结核性胸膜炎

nullnull结核性胸膜炎 （Tuberculous Pleural Effusion）第二篇 呼吸系统疾病 赵建平学时数：1学时第十一章null讲授目的和要求1.掌握结核性胸膜炎的诊断及鉴别诊断。 2.掌握结核性胸膜炎的治疗原则。 null讲授主要内容 概述 病因和发病机制 病理 临床现 实验室和其他检查 诊断 鉴别诊断 治疗 nullAnatomy： 解剖学： Visceral pleura 脏层胸膜 Parietal pleura 壁层胸膜 Latent space 潜在腔隙概 述null I.Etiology: Mycobacterium tuberculosis 病因：结核分枝杆菌 病因和发病机制nullDiscovered by Dr.Koch in 1882 由Dr.Koch 于1882年发现 Acid-fast 抗酸染色性nullPathogenesis :two theories 发病机制：两种学说 Delayed hypersensitive reaction 迟发性高敏反应 Pleural infection 胸膜感染null 1.Pleural congestion with cell infiltration, unilateral in most cases. 胸膜充血，细胞浸润，多数病例累及单侧胸膜病 理null In the early stage, polymorphs predominate. 早期以多型核细胞为主 Typically, lymphocytes predominate. 典型表现以淋巴细胞为主 2. Tuberculous nodules 结核结节 3. Exudative effusion 渗出液null临床表现Symptoms 症状 Age, often seen in young people, but also in elderly people 1. 年龄，多见于年轻人，但也可见于老年人 Fever, typically 37～38C, but can be >39C 2. 发热，典型者37-38C，但也有>39C者nullChest pain, more severe when there is only little fluid. 3. 胸痛，胸水少时明显 Breathlessness, when there is a lot of fluid. 4. 气短，胸水多时明显 nullPhysical signs 体征 Inspection: fullness of chest in the involved side. 1. 视诊：患侧胸廓饱满 2. Palpation: trachea shifts to the other side, weakness of vocal fremitus . 2. 触诊：气管向健侧移位，触觉语颤减低null3.Percussion: dullness in the involved side. 3. 叩诊：患侧实音 4.Auscultation:disappearance of breathing sound 4. 听诊：患侧呼吸音消失null实验室和其他检查1. Chest X-ray 胸片 Fluid is visible only when more than 300 ml. 胸水超过300ml时胸片可以发现 CT is needed in a few cases. 少数病例需做CT nullnullnullnullPericardial effusion 心包积液null2. Ultrasonic examination 超声检查 More accurate than X-rays. 诊断胸水比X线准确 Can provide vital information for thoracentesis. 能为胸腔穿刺术提供关键资料null3. Thoracentesis and fluid examination ---- essential 胸腔穿刺术－－诊断的关键null(1)Fluid routine -- exudate 胸水常规－渗出液 specific gravity > 1.018; 比重> 1.018 WBC > 500/cmm, predominated by polymorphs at early stage and lymphocytes later 白细胞计数> 500/cmm, 早期以多型核细胞为主，以后以淋巴细胞为主 protein > 3gram/dl 蛋白含量> 3gram/dlnull(2) Acid-fast staining for acid-fast bacilli (not sensitive). (2)抗酸染色（不敏感） (3) Culture for tuberculous bacilli (time consuming). (3) 结核杆菌培养（费时间） (4) Others: culture for bacteria, cytological exam, etc. (4) 其他：细菌培养，细胞学检查，等等null4.Pleural needle biopsy ---- tub. granuloma 4. 胸膜活检 －－ 发现结核结节 5.Others: Eos. count, liver function, immunoglobulin, …… 5. 其他检查：血嗜酸细胞计数，肝功能，免疫球蛋白，等等 nullsymptoms + physical signs + fluid exam. 症状 ＋ 体征 ＋ 胸水检查 retrospective, exclusive. 回顾性，排他性 诊断标准null Is there pleural effusion? 有无胸水？ Is it transudate or exudate? 胸水是漏出液还是渗出液？ What is the specific etiology? 胸水的病因是什么？鉴别诊断nullTransudate 漏出液 1. Heart diseases 心脏病 2. Kidney diseases 肾脏病 3. Liver diseases 肝脏病 4. Malnutrition 营养不良 5. Endocrine diseases 内分泌疾病nullExudate 渗出液 1. tumorous diseases 1. 肿瘤类疾病 2. bacterial infection empyema – purulent fluid reactive pleural fluid 2. 细菌感染 脓胸 －－ 脓性胸水 反应性胸水 null3. connective tissue diseases 3. 结缔组织疾病 4. parasite infection, such as paragonimiasis 4. 寄生虫感染，如肺吸虫病 5. Others 5. 其他null anti-tuberculous chemotherapy 1. 抗结核病化疗 In the same way as pul. Tuberculosis 与肺结核相同 治 疗nullKeys 关键 Initiate treatment as early as possible 早期 Use multiple drug regimen 联合 Use adequate dosage 适量 Give medicines in a regular bases 规律 Treat patients long enough(>6 mon.) 足程 null2. drainage of pleural fluid 2. 引流胸水 3. corticosteroids ---- controversial 3. 糖皮质激素 －－ 有争议nullGood in most cases. 大多数患者预后良好 预 后null结核性胸膜炎应与哪些疾病相鉴别？复习思考题