tip. Tuberculosis usually does not broadcast and lymph nodes, and it rarely causes blood to spread. However, the local inflammatory reaction in the lung is intense, and cheese-like necrosis and cavities are prone to occur. Obviously different from primary tuberculosis, it can be considered as the phenomenon of Koch in the human body.

The evolution from infection with tuberculosis to the formation of tuberculosis, and the common clinical types that result from it, are described below. It must be pointed out that most lesions can absorb dissipated or indurated calcification at some stage of the course of the disease, especially after the rational use of anti-tuberculosis chemotherapy drugs, it is easier to heal and healed. Only a small number of patients have deteriorated due to low or poor treatment.

First, the original hair tuberculosis

When the body's resistance is reduced, the inhaled tuberculosis forms an exudative foci in the lungs, and the site is mostly in the upper, middle or lower part of the upper lobe (larger part of the lung ventilation), causing lymphadenitis and lymphangitis. Caseous necrosis can occur in both the lesion and the lymph nodes. The primary lesion of the lung, lymphangitis and local lymphadenitis, collectively referred to as the primary syndrome. The original type of tuberculosis occurs mostly in children, and can also be found in adults in remote mountainous areas and rural areas entering the city for the first time. Most patients can be asymptomatic, or have only mild symptoms like a cold, such as low fever, light cough, loss of appetite, weight loss, etc., which will improve in a few weeks. X-ray shows the primary lung, lymphatic vessels and lymph nodes in the lungs. Most lesions can absorb or calcify on their own. If the primary lesion in the lung is close to the pleura, it can cause pleurisy when the body is in an allergic state. Primary lung lesions usually absorb faster, generally do not leave traces or only become small calcifications, hilar lymphadenitis can be prolonged and spread to adjacent mediastinal lymph nodes. If the enlarged hilar lymph nodes compress the bronchi, it can lead to atelectasis, distal lung inflammation, or secondary bronchiectasis. The hilar or mediastinal lymph node tuberculosis is more common than the primary syndrome.

The primary lesion of the lung, lymphangitis and local lymphadenitis, collectively referred to as the primary syndrome.

The primary lung of the original tuberculosis, especially the tuberculosis in the hilar lymph node, often enters the blood circulation and spreads to various organs of the body, but often the body is resistant to the disease, so that the lesion is confined to the lungs. The tip (or upper part of the lung), bone, brain, liver, genitourinary organs, etc. gradually heal, but the tuberculosis bacteria in it can survive for a long time and become a possibility of recurrence (formation of secondary tuberculosis).

Second, blood line spread type tuberculosis

This type is the more serious of all types of tuberculosis. Mostly developed from the original type of tuberculosis, but most of the adults are caused by extrapulmonary tuberculosis (such as cheese-like lesions of the genitourinary organs) ruptured to the blood vessels.

Acute miliary tuberculosis is part of acute systemic disseminated tuberculosis. It has acute onset, systemic toxic symptoms, often accompanied by tuberculous meningitis, and X-ray shows that both lungs are densely meshed and clear. The miliary shadows, about 2 mm in diameter, are roughly equal in size and density. The first chest X-ray may have no obvious miliary shadow, or only diffuse reticular changes may be misdiagnosed as other febrile diseases such as typhoid fever and sepsis.

The lungs are covered in a dense mesh shadow, with a clear miliary shadow, with a diameter of about 2 mm, and the size and density are roughly equal.

If the body's resistance is strong, a small amount of tuberculosis bacteria enters the lungs through the circulation of blood. The blood-scattering lesions are often uneven in size, old and new, and are symmetrically distributed in the middle of the lungs, called subacute or chronic blood. Disseminated tuberculosis. The disease develops slowly, usually without significant symptoms of poisoning, and the patient may have no symptoms, even when X-ray examination is found. At this time, the lesions are more stable or have been hardened to heal.

Invasive pulmonary tuberculosis

It is the most common type of tuberculosis, and its symptoms, signs and X-ray findings may vary greatly depending on the nature, extent and stage of development of the lesion.

Most of the tuberculosis bacteria that are latent in the lungs due to dissemination of the blood through the blood (hidden bacteremia) gradually die. When the human immunity is reduced, the tuberculosis cells that are lurking in the lesions have the opportunity to reproduce and form exudation. A cheese-like lesion with a predominantly cell infiltration and varying degrees is called invasive pulmonary tuberculosis (endogenous infection). The primary lesion may also progress directly to infiltrating pulmonary tuberculosis.

Most of the tuberculosis bacteria that are latent in the lungs due to dissemination of the blood through the blood (hidden bacteremia) gradually die. When the human immunity is reduced, the tuberculosis cells that are lurking in the lesions have the opportunity to reproduce and form exudation. A cheese-like lesion with a predominantly infiltrating cell with varying degrees.

In addition, close contact with patients with tuberculosis, repeated respiratory infections, infiltration of tuberculosis due to reinfection (exogenous infection), but less common, and no bacteremia. Invasive pulmonary tuberculosis is mostly adult patients, with slow onset, early and small lesions, often without obvious symptoms and signs. It is often found by a health check or a chest X-ray for other reasons. Clinical symptoms depend on the extent of the lesion and the reactivity of the human body. I was in the upper and lower part of the clavicle, and the X-ray showed a patchy, floc-like shadow with blurred edges. When the human body is in an allergic state, and a large number of tuberculosis bacteria enter the lungs, the lesions are necrotic and liquefied, and then the bronchial spread of the cavity and the lesion is formed. Invasive pulmonary tuberculosis with large caseous necrotic foci, often acute progression, severe toxicity symptoms, clinically known as cheese-like (or tuberculous) pneumonia. After the cheese-like necrotic area is partially dissipated, a fibrous envelope is formed around it; or the drainage bronchus of the cavity is blocked, and the cheese in the cavity is difficult to be discharged, and it is condensed into a spherical lesion, which is called "tuberculosis ball".

When the lesion is in the stage of inflammatory exudation, cell infiltration, and even caseous necrosis, after appropriate anti-tuberculosis chemotherapy, the inflammation absorption dissipates, leaving a small cheese-like lesion surrounded by fibers, gradually losing water and drying, and even calcification, becoming a residual knot. A nodular lesion, called a fiber induration lesion or clinical recovery. Effective chemotherapy can make the cavity gradually shrink, close, or the hollow tissue defect still exists, and the tuberculosis bacteria have been completely eliminated, called "open cavity healing."

Fourth, chronic fibrovascular tuberculosis

Tuberculosis was not discovered or treated improperly, the cavity was long-term unhealed, the cavity wall was thickened, and the lesions were extensively fibrotic; the random body immunity fluctuated, the lesions were absorbed, repaired and deteriorated, and the progress alternated, becoming chronic fibrovascular tuberculosis. The lesions often have repeated bronchial dissemination, lesion absorption, repair and deterioration, and alternating development, becoming chronic fibrovascular tuberculosis. The lesions often have repeated bronchial dissemination, the course of disease is prolonged, the symptoms are ups and downs, and tuberculosis is present in the sputum, which is an important source of infection for tuberculosis. X-ray shows single or multiple thick-walled cavities on one or both sides, often accompanied by bronchial disseminated lesions and significant pleural thickening. Due to the contraction of the lung tissue fibers, the hilar is pulled upward, the lung pattern is in the shape of a weeping willow, and the mediastinum is pulled toward the diseased side. Adjacent or contralateral lung tissue often has compensatory emphysema, often complicated by chronic bronchitis, bronchiectasis, secondary infection or chronic pulmonary heart disease. Extensive destruction of lung tissue, fibrous tissue hyperplasia, further leading to contraction of the lung or whole lung ("destroy the lungs"). Such changes can be seen as a legacy of secondary tuberculosis.

Single or multiple thick-walled cavities on one or both sides, often accompanied by bronchial disseminated lesions and significant pleural thickening. Due to the contraction of the lung tissue fibers, the hilar is pulled upward, the lung pattern is in the shape of a weeping willow, and the mediastinum is pulled toward the diseased side.

Five, cheese pneumonia (tuberculous lobar pneumonia)

More common in the body weakened infected with tuberculosis, mostly caused by bronchial lymph node necrosis through the bronchial to the lobe, or by the rapid deterioration of invasive tuberculosis. There are more right upper lobe, initially large exudative lesions, rapid cheese necrosis, dissolution and formation of wallless cavities, patients with severe symptoms of poisoning, rapid failure, right upper lobe may have physical signs. Blood counts of white blood cells and neutrophils often increase, and erythrocyte sedimentation rate increases. Mycobacterium tuberculosis can be positive after 2 to 3 weeks of onset. X-ray chest X-ray: visible shadows with uneven density in the upper right lobe, which dissolve rapidly in a dozen days or weeks, forming a serigraphy cavity, which can have bronchial dissemination.

Six, tuberculous pleurisy

It is a pleural inflammation caused by infection with Mycobacterium tuberculosis. Clinically, it is often divided into three types: dry pleurisy, exudative pleurisy, and tuberculous empyema (rare).

The onset can be urgent and slow, and more rapid. Symptoms of systemic poisoning include: moderate to high fever, night sweats, fatigue, general malaise, etc. Local symptoms may have chest pain, dry cough, and a large number of pleural effusions may have shortness of breath, chest tightness, sitting breathing and purpura.

Dry pleurisy has limited respiratory movements on the affected side, local tenderness, pleural friction, and auscultation with pleural friction. When there is more pleural effusion in exudative pleurisy, the affected side is full of thoracic, the intercostal space is widened, the respiratory motility and vocal fibrillation are weakened, the trachea and heart are shifted to the healthy side, and the dull sound is deducted below the liquid level, and the breath sound is weakened or disappeared. There may be bronchoalveolar breath sounds above the liquid level, occasionally small blisters. The liver dullness disappeared when the right pleural effusion was present. If there is partial pleural adhesion to the pleural adhesion, the respiratory movement is limited to the dullness and the breath sound is weakened.

Seven, other extrapulmonary tuberculosis

Other extrapulmonary tuberculosis is named according to the location and organs, such as: bone and joint tuberculosis, tuberculous meningitis, kidney tuberculosis, intestinal tuberculosis, etc.

In summary, the clinical evolution of tuberculosis is a reflection of the contrast between the human body and tuberculosis. When the human body has strong resistance and regular treatment, the lesions can be dissipated and absorbed, or indurated calcification and tend to fall ill; on the contrary, if the human body has low resistance and fails to be treated properly, the lesion can be necrotic, liquefied, and voided. Deteriorating development. If the condition is repeated, the deterioration and repair occur alternately, the new and old lesions can exist at the same time, and further merge with emphysema and pulmonary heart disease.

diagnosis:

1. There is a history of close contact with tuberculosis, or a history of tuberculosis that is easily induced or complicated. In the past, patients with tuberculous pleurisy, cervical lymphatic tuberculosis or anal fistula have been diagnosed.

2. Have early symptoms of tuberculosis, such as cough, blood in the sputum, long-term low fever, weight loss, loss of appetite, fatigue, night sweats, etc.

3. Hearing a wet voice in the fixed part of the supraclavicular, inferior or scapular region, especially at the end of the cough and then inhaling the hearing, is meaningful for the early diagnosis of tuberculosis.

4. Mycobacterium tuberculosis was found in sputum, blood sedimentation accelerated, and mycobacterial positive was detected by PCR.

5. Imaging examination of the lesions with blurred edges and irregular cloud-like shadows or voids, new diffuse lesions, helpful for the diagnosis of tuberculosis in the advanced stage of activity.

Identification

The clinical and X-ray findings of tuberculosis are often similar to many non-tuberculous lung diseases and are easily misdiagnosed. It must be emphasized that according to the comprehensive analysis of medical history, relevant laboratory examination data, X-ray films, etc., the necessary fashion needs dynamic observation and careful identification.

First, lung cancer

Central type of lung cancer often has blood in the sputum, with shadows near the hilar, similar to hilar lymph node tuberculosis. Peripheral lung cancer can be spherical and lobulated, and needs to be differentiated from tuberculosis. Lung cancer is more common in men over 40 years old; often no obvious signs of toxicity, more irritating cough, chest pain and progressive weight loss. X-ray chest radiograph shows satellite lesions and calcification around the tuberculosis ball, and the edge of the cancer lesion often has notch and burr. Chest CT scan is often helpful in identifying the two. CT findings of central lung cancer have a thickened bronchial soft tissue patch attached to one side of the thickened bronchial wall. The contour of the mass is irregular, the lung segment and the lobes of the lung are irregularly narrow, and the mediastinum Lymph node enlargement, etc. Combined with tuberculosis, exfoliated cell examination and fiberoptic bronchoscopy and biopsy, it can often be identified in time. The coexistence of lung cancer and tuberculosis should also be noted. Clinically, it is difficult to completely eliminate lung cancer. In combination with specific conditions, if necessary, you should consider thoracotomy to avoid delay in treatment.

Second, pneumonia

Typical pneumococcal pneumonia is not difficult to distinguish from invasive pulmonary tuberculosis. The infiltrating pulmonary tuberculosis, which progresses faster, expands to the entire lobes and forms caseous pneumonia, which is easily misdiagnosed as pneumococcal pneumonia. The former has a rapid onset, high fever, chills, chest pain and shortness of breath, cough and rust, and X-ray signs are often limited to one leaf, and antibiotic treatment is effective. Case-like pneumonia has many symptoms of tuberculosis, slow onset, coughing yellow mucus, X-ray signs are mostly located in the right upper lobe, which can affect the right upper tip and the back, which are cloud-like, uneven density, and can appear The eclipse is empty. Anti-tuberculosis treatment is effective, and tuberculosis is easy to find.

Symptoms of inflammation on the X-ray with mild cough, hypothermia, mycoplasma pneumonia, or allergic pneumonia (eosinophilic pulmonary infiltrates), similar to early invasive pulmonary tuberculosis, for such cases that are difficult to identify at one time, Do not rush to anti-tuberculosis treatment. Mycoplasmal pneumonia usually dissipates spontaneously in a short period of time (2 to 3 weeks); the infiltrating shadow of allergic pneumonia is often migratory, and eosinophils in the blood increase.

Third, lung abscess

Pulmonary abscess cavity is more common in the lower lobe of the lung. The inflammation around the abscess is more serious, and there is often a liquid level in the cavity. Tuberculosis cavities occur mostly in the upper lobe of the lungs, the walls of the cavity are thinner, and there are few liquid levels in the cavity. In addition, lung abscess is more acute, high fever, a lot of purulent sputum, no tuberculosis in the sputum, but there are many other bacteria, the total number of white blood cells and neutrophils, antibiotic treatment is effective. Chronic fibrosis-type pulmonary tuberculosis is easily confused with chronic lung abscess when it is infected, and the latter is negative for tuberculosis.

Fourth, bronchiectasis

Chronic cough, sputum and repeated hemoptysis need to be differentiated from chronic fibrovascular tuberculosis. However, the bronchiectasis of the bronchiectasis was negative, and there were no abnormalities in the X-ray chest radiographs or only partial thickening of the lungs or curling shadows. CT helped confirm the diagnosis.

Fifth, chronic bronchitis

The symptoms of chronic bronchitis in the elderly are similar to those of chronic fibrovascular tuberculosis. In recent years, the incidence of tuberculosis in the elderly has increased. It is necessary to carefully identify the two, and timely X-ray examination can help to confirm the diagnosis.

Sixth, other febrile diseases

Various types of tuberculosis often have different types of fever, so tuberculosis is often one of the main causes of clinical fever. Typhoid, sepsis, leukemia, mediastinal lymphoma and sarcoidosis are similar to tuberculosis. Typhoid fever has high fever, decreased white blood cell count and clinical manifestations of liver and spleen, which is easily confused with acute miliary tuberculosis. However, typhoid fever type often presents with heat retention, relatively slow pulse, skin rose rash, positive serum typhoid agglutination test, blood and fecal typhoid culture positive. Septicemia onset, chills and relaxation of heat, white blood cells and neutrophils, often have recent skin infections, history of squeezing or urinary tract, biliary tract infections, common skin defects, migration in the course of the disease Infected or septic shock, blood or bone marrow culture can be found in pathogenic bacteria. Acute miliary tuberculosis has fever, hepatosplenomegaly, and specific X-ray findings appear several weeks after onset. Occasionally, the blood picture shows a leukemia-like reaction or an abnormal increase in monocytes, which needs to be differentiated from leukemia. The latter has a significant tendency to hemorrhage, and bone marrow smear and dynamic chest X-ray follow-up can help establish a diagnosis. Adult bronchial lymphatic tuberculosis often manifests as fever and hilar lymphadenopathy, and should be differentiated from sarcoidosis and mediastinal lymphoma. Tuberculosis patients with positive test, anti-tuberculosis treatment is effective; and lymphoma develops rapidly, often with liver and spleen and superficial lymph nodes, the diagnosis often depends on biopsy. Sarcoidosis usually does not produce fever, and hilar lymphadenopathy is mostly bilateral, with a negative test of lignin, effective glucocorticoid therapy, and biopsy should be performed if necessary to confirm the diagnosis.

The above is only a few major common diseases. In the specific identification, it is necessary to comprehensively grasp and analyze the diagnosis basis of the tuberculosis patients have, and should be familiar with the characteristics of such easily confused diseases. Try to check as much as possible, but also carefully observe and strictly compare and judge.

complication:

Since the widespread use of anti-tuberculosis drugs, complications of tuberculosis tube dissemination, such as laryngeal and intestinal tuberculosis, have been rare.

1. Pneumothorax pulmonary cavity and cheese-like lesions close to the pleural site, can cause tuberculous pus. Miliary tuberculosis can cause bilateral spontaneous pneumothorax.

2. Endobronchial stenosis is caused by endobronchial lesions.

3. Bronchiectasis tuberculosis lesions repeatedly progress and fibrosis, resulting in the destruction of the normal structure of the bronchus in the lungs, can cause secondary bronchiectasis, often repeated hemoptysis. Often located in the upper lobe, called dry branch expansion. Can cause fatal hemoptysis.

4. The pleural effusion of empyema exudative pleurisy, if not treated in time, can be gradually cheeseified or even purulent, becoming tuberculous empyema. It is the result of the progression of cardiovascular and cavitary lung tuberculosis infection, often occurring after pneumothorax, accompanied by failure and loss of resistance to infection.

5. Pulmonary aspergillosis is common in tuberculous cavities. Hemoptysis is the leading cause of death in this disease.

6. Chronic pulmonary heart disease caused by severe pulmonary tuberculosis caused by extensive destruction of lung tissue. Chronic fibrovascular tuberculosis or one-sided lung damage, complicated by emphysema, bullous bullae, can cause spontaneous pneumothorax, can also lead to chronic heart disease, and even cardiopulmonary failure.

In the primary infection, tuberculosis is distributed along with the blood, and is lurking in other organs. Once the human immunity is extremely weak, tuberculosis of the organ can be produced, and lymph nodes, meninges, bones, and genitourinary tuberculosis are common.

AIDS is prone to secondary tuberculosis or non-tuberculous mycobacterial infections. In some developed countries, the tuberculosis epidemic has been significantly reduced, but due to the AIDS epidemic, Pneumocystis carinii, cytomegalovirus infection and tuberculosis patients have increased. In developing countries, the main complication of human immunodeficiency virus (HIV) infection and AIDS patients is tuberculosis infection, which is common in the old obsolete tuberculosis (endogenous recurrence). At the same time, suffering from tuberculosis and AIDS, its diagnosis is difficult, the curative effect is poor, and the mortality rate is high.

treatment:

Western medicine treatment

Anti-tuberculosis chemotherapy treatment plays a decisive role in controlling tuberculosis. Rational chemotherapy can eliminate the bacteria in the lesion and eventually heal. Resting with nutritional therapy only serves as an auxiliary.

First, anti-tuberculosis chemotherapy treatment (referred to as chemotherapy)

(1) Principles of chemotherapy

The main role of chemotherapy is to shorten the infection period, reduce mortality, infection rate and prevalence. For each specific patient, in order to achieve the main measures of clinical and biological cure, rational chemotherapy refers to the principle of adhering to the early, combined, appropriate, regular and full use of sensitive drugs for active tuberculosis. The so-called early refers to the early treatment of patients, once the diagnosis and diagnosis, immediately after administration; combined refers to the combination of two or more drugs according to the characteristics of the disease and anti-tuberculosis drugs to enhance and ensure the efficacy; appropriate amount refers to different conditions and Different individuals stipulate different doses to be administered; even if the patient must strictly follow the prescription method prescribed by the chemotherapy regimen, the patient should be treated regularly, and the program should not be arbitrarily changed or stopped without any reason, and the drug should not be used at random; the whole process means that the patient must follow the plan. The prescribed course of treatment is consistent with the course of treatment, and short-course chemotherapy is usually 6 to 9 months. In general, newly diagnosed patients are treated according to the above principles, with a therapeutic effect of 98% and a recurrence rate of less than 2%.

Active tuberculosis is an indication for chemotherapy. There is no need for chemotherapy for indurated lesions. As for partial induration and sputum negative, one stage can be observed. If the X-ray lesion has no activity, the sputum is still negative, and there is no obvious tuberculosis toxicity, no chemotherapy is needed.

1. Early, combined, appropriate, regular, and full-time active lesions are in the exudation stage, or there is caseous necrosis or even cavity formation. The tuberculosis bacteria in the lesions are mainly group A, with strong growth and metabolism, and anti-tuberculosis drugs. It can exert the maximum bactericidal or bacteriostatic effect. The local blood supply of the lesion is rich, and the drug concentration is also appropriate, which helps to promote the absorption of inflammatory components, shrinking or closing the cavity, and turning the bacillus into the yin. Therefore, the early rational chemotherapy for active lesions is satisfactory.

Experiments have shown that there are about 106 to 1010 tuberculosis bacteria per 1 g of cheese stove or cavity tissue. Tuberculosis bacteria that have never been exposed to anti-tuberculosis drugs are not exactly the same. About one out of every 105 to 106 tuberculosis bacteria is resistant to isoniazid or streptomycin due to genetic mutations. At the same time, only one of the 1011 tuberculosis bacteria was resistant to the two drugs, and fewer bacteria were resistant to the three drugs. It can be seen that if a single drug is used, although some sensitive bacteria can be eliminated, it is possible to leave a few resistant bacteria to continue to multiply, and finally the resistant bacteria grow. If two or more drugs are used in combination, the drug-resistant bacteria are reduced, and the effect is better than that of the single drug.

The dosage should be appropriate, the dose is insufficient, the drug information in the tissue can reach the effective concentration, and the bacteria are prone to secondary resistance. If the dose is too large, it may cause adverse reactions. Tuberculosis grows slowly, sometimes only occasionally (B, C flora), so the drug should be kept at an effective concentration for a long time in the body. Regular medication throughout the course, but early withdrawal is the key to successful chemotherapy.

2. The drug concentration in the blood of the drug and tuberculosis (including macrophages) can be bactericidal at a conventional dose of 10 times or more of the minimum inhibitory concentration (MIC) in the test tube, otherwise it will only have a bacteriostatic effect. Conventional amounts of isoniazid and rifampicin can reach this level both inside and outside the cell, called full fungicide. Streptomycin and pyrazinamide are also fungicides, but streptomycin can exert its maximum effect in an alkaline environment, and rarely infiltrates into phagocytic cells, and is ineffective against intracellular tuberculosis. Although pyrazinamide can penetrate into phagocytic cells, it only has a bactericidal effect in an acidic environment, so both can only be used as semi-bactericides. Ethylamine butanol and sodium p-aminosalicylate are all bacteriostatic agents. The drug concentration in conventional doses can not reach 10 times of MIC. If the dosage is increased, adverse reactions are likely to occur.

Most of the tuberculosis bacteria in the early lesions are outside the cell. At this time, the bactericidal effect of isoniazid is the strongest, followed by streptomycin. Inflammation causes the local pH of the tissue to decrease, and the bacterial metabolism to slow down (C flora), along with some tuberculosis bacteria (B flora) that are phagocytosed in the cells, which are sensitive to rifampicin and pyrazinamide. Killing such residual bacteria (B flora) helps to reduce future recurrence.

(two) chemotherapy methods

1, "standard" chemotherapy and short-course chemotherapy used to routinely use 12 to 18 months of treatment, called "standard" chemotherapy, but because of the long course of treatment, many patients can not be completed, the efficacy is limited. Since the advent of rifampicin, it has been combined with other drugs and found that 6 to 9 months of treatment (short-course chemotherapy) has the same effect as standard chemotherapy. Therefore, short-course chemotherapy is widely used, but the requirement must include two kinds of bactericidal drugs. Haze and rifampicin have strong sterilization (for group A) and sterilization (for group B and C).

2,. Intermittent medication, two-stage medication experiments show that tuberculosis often delays growth for several days after several hours of contact with the drug. Therefore, regular administration of medication 3 times a week (intermittent medication) can achieve the same effect as daily medication. Within 1 to 3 months of starting chemotherapy, daily medication (enhancement phase), and intermittent medication 3 times per week (consolidation phase), the effect is basically the same as daily medication, which is conducive to supervising medication and ensuring complete chemotherapy. When using intermittent therapy with 3 times a week, it should still be combined. Each dose of isoniazid, rifampicin, ethambutol can be increased appropriately; but streptomycin, sodium p-aminosalicylate, B There are many adverse reactions such as sulphonic acid, and the dosage should not be increased each time (Table 1).

Table 1 Adult doses and major adverse reactions of commonly used anti-tuberculosis drugs

Drug name abbreviation daily dose (g) intermittent therapy one day (g) bacteriostatic mechanism main adverse reactions

Isoniazid H, INH 0.30.6 ~ 0.8 DNA synthesis of peripheral neuritis, occasional liver damage

Rifampicin R, RFP 0.45～0.6*0.6～0.9 mRNA synthesis liver function damage, allergic reaction

Streptomycin S, SM0.75～1.0△0.75～1.0 protein synthesis hearing impairment, dizziness, renal dysfunction

Pyrazinamide Z, PZA 1.5～2.02～3 pyrazinic acid bacteriostatic gastrointestinal discomfort, liver function damage, hyperuricemia, joint pain

Ethambutol E, EMB0.75~1.0**1.5~2.0RNA synthetic optic neuritis

Sodium aminosalicylate P, PAS8～12***10～12 intermediate metabolic gastrointestinal discomfort, allergic reaction, liver function damage

Synthesis of gastrointestinal discomfort and liver function damage by profenamide 1321Th0.5～0.750.5～1.0 protein

Kanamycin K, KM0.75~1.0△0.75～1.0 protein synthesis hearing impairment, dizziness, renal dysfunction

Capreomycin Cp, CPM0.75~1.0△0.75~1.0 protein synthesis of hearing impairment, dizziness, renal dysfunction

Note: * Weight <50kg with 0.45, ≥50kg with 0.6; S, Z, Th dosage is also adjusted according to body weight; * *25mg/kg for the first 2 months, then reduced to 15mg/kg; * * *2 points per day Take it (other medicines are once a day); △ 0.75g for the elderly every time.

3, supervise the use of drugs for anti-tuberculosis drugs for at least six months, even for up to a year and a half, patients often difficult to adhere to. It is especially necessary for medical staff to supervise the use of medicines on time and strengthen visits. In the intensive phase, once a day, the peak blood concentration can be formed, which is better than the daily divided drug, and is convenient for the patient, and improves the patient's adherence rate and completes the whole process.

(three) anti-tuberculosis drugs

The ideal anti-tuberculosis drug has the functions of sterilization, sterilization or strong bacteriostasis, low toxicity, reduced adverse reactions, low cost, convenient use, sufficient drug source; the drug can reach an effective concentration in the blood after oral or injection, and It can penetrate into phagocytic cells, peritoneal cavity or cerebrospinal fluid, and the effect is rapid and long-lasting.

1. Isoniazid (H) has the advantages of strong bactericidal power, oral administration, less adverse reactions, and low cost. Its role is mainly to inhibit the synthesis of tuberculosis deoxyribonucleic acid (DNA) and hinder the synthesis of bacterial cell walls. After oral administration, it absorbs quickly, penetrates into the tissue, and passes through the blood-brain barrier to kill metabolically active or static tuberculosis inside and outside the cell. The concentration of drugs in pleural fluid, cheese-like lesions and cerebrospinal fluid is also quite high. The usual dose is 300mg (or 4-8mg/kg per day) for adults, once orally; 5-10mg/kg per day for children (not more than 300mg per day). The dose of tuberculous meningitis and acute caste tuberculosis can be increased appropriately (increased dose may be complicated by peripheral neuritis, can be prevented by vitamin B6 300mg daily; but large doses of vitamin B6 can also affect the efficacy of isoniazid, so use In general doses of isoniazid, it is not necessary to add vitamin B6), and the normal dose can be restored after the acute toxicity symptoms are alleviated. Isoniazid is inactivated by acetylation in the body, and the rate of acetylation often has individual differences. The rapid acetylation has a lower blood concentration, and it is considered that the dose must be increased when intermittently administered.

There are few adverse reactions in the conventional dose of this drug, occasionally peripheral neuritis, central nervous system poisoning (excitation or inhibition), liver damage (increased serum alanine aminotransferase). After using isoniazid for 3 months alone, the resistance rate of sputum bacteria can reach 70%.

2. Rifampin (R) is a semisynthetic derivative of rifamycin, which is a broad-spectrum antibiotic. Its mechanism for killing tuberculosis is to inhibit the RNA polymerase of the cells and hinder their mRNA synthesis. Rifampicin has a role in intracellular and extracellular metabolism and occasionally propagated tuberculosis (A, B, C bacteria), often combined with isoniazid. Adults once a day, oral administration of 450 ~ 600mg. The drug has mild adverse reactions, except for digestive tract discomfort and flu syndrome, and occasional transient liver damage. Long-acting rifamycin derivatives such as rifapentine (DL473) have a long half-life in humans and are administered orally once a week. The effect is similar to that of daily rifampicin. Helix piperidine rifamycin (ansamycin, LM427, rifabutin) is more potent than rifampicin in certain strains that have failed other anti-tuberculosis drugs, such as Mycobacterium avium.

3. Streptomycin (S) is a broad-spectrum aminoglycoside antibiotic that has a bactericidal effect on tuberculosis, can interfere with the enzyme activity of tuberculosis, and hinder protein synthesis. It has less effect on intracellular tuberculosis. Dosage: 1 g per day for intramuscular injection in adults (0.5 to 0.75 g for those over 50 years old or with renal dysfunction). Intermittent therapy was given twice a week, 1 g per muscle injection. Pregnant women should be used with caution.

The main adverse reaction of streptomycin is the 8th cranial nerve damage, which is characterized by dizziness, tinnitus, deafness, severe cases should be discontinued in time, and severe renal impairment should not be used. Other allergic reactions include rash, exfoliative dermatitis, drug fever, etc., anaphylactic shock is less common. Drug use alone is susceptible to drug resistance. Other aminoglycoside antibiotics, such as kanamycin, capreomycin, and zirconia, also have anti-tuberculosis effects, but the effects are not as good as streptomycin, and the adverse reactions are similar.

4, pyrazinamide (Z) can kill TB cells in the acidic environment of tuberculosis. Dosage: 1.5g daily, 3 times orally, occasionally adverse reactions such as hyperuricemia, joint pain, gastrointestinal discomfort and liver damage.

5, ethambutol (E) has a bacteriostatic effect on tuberculosis, when combined with other anti-tuberculosis drugs, can delay the resistance of bacteria to other drugs. Dosage: 25mg/kg, once a day orally, changed to 15mg/kg after 8 weeks, the adverse reactions are rarely the advantage, occasionally gastrointestinal discomfort. When the dose is too large, it can occlude posterior optic neuritis, vision loss, visual field reduction, central blind spots, etc., once the drug is stopped, it can recover.

6, rightAminosalicylic acidSodium (sodium para-aminosalicylate. P) is a bacteriostatic agent that can be combined with streptomycin, isoniazid or other anti-tuberculosis drugs to delay drug resistance to other drugs. Its antibacterial effect may compete with para-aminobenzoic acid (PABA) during the synthesis of tuberculosis folic acid, affecting the metabolism of tuberculosis. Dosage: 8-12 g per day for adults, orally every 2 to 3 times. Adverse reactions include loss of appetite, nausea, vomiting, and diarrhea. This medicine can reduce the gastrointestinal reaction after taking it. It can also be added to the 5% to 10% glucose solution 500ml daily in the dark, and it is still taken orally after 1 month.

(four) chemotherapy program

Choose a chemotherapy regimen depending on the severity of the disease, the presence or absence of bacilli and bacterial resistance, as well as the economic status and supply of the drug. Whatever you choose, you must be in compliance with the aforementioned chemotherapy principles.

1. In the case of initial treatment without anti-tuberculosis drugs, some sputum smear positive tuberculosis (smear positive), the condition is heavier and contagious; some smear negative, the lesion range is not large, the chemotherapy regimen used There are also differences in strength and weakness.

The initial treatment of smear positive cases, regardless of whether the culture is positive, can be used for a six-month short-course chemotherapy regimen based on the combination of isoniazid (H), rifampicin (R) and pyrazinamide (Z). The sputum is often turned negative and the treatment is short, which is convenient for follow-up management.

(1) Streptomycin (or ethambutol), isoniazid, rifampicin and pyrazinamide in the intensive phase for the first 2 months, once a day; continue to use isoniazid and rifamp in the next 4 months Flat, once a day, expressed in 2S (E) HRZ / 4HR.

(2) 2S(E)HRZ/4H3R3 can also be administered on the next day during the consolidation period (ie, 3 times a week). (The number in the lower right corner is the number of medications per week).

(3) It can also be administered intermittently throughout the process, represented by 2S3(E3)H3R3Z3/4H3R3.

(4) Isoniazid, streptomycin and sodium p-aminosalicylate (or ethylamine) were used during the intensive phase. The two drugs were used for 10 months in the consolidation period, and expressed as 2HSP(E)/10HP(E).

(5) Isolation period 1 month with isoniazid, streptomycin, consolidation period of 11 months, 2 times a week, expressed as 1HS/11H2S2.

The above (1), (2), and (3) are short-course chemotherapy regimens, and (4) and (5) are “standard schemes”. If possible, use a short-course chemotherapy regimen as much as possible.

In patients with newly diagnosed sputum sputum sputum, in addition to miliary tuberculosis or patients with obvious new social holes, the following chemotherapy regimens can be used: 12SHRZ/2H2R2; 23H2R2Z2/2H2R2 (all-day application); 31SH/11HP (or E).

For newly diagnosed patients, the International Hepatitis Prevention and Lung Disease Association recommended a chemical regimen for the national flood control (Table 2), which can be used as a reference for the development of treatment plans.

Table 2 National Tuberculosis Chemotherapy Program for Flood Control

Treatment chemotherapy regimen chemotherapy regimen

6 months 2RHZ/4RH8 months 2SRHZ/6TH or 6EH

2ERHZ/4RH or 4R2H22SRHZ/6S2H2Z2

2SRHZ/4RH or 4R2H2

2, re-treatment regimen initial treatment chemotherapy is unreasonable, tuberculosis produces secondary drug resistance, sputum bacteria continue to be positive, the disease is delayed. Retreatment cases should be combined with sensitive drugs. Drug susceptibility testing helps to select medications, but it takes longer and costs more. Clinically, depending on the patient's previous medication, choose rarely used ones that have not been used in the past, or have used the drugs in combination (possibly the pathogens are still sensitive to them), and the other schemes, combined with two or two The above sensitive drugs.

For retreatment cases, the following options are generally available:

(1) 2S (E) HRZ / 4HR, supervise chemotherapy, to ensure regular medication. At the end of the 6-month course, if the sputum has not turned negative, the consolidation period can be extended by 2 months. If the prophylaxis continues to be positive if the treatment is extended, the following retreatment regimen can be used.

(2) For patients who have failed treatment in the initial treatment, 2S3H3Z3E3/6H3R3E3 can be used.

(3) Chronic bacteria can be used in combination with sensitive first-line drugs and second-line drugs, such as kana toxin (K), prothionamide (1321Th), and capreomycin (Cp). Adverse drug reactions should be closely observed. It is suitable for 6 to 12 months. Fluoroquinolones have moderate anti-tuberculosis effects, and cases that have developed resistance to commonly used drugs can be added to the combination. If the sputum is overcast, or serious adverse reactions occur, they are all indications for withdrawal.

(5) Disease judgment and efficacy evaluation, treatment failure

1, the disease and efficacy assessment according to the extent of the activity of the disease can be divided into the advanced period, the absorption improvement period and the stable period. Generally, the period of improvement and the stable period of improvement are improved, and the progress period is worse. The judgment should be based on a comprehensive analysis of clinical symptoms, X-ray representation and baculation.

(1) Clinical symptoms: Pay attention to observe whether there are symptoms of tuberculosis deterioration and its procedures in the afternoon, such as low fever, night sweats, loss of appetite, lack of body, weight loss. The alleviation or disappearance of such symptoms suggests that the condition improves; if the symptoms are significant or slightly heavier, the condition is worse. In addition, changes in respiratory symptoms such as cough, cough, and hemoptysis can also be used as a reference.

(2) X-ray examination: it is an indispensable indicator for judging the condition, and it is also an important basis for monitoring the outcome of the disease. For patients without obvious clinical symptoms, X-ray examination is mainly used. X-ray can determine the location, extent and nature of the lesion. , and can observe the dynamic changes before and after the control. Cloud flocculent invasive lesions are absorbed, dissipated, and narrowed; or converted to high-density, well-defined proliferative lesions such as fibrosis and calcification; the original cavity shrinkage, closure, etc. indicate that the condition is improved or healed. Conversely, the transition from proliferative lesions to exudative lesions, or the extent of invasive lesions, bronchial dissemination or acute, subacute hematogenous dissemination, caseous necrotic lesions, cavity formation, etc. are all worsening.

(3) sputum bacteria: tuberculosis patients in the sputum or not is an important indicator to determine the condition of the procedure and assessment of efficacy. Moreover, the specificity of the sputum test is less disturbed by human factors. If the sputum continues to be positive, it is open tuberculosis, indicating a high degree of disease activity, and is a social source of TB, posing a threat to the surrounding population. Repeated examination after treatment, found that the amount of tuberculosis is small or negative, indicating that the period of improvement; if at least once a month, the negative for consecutive months, it indicates a stable period. Thereafter, if the bacteria is reappeared again, the lesion is deteriorated. Accelerated erythrocyte sedimentation indicates that the lesions are active and worse; however, active pulmonary tuberculosis does not have a erythrocyte sedimentation rate, and the lesions are improved. The erythrocyte sedimentation rate in the stable phase is almost normal.

2. At the end of the treatment failure, the sputum failed to turn negative, or turned to yang in the curative effect. X-ray showed that the lesion was not absorbed and stabilized, and further deteriorated, indicating that the treatment failed, forming so-called refractory pulmonary tuberculosis. In addition to infection with drug-resistant tuberculosis, irregular drug use, intermittent medication or monotherapy, some patients are allergic to chemotherapy drugs, can not use chemotherapy drugs or serious adverse reactions due to chemotherapy drugs, it is difficult to adhere to treatment, the body Immunity is low (HIV infected), poor physical fitness and other factors.

The prevalence of drug-resistant tuberculosis (DR-TB), especially multidrug-resistant tuberculosis (MDR-TB), is facing new challenges in anti-tuberculosis treatment. In 1994, the WHO and the International Association for the Prevention of Tuberculosis began a global plan for the monitoring of drug resistance to tuberculosis. The results of three years of work showed that monitoring of 35 countries on five continents representing 20% of the world's population found that it is resistant to HR. MDR-TB accounts for 2% to 14%, and most of them are secondary multidrug resistance caused by human factors such as single-agent, irregular, and irrational combination therapy. In countries with weak tuberculosis control, primary multidrug resistance is also on the rise. Once drug-resistant tuberculosis occurs, the chemotherapy drugs used are expensive, have poor efficacy, and have serious adverse reactions. The treatment cost can be 100 times that of new smear-positive pulmonary tuberculosis patients. Adhere to the rational use of chemotherapy, take comprehensive prevention measures, improve the body's immune function, etc., help prevent the occurrence of drug-resistant tuberculosis.

In order to effectively prevent treatment failure, the chemotherapy program must be correctly formulated, and patients should adhere to the early, appropriate, regular, and comprehensive use of sensitive drugs under supervision. The new chemotherapy regimen will only be changed if a serious adverse reaction has occurred or if the bacteria have been confirmed to be resistant. The new program should include more than two sensitive drugs.

Second, symptomatic treatment

(1) Symptoms of toxicity

The toxic symptoms of tuberculosis can disappear within 1 to week of effective anti-tuberculosis treatment, and usually do not require special treatment. Patients with caseous pneumonia, acute miliary tuberculosis, tuberculous meningitis with high fever and other serious tuberculosis symptoms, or tuberculous pleurisy with a large number of pleural effusions, should rest in bed and use anti-tuberculosis drugs as soon as possible. Can also use effective anti-tuberculosis drugs, plus glucocorticoids (usually prednisone, 15 ~ 20mg daily, divided into 3 or more times), to reduce inflammation and allergic reactions, promote exudate absorption, reduce fibrous tissue Formation and pleural adhesions. The symptoms of toxicity were alleviated, and the dose of prednisone was decreased, and the drug was discontinued after 6 to 8 weeks. Glucocorticoids have no effect on established pleural thickening and adhesion. Therefore, it should be used with caution on the basis of effective anti-tuberculosis treatment.

(two) hemoptysis

If only blood in the sputum or a small amount of hemoptysis, mainly symptomatic treatment, including rest, cough, sedation, commonly used drugs are spray vetoviline, soil root powder, codeine, Kabak network (Anluo blood). Elderly patients with debilitating and pulmonary dysfunction should be treated with strong antitussive drugs to avoid suffocation caused by inhibition of cough reversal and respiratory center. Other causes of hemoptysis, such as mitral stenosis, pulmonary infection, pulmonary infarction, coagulopathy, autoimmune diseases, etc., should be excluded.

When you have moderate or large amounts of hemoptysis, you should rest in bed strictly, place an ice pack on your chest, and match with blood. Take the lateral position and gently cough up the blood stored in the trachea. Pituitrin 10U was added to 20-30 ml of normal saline or glucose solution, and was intravenously injected (15 to 20 minutes), and then maintained intravenously with 10 to 40 U in 5% glucose solution 500 ml. Pituitary vasopressin has the function of contracting small arteries, including coronary arteries and capillaries, reducing pulmonary blood flow, thereby reducing hemoptysis. The drug can still shrink the uterus and smooth muscle, so it should not be used for patients with hypertension, coronary atherosclerotic heart disease and pregnant women. Excessive injection can cause adverse reactions such as nausea, impotence, palpitations, and pale complexion.

If the amount of hemoptysis is too much, appropriate blood transfusions may be used as appropriate. If the hemoptysis is not enough, the bleeding site can be found by fiberoptic bronchoscopy, and local instillation is carried out with norepinephrine 2~4mg+4°C physiological saline 10-20ml. Or use a bronchoscope to place Fogarty balloon catheter (outer diameter 1mm, inflated 0.5 ~ 5.0ml) to block bleeding at the bleeding site. In addition, the Kinoshita method can be used to treat hemostasis with thrombin or fibrinogen via bronchoscopy. If necessary, adequate preparation should be made for rescue. Repeated massive hemoptysis with the above method is ineffective, the contralateral lung has no active disease, the lung function reserve is acceptable, and there is no obvious contraindication, the lung lobe and segmentectomy can be considered in the case of clear bleeding site.

Hemoptysis is the main cause of hemoptysis. It needs to be strictly guarded and actively prepared for rescue. The symptoms of hemoptysis include chest tightness, suffocation, lip blemishes, pale face, cold sweat, and restlessness. Rescue measures should be specially injected to keep the airway open, take a prone position with a head low of 45°, pat the back, quickly drain the blood, and excavate or suck the blood clots of the outlet, throat, throat and nose as soon as possible. It is necessary to use a rigid bronchoscope to attract, endotracheal intubation or tracheotomy to relieve airway obstruction.

Third, surgical treatment

Surgery has been less used in the treatment of tuberculosis. For tuberculosis spheres larger than 3cm and lung cancer difficult to identify, re-treatment of unilateral fiber thick-walled cavity, long-term medical treatment failed to make the sputum negative, or unilateral damaged lung with bronchiectasis, has lost function and has repeated Hemoptysis or secondary infection can be used for lobectomy or pneumonectomy. Pulmonary pleural resection is recommended for tuberculous empyema and/or bronchial pleural effusion after medical treatment is ineffective and with ipsilateral active pulmonary tuberculosis. Surgical treatment contraindications are: bronchial mucosal active tuberculosis lesions, but not within the scope of resection, poor general condition or obvious heart, lung, liver, kidney dysfunction.

Surgical treatment accounts for only a small portion of tuberculosis treatment, and the most important treatment is a specific anti-tuberculosis drug. After years of practice, there are mature experiences in the treatment of tuberculosis, and there are standardized treatment methods. Surgery is considered only if the drug treatment failure is not effective. Patients with anti-tuberculosis drugs should be applied without exception before and after surgery.

In 1993, China's thoracic surgery in the field of tuberculosis, lung cancer surgery indications academic seminar, proposed to meet the current clinical actual tuberculosis surgery indications.

Indications for cavitary tuberculosis surgery:

1 After treatment with anti-tuberculosis drugs and re-treatment (about 18 months), there is no obvious change or increase in cavities, and those with positive sputum, especially those with tuberculosis resistance

2 such as repeated hemoptysis, secondary infection (including fungal infection), etc.

3 can not rule out cancerous hollows

4 atypical mycobacteria, lung cavity chemotherapy is not effective or high.

Indications for tuberculosis surgery:

1 tuberculosis ball treated with regular anti-tuberculosis for 18 months, sputum positive, hemoptysis

2 tuberculosis can not exclude lung cancer

3 tuberculosis diameter > 3cm, no change under regular chemotherapy, for relative surgical indications.

Indications for damaged lung surgery: There are still bacteria, hemoptysis and secondary infections after regular anti-tuberculosis treatment.

Surgical indications for hilar mediastinal lymphadenopathy

1 ruled anti-tuberculosis treatment, lesion enlargement

2 lesions compress the trachea, bronchi caused severe dyspnea

3 lesions pierced the trachea, bronchus caused atelectasis, caseous pneumonia, medical treatment is invalid

4 can not rule out mediastinal tumors.

Large hemoptysis emergency surgery indications

124h hemoptysis>600ml, invalid after medical treatment

2 bleeding site is clear

3 cardiopulmonary function and general condition permit

4 repeated large hemoptysis, there have been suffocation, suffocation aura or hypotension, shock.

Spontaneous pneumothorax surgery indications

1 multiple pneumothorax (2 to 3 times or more)

2 patients with closed thoracic drainage for more than 2 weeks continue to leak

3 liquid gas chest with early signs of infection

4 blood gas chest after thoracic closed drainage after the lung is not re-expanded

5 pneumothorax combined with obvious pulmonary bullae

6 patients with a history of pneumothorax on the side and the opposite side should be operated early.

1. Preparation before pneumonectomy

(1) Chest X-ray examination: This is the main basis for determining the indications and surgical methods of surgery. To collect all the X-ray chest radiographs after onset, to understand the stability of the lesions and whether the lesions are disseminated, X-ray films within 1 month before surgery to see if there are any new lesions; residual lesions or fibrosis on X-ray It can also have a greater impact on lung function, and if necessary, preoperative CT examination can better show small lesions.

(2) TB tuberculosis and drug resistance test: to understand whether tuberculosis is active, for a large number of patients with bacteriuria, it is best to double-lumen intubation during surgery, and pay attention to sucking, to avoid the spread of lesions. Understanding the drug resistance situation is conducive to medication before and after surgery.

(3) Differential diagnosis: The main purpose is to identify whether the patient's shadow is cancer or tuberculosis and cancer. There is also damage to the lungs, when one side of the pleura is thickened, there are some translucent areas, the cause of which is in addition to tuberculosis, as well as bronchiectasis, chronic lung infection can eventually occur, such as tuberculosis negative, no contralateral Dissemination of the lesion may not be tuberculosis. Lung cancer biopsy can be performed by percutaneous or bronchoscopy to identify cancer cells for identification.

(4) Pulmonary function test: to understand whether the patient's lung function can endure surgery, that is, whether it can withstand the surgical strike, and whether the postoperative residual lung function can maintain proper quality of life and work ability, which must be considered in combination with resection of the lesion. The most reliable and simple method is maximum ventilation (or maximum expiratory volume in 1 second). If the expected value is >80%, it can be considered normal and any surgery can be performed. If >60% should be considered comprehensively, <40% is considered a contraindication.

(5) Cardiac function examination: The age of patients with pulmonary tuberculosis is generally not large, and there are not many problems with heart function. However, for elderly patients and critically ill patients, it is necessary to check for occult cardiovascular disease, such as hypertension, arteriosclerosis, or myocardial or coronary artery disease.

(6) Liver and kidney function tests: Some anti-tuberculosis drugs affect liver function, and need to be cured after surgery.

(7) Supplementing nutrition and correcting anemia: In severe cases, malnutrition should be supplemented with nutrition before surgery and correcting anemia; long-term bed rest should be properly exercised. During the operation, blood should be routinely prepared, and blood transfusion should be performed when there is a large amount of bleeding.

2. Pneumonectomy The choice of lung resection is based on the principle of removing the lesion and retaining the largest amount of lung tissue. The specific surgical procedure is not much different from the surgery for the treatment of non-tuberculous lesions. According to the number of resected tissues, the resection of the lung can be divided into lesion excavation, wedge resection, segmentectomy, lobectomy, lobectomy plus lung segment resection, different segmental segmentectomy, total lung resection, bilateral partial resection, etc. Various surgical methods have their own characteristics and adaptation range. The choice of specific surgical type should be determined according to the results of X-ray imaging examination and intraoperative exploration.

(1) Excavation of lesions: It is often used for the treatment of benign tumors on the surface of the lungs such as inflammatory pseudotumor and hamartoma. This method is not needed for tuberculosis treatment. The main application of lesions in the diagnosis of benign lung disease and tuberculosis can not be identified, the lesions are first excavated during surgery to send pathological frozen examination, if it is definitely tuberculosis, it should be enlarged.

(2) Wedge resection: There are few opportunities for the application of tuberculosis treatment, only for small tuberculosis balls and tuberculosis lesions below 1 cm. Under normal circumstances, the satellite lesions around the main lesions of tuberculosis are not easy to cut, and even appear in the margin of the margin, prone to complications.

(3) Segmentectomy: for localized residual cavities and fibrous caseous lesions. After the application of more effective anti-tuberculosis drugs, tuberculosis is often limited, and segmental resection can maximize the preservation of healthy lung tissue. The most commonly used is the posterior segment of the left upper lobe and the resection of the lower segment. Because the volume of each segment is not large, the anatomical variation is more, it is difficult to separate and the lesions are mostly the voids of the bacteria. Generally, it is recommended to do "clean" lobectomy.

(4) lobectomy: the lesion is confined to one lobe for lobectomy; several lung segments involving the ipsilateral lung or different lungs and lung segments of the two lungs can be treated with multiple resections, multiple leaves or lungs plus lung segments cut. This is the most commonly used surgical procedure, which allows for a more complete resection of the lesion and sufficient healthy lung tissue. Surgical operation is easier than lung segment resection, but if the fissure is fusion, incomplete, or tight adhesion, there are problems such as air leakage and bleeding on the surface of the lung. The spread of tuberculosis lesions is common in the bronchial pathway, with few direct cross-leaves, so the risk of rupture of the lesion is small. As long as the lungs are healthy, even after the right middle, lower lobe or upper middle lobe is removed, the residual cavity can be filled. Often done is the left upper lobe or the right upper lobe plus the lower tip segment, the left upper tip and the posterior segment plus the lower tip segment. This type of resection has two bronchial stumps, multiple lungs with damaged surfaces, and the left lung tissue is not commensurate with the shape of the thoracic cavity. The surgical complication rate is the highest, and this type of resection is used as little as possible.

(5) Pneumonectomy: a lung lesion on one side, a persistent sputum positive, repeated hemoptysis or secondary infection, should be a total pneumonectomy. After the upper and lower lobe resection, if only the middle lobe is retained, the middle lobes may be distorted after surgery, resulting in atelectasis and pleural effusion. Pneumonectomy should also be considered. It is not too difficult to operate from the operation, but due to the treatment of one side of the pulmonary arteriovenous total trunk, if there is a greater risk of injury, the lung tissue lost by total lung resection is more, only for one side of the lungs and other extensive lesions. Happening. The right lung is large in volume. For example, the resected lung still has a certain function, and the left side has a certain function due to the old lesions. The postoperative respiratory function is poor, and it may form respiratory disability. The lesions are severe enough to require pneumonectomy, and there are often disseminated lesions on the contralateral side. It is necessary to carefully estimate the contralateral lesions, and the lesions must be stable and have fairly normal lung function. Due to the mediastinal shift after total resection, the left lung volume increases, there will be a certain degree of emphysema, and the lung function gradually declines after many years, and even forms pulmonary hypertension and pulmonary heart disease. Therefore, some advocate the addition of thoracoplasty at the same time or later after pneumonectomy. Most people do not advocate routine thoracoplasty after pneumonectomy. The residual cavity left after pneumonectomy is generally asymptomatic and most disappear after weeks or months. Only in a few cases after the upper lobe resection, the remaining lung lobe is small or there are also tuberculosis lesions, the adhesion is severe, and it is difficult to loosen out to consider local thoracoplasty: the posterolateral section of the 2nd to 4th ribs is removed, and the anterior segment is retained to avoid The front chest wall is trapped in deformity. In order to avoid thoracic deformity, pleural plasty can also be used: after the upper lobe is removed, the pleural effusion is removed from the thoracic cavity, and the ribs are not removed, so that the pleural cavity becomes the pleural cavity, and the oozing can remain in the cavity. Maintaining the mediastinum in the median position can effectively limit excessive lung expansion.

(6) bilateral lung resection: if there are localized lesions on both sides, it is necessary to perform leaf or segmental resection. It is feasible to have bilateral resection in the same period or stage. Bilateral simultaneous lung resection, indications for the patient's good physical condition, good lung function, the resection range is one side of the leaf plus the contralateral side of 1 to 2. Simultaneous surgery reduces the pain of reoperation and also avoids deterioration or spread of lesions on the unresected side. However, postoperative treatment is more difficult, and there are drainage tubes on both sides, which affects effective cough and expectoration. There are currently few indications for bilateral lung resection. More choices of safer bilateral staging, if one side of the surgery is well restored, after 3 to 6 months, the contralateral surgery, the second postoperative, lung function often has a greater impact, slow recovery.

3. Pulmonary tuberculosis after pneumonectomy After treatment of general chest surgery, such as monitoring of vital signs, nutrition, early activities, etc., the special problem that must be paid attention to after pulmonary tuberculosis is to maintain the chest drainage tube and the patency of the respiratory tract.

After partial resection of the lung, there is always some bleeding and gas accumulation in the thoracic cavity. The drainage tube must be drained to restore the physiological negative pressure state of the thoracic cavity, so that the remaining lungs expand to fill the chest cavity, and the residual cavity no longer exists. This is a reduction. Important measures for post-complication. Keep the chest drainage tube unobstructed. Note: 1 The interdural drainage tube should be placed in a suitable position. If the tube is too low to stimulate the diaphragm muscle pain, it must be removed too early, and the liquid cannot be fully discharged. 2 The drainage tube should be squeezed frequently after surgery so that the liquid does not remain in the tube. Sit up in the case of the patient's physical strength, take the method of tilting forward and backward, shaking left and right, etc., so that the liquid flows as far as possible to the vicinity of the drainage tube. 3 Prevent the drainage tube from being too long, twisted, pressed or pulled out to the skin. Frequent X-ray examination, such as seeing the position of the drainage tube is not suitable, separated from the liquid gas chamber, can be properly pulled out or rotated to adjust, if necessary, add low vacuum suction. 4 Ask the patient to take a deep breath, cough, so that the lungs expand, the residual cavity is quickly eliminated, and the drainage tube can be removed. The drainage tube is generally placed for 24 to 72 hours. According to the duration of drainage exhaust, the extubation indications: 1 no gas is discharged in the chest, the drainage fluid gradually decreases to disappear; 2 the water column in the water seal bottle has no fluctuation; the 3X line examination has the lung expanded There is no fluid and gas, or the liquid gas has been separated from the drainage tube, and the drainage tube has no effect. If you suspect a chest infection, or continue to leak, the placement time can be extended for several days. The lungs were removed and the drainage tube (usually in the upper upper chest) was used. The main purpose was to understand and adjust the negative pressure in the chest. After the operation, the pressure was clamped, and then the chest pressure was released briefly to release the gas or liquid.

4. Postoperative complications of pneumonectomy In addition to general thoracic surgery complications such as hemorrhage, atelectasis, pneumonia, and wound infection, complications associated with tuberculosis are:

(1) Tubular dissemination of tuberculosis lesions: Because of the tuberculosis operation, most patients with empty cavity drainage can not effectively remove the sputum under anesthesia. If the suction is not timely or insufficient, it may cause the lesion to spread. Postoperatively, due to various reasons such as pain, it is not possible to drain, and there are similar hazards. Tuberculosis spread often coincides with bronchial pleural sputum. The secretion of bacteria is easily inhaled into the ipsilateral lung or contralateral lung through the fistula. After the tuberculosis bacteria invade the lungs, the shadows appear in the lungs for several weeks. Surgery and bronchopleural palsy caused by lesions often lead to mixed infection, patients quickly appear high fever and other symptoms of poisoning, cough, jaundice, sputum can easily find tuberculosis. X-rays on the chest X-ray showed scattered flaky infiltration shadows, and progressed very quickly. It is necessary to actively give various anti-tuberculosis drugs and general antibiotics. The main point of prevention is to choose surgery when the lesion is relatively stable; preoperative routine anti-tuberculosis drug treatment to control the amount of bacteria; patients with bacilli must use tracheal double lumen intubation; intraoperative enhanced suction, postoperative promotion of sputum.

(2) Bronchial pleural fistula: For bronchial stump fistula and bronchospasm on the lung surface, it is easier to heal without special treatment. The focus is on pleural effusion caused by pleural fistula and endobronchial tuberculosis caused by improper suture of endometrial tuberculosis in the bronchial stump. The former often appears early in the postoperative period, and the latter occurs later. After pneumonectomy, if the chest drainage tube is found to have been leaking for more than 10 to 14 days, bronchial-pleural palsy should be suspected. The performance of the sputum caused by the defect of the suture technique: the postoperative drainage tube has a long-lasting air leak, cough, and blood stasis. Late sputum often coughs, sputum with blood, shortness of breath, such as the lungs have been fully expanded, chest X-ray examination showed a cavity or a liquid level at the same time, the original residual cavity does not shrink but expand. The chest cavity is quickly infected. After thoracic puncture, the gas can not be exhausted. Methylene blue is injected from the cavity, and the blue sputum is coughed up quickly, or the contrast agent is injected from the bronchus and appears in the chest cavity. When the bronchial stump is breathing, there is gas in and out, and there is also sputum entering the chest cavity (more than a pus), and the infection is not easy to control.

Treatment: First, supportive therapy, control infection, eliminate the residual cavity, and finally heal the stump. The first-aid measure is to place a closed thoracic drainage or a vacuum suction, and about 20% of the fistula can be closed. If the mouth is not healed, the residual cavity persists and should be changed to open drainage. After the stable infection control of the lesion, thoracoplasty is performed to eliminate the residual cavity.

The infection caused by infection should pay attention to prevention: 1 surgery until the disease is relatively stable. 2 grasp the timing of surgery, the estimated disease can not be cured of the disease, do not delay too long, until the drug has developed resistance, then transferred to surgery, retain one or two effective anti-tuberculosis drugs after surgery. 3 preoperative bronchoscopy of a large number of patients with bacteriuria, to understand whether there is no tuberculosis in the bronchus. 4 lesions are wide, and there are certain active patients. Try to avoid lung segment resection and compound resection. 5 During surgery, pay attention to the bronchial stump not to stay too long, properly cover the cover, do not tear the lesion to contaminate the chest. Take appropriate measures to avoid the formation of residual cavities (such as proper fixation of the residual lung, make its shape more compatible with the chest cavity, pleural detachment, so that the parietal pleura is attached to the surface of the lung, leaving the residual cavity outside the pleura, and the bloody exudate Filling, finally absorbing the machine, etc.). 6 postoperative as soon as possible to expand the residual lung, eliminate the residual cavity, visceral adhesion of the visceral layer of the wall, even if the bronchial stump is infected, it can be controlled by drugs, not to break open, forming a cavity, affecting the mouth of the mouth.

(3) Pulmonary resection and residual cavity formation: This is a problem that can be encountered after various lung diseases, but it is more meaningful after tuberculosis surgery. The residual cavity itself may be a manifestation of a slight leak of bronchospasm.

After pneumonectomy, the thoracic cavity of the operation side is raised by the diaphragm, the mediastinum is displaced, the intercostal space is narrowed and narrowed, and finally the fluid in the chest is mechanized, and the residual cavity disappears. There is a similar change after partial resection of the lungs, so there is only one upper or top lung, which can often fill the chest. However, if for some reason, other factors that cause the chest to shrink are not effective, the remaining lungs cannot fully expand, or the volume is too small, and a residual cavity will be formed. If the lungs do not continue to leak, most of the residual cavity is treated. Will disappear, some in the cavity there is exudate, after the exudate absorption, pleural adhesion cavity disappeared. If the thoracic or closed drainage gas is not exhausted, and the residual cavity persists, there is a possibility that the bronchial pleural sputum exists. After confirming the diagnosis, it is treated according to the above various methods.

Prevention of residual cavity: keep the drainage tube unobstructed after operation, take out the gas liquid; pay attention to drainage, keep the airway open, and make the lungs expand as soon as possible; if the residual lung volume is small during the operation, it can not be filled, and the nerve crush is performed in time. Surgery, make the diaphragm rise, or add artificial pneumoperitoneum to the top of the diaphragm after surgery; or remove the parietal pleura during surgery to change the pleural cavity into the pleural cavity.

(4) postoperative empyema: bronchospasm with almost no exception with empyema, infection can be tuberculous, non-tuberculous or mixed, clinical manifestations of fever, chest pain, such as more pus in the chest, breathing difficulties. There are frequent coughs and coughing up purulent sputum. Treatment: In the early systemic medication and supportive therapy, after thorough pus or drainage, the infection is controlled, the lungs are inflated, the residual cavity disappears, and the empyema can be cured.

prevention:

Tuberculosis is one of the oldest infectious diseases in human diseases. Humans have struggled with it for thousands of years, but tuberculosis is still prevalent worldwide, posing a serious threat to human health and life. Globally, due to the emergence and expansion of drug-resistant tuberculosis, the serious infection of tuberculosis and human immunodeficiency virus (HIV) and the imperfect rules of tuberculosis control in many countries, the global tuberculosis business has shown a clear upward trend. Among all infectious diseases worldwide, tuberculosis has become the leading cause of death among adults. The number of deaths due to tuberculosis worldwide exceeds the combined deaths of AIDS, malaria, diarrhoea, and tropical diseases each year, and kills 300,000 children. According to a press release issued by the WHO, in 1997, more than 7 million new cases of tuberculosis were detected worldwide, and nearly 3 million people died of tuberculosis.

More and more tuberculosis is resistant, which is the main factor that makes tuberculosis may become a refractory disease and an increase in the epidemic. Chemical drugs are currently the most powerful weapon to control tuberculosis, and more than 95% of newly-occurring patients can be cured through reasonable medical treatment and can prevent drug resistance. However, if the medication is improper or poorly managed, such as irregular medication, the treatment may fail, resulting in the further spread of drug-resistant cases and tuberculosis resistant to multiple drugs. Chemical drugs are often difficult to function in patients who are infected with drug-resistant tuberculosis.

In addition, it is estimated that there are currently 50 million refugees and immigrants in the world, half of whom have been infected with tuberculosis. Due to the mobility and particularity of their lives, once the disease is usually difficult to receive reasonable treatment, it is also caused by the spread of tuberculosis, especially drug-resistant tuberculosis. one of the reasons. WHO estimates that at least two-thirds of patients worldwide are at risk of developing multiple drug resistance. High drug resistance and the continued spread of multidrug-resistant tuberculosis will make tuberculosis difficult to control with existing chemotherapy.

The global trend of rapid growth of the tuberculosis epidemic has presented serious challenges to international public health. To this end, WHO announced to the world in April 1993 that the world is in a state of tuberculosis. The WHO is eager to arouse the attention of governments and international organizations around the world to control tuberculosis epidemics through this unusual initiative taken for the first time in its history.

Since the founding of the People's Republic of China, China's tuberculosis prevention and control work has been gradually carried out and strengthened, and remarkable achievements have been made. However, tuberculosis still seriously jeopardizes the health of our people, and the epidemic situation is also very serious. There are nearly 330 million cases of tuberculosis infection in the country, and there are more than 5.9 million tuberculosis patients, accounting for about a quarter of the world's tuberculosis patients. The number of deaths due to tuberculosis is as high as 250,000 per year, which is twice the total number of deaths from various infectious diseases. It is particularly noteworthy that due to the irregular diagnosis and incomplete treatment of tuberculosis in some areas, the proportion of drug-resistant patients in our tuberculosis patients is as high as 28% to 41%, and a large number of re-treatment patients appear.

The cause of tuberculosis is clear, there are measures to prevent it, and there are ways to cure it. However, only by carefully doing all aspects of treatment, management, prevention, and inspection, it is possible to find out that it must be cured and the treatment must be thorough, and it is possible to improve the tuberculosis epidemic. Until control.

Controlling the source of infection, cutting off the route of infection, enhancing immunity, and reducing infection are the basic principles for controlling the spread of tuberculosis. BCG can protect uninfected people, making it less prone to infection after infection, even if the disease is easy to heal. Effective chemical treatment (chemotherapy) can make the sputum bacteria turn faster and faster in the case of already ill, but it must be strictly disinfected and isolated before infection. To this end, it is of vital importance to find patients, correct treatment and vaccination with BCG. The prevention and treatment networks at all levels can provide guarantees for the implementation of the above measures.

First, the prevention system

Establishing and improving flood control organizations at all levels is the key to prevention and control. The work of the prevention and treatment institutions (health and epidemic prevention stations, tuberculosis prevention and treatment stations) includes: investigating the epidemic situation of tuberculosis, formulating prevention and treatment plans, conducting education on the basis of training, training and prevention of backbones, and assessing the effects of prevention and treatment and exchange of experience. Tuberculosis should be included in primary primary health care so that prevention and treatment can be implemented in the vast rural areas.

Second, found the patient

The source of infection for tuberculosis is the patient who is sterilized. A smear-positive bacterium can infect 5 to 10 people per year. Therefore, the current global prevention and treatment strategy is to identify and cure smear-positive (bacterial) tuberculosis patients as the main problem. Healing patients with bactericidal bacteria can help control infectious agents and improve the epidemic.

Asymptomatic patients must actively seek. X-ray examination of the collective lung can detect early patients, but most of them are still found after some symptoms are seen. Suspicious people should be further investigated. Patients with strong positive-positive children, or close contacts with sputum smear-positive water-resistant patients, often have tuberculosis patients. Some patients have symptoms and visit a general hospital. The X-ray examination confirmed the diagnosis, which is the main channel for patients found in China. The confirmed cases should be promptly and rationally chemotherapy or introduced to the tuberculosis prevention and treatment institution for supervision and chemotherapy, and regular follow-up until recovery.

Third, management of patients

Register patients with tuberculosis and strengthen management. Tuberculosis requires long-term treatment, so it is important to seek a safe, effective, responsive, and economically resistant anti-tuberculosis therapy. In 1995, the WHO proposed a strategy of “controlling infectious sources” and “supervised treatment + short course chemotherapy (DOTS)”. Its superiority is to promote cooperation between doctors and patients, and to implement economics for non-hospital patients. Unified, institutionalized and comprehensive supervision of chemotherapy. The experience gained by DOTS therapy in China and some other countries suggests that DOTS should implement the main responsibility for treating tuberculosis to medical workers, thus ensuring regular drug use and improving the cure rate.

Fourth, the treatment site

Reasonable anti-tuberculosis drug treatment can not only cure tuberculosis, but also turn sputum and yang to eliminate the source of infection. Efficient anti-tuberculosis drugs are equally satisfactory at home or in hospitals. At present, only a few patients with severe symptoms or complications need short-term hospitalization.

Fives,BCGVaccination

BCG is a live avirulent bovine tuberculosis vaccine that allows the body to acquire acquired immunity against tuberculosis. It is vaccinated against uninfected newborns, children and adolescents. Those who have been infected with tuberculosis (positive for the test) are not required to be vaccinated.

BCG can not prevent infection, but it can reduce the incidence and condition of the infection. After vaccination with BCG, the incidence of tuberculosis in the same age group is reduced by 80%, and the protective capacity can be maintained for 5 to 10 years. The immunity of BCG is "inactivated by live bacteria", and the live bacteria are gradually reduced in the human body, and the immunity is reduced. Therefore, those who are negative for the reaction of the nodules need to be replanted every few years. The repopulation targets are 7 years old in urban and rural areas and 12 years old in rural areas. The immune effect of BCG is positive, but it is also relative.

Since the founding of the People's Republic of China, the large-scale promotion of BCG vaccine in China has greatly reduced the incidence and mortality of children with acute miliary tuberculosis and tuberculous meningitis. Because it does not directly reduce the social source (children's patients are mostly negative), it has little impact on the overall population of tuberculosis.

Inoculation method: The effective period of the liquid bacterin is 4-6 weeks, and the freeze-dried bacterin is valid for 1 year. The vaccine should be transported and stored at low temperature (2～10°C) and protected from light (“cold chain”); The inoculation site was taken from the lower end of the outer edge of the deltoid muscle of the left upper arm. The intradermal injection method is commonly used, and the positive conversion rate of the auxin reaction after inoculation is as high as 90% or more. 2 to 3 weeks after the inoculation of BCG, the general local redness, ulceration, and self-healing within a few weeks.

The clinical cure and recovery of tuberculosis have different meanings. Tuberculosis lesions can be healed after treatment or mild lesions without treatment. The way of healing varies depending on the nature, extent, type, rational treatment and immune function of the body. There are several ways of healing: 1 absorption (dissipation), the lesions can be completely absorbed (dissipated) and healed due to unbroken lung tissue structure; 2 fibrosis, fibrous tissue hyperplasia during lesion absorption, argyrophilic fibroblasts Significantly increased and collagen fibrosis, and finally formed into a cord-like or star-shaped scar and healed; 3 calcification, refers to cheese-like necrotic tuberculosis, when the body's resistance is enhanced, the tuberculosis in the lesion is low, and the fecundity is weakened, Calcium carbonate and calcium phosphate are deposited in the necrotic foci, and the lesions are dehydrated and dried to form calcification. 4The fibrous cheese is formed. The larger dry lesions are not easily absorbed or fibrotic and calcified, but the fibers of the periorbital hyperplasia The granulation tissue is wrapped to form a fiber cheese stove, and the larger one becomes a tuberculoma. Although it can be stabilized for a long time, the tuberculosis bacteria in the state of resting or hibernation can survive for a long time, and the drug is difficult to penetrate into the lesion to play a role in killing bacteria. Become the root of re-ignition; 5 cavity healing, cavity formation is caused by dry sputum necrosis after liquefaction, its healing can be proliferated by the surrounding fibers and gradually shrink So that closure; also due to bronchial obstruction in communication with the cavity, the air absorbing hole, so that the wall is closed necrotic tissue fibrosis. This kind of healing is not reliable. It often has long-term survival of tuberculosis. The inner wall of the cavity has a bronchial epithelium extending and covering, which is called purifying the cavity or opening and healing.

The clinical cure of tuberculosis refers to the healing of various forms mentioned above, which stabilizes the lesion and stops the sterilizing, and the symptoms of tuberculosis completely disappear, but there may still be tuberculosis in the lesion, especially the cavity closure of the fibrous cheese stove and bronchial obstruction. Tuberculosis bacteria often exist in a static state. Once the body's resistance declines, the tuberculosis bacteria may re-energize and reproduce and cause re-ignition and dissemination. This situation is not really cured, so it can only be called clinical cure. .

Tuberculosis healing refers to the complete elimination of the lesion, including complete absorption or surgical resection, or confirmation of the survival of the tuberculosis within the lesion after all of the above forms of healing, that is, the pathological true cure, can be called tuberculosis recovery.