肺结核合并爱滋病治疗课件

1、肺結核合併愛滋病治療台北榮民總醫院 感染科國立陽明大學愛滋病預防及研究中心王永衛 醫師肺結核合併愛滋病治療台北榮民總醫院 感染科TAIWAN0.08 %(0.03-0.14)Worldwide Adult Prevalence of HIV InfectionHIV-infected Persons Total: 18386 (in 2009) AIDS: 5811 Deaths: 2418 On ART 5000 (33%)1,000,000 -1,200,000 HIV-infected individuals in USA, 2007, 57% on ARTSynovate Health

2、care U.S. HIV Monitor Q2, 2007; Centers for Disease Control and Prevention (CDC) : ; Taiwan Center for Disease Control (2009 report)目前愛滋病毒感染存活人數:4000萬人每年新感染HIV人數:500萬人每年愛滋病患死亡人數:300萬人TAIWANWorldwide Adult Prevalen12001100100090080070060050040030020010001:5121:2561:1281:641:321:161.81.41.20WeeksYears

3、0369123456789101112CD4 T Cells/mm3Plasma Viremia TiterPrimaryinfectionPossible acute HIV syndromeWide dissemination of virusSeeding of lymphoid organsClinical latencyDeathOpportunisticdiseasesConstitutionalsymptoms()()Natural History of HIV Infection12001:512WeeksYears03691234567肺结核合并爱滋病治疗课件肺结核合并爱滋病

4、治疗课件結核病三千年歷史的古老疾病埃及時代西元前 3700-1000年結核病三千年歷史的古老疾病埃及時代西元前 3700-10誰是肺結核病人?魯迅李叔同林徽音林黛玉身邊隨時都有機會接觸病人，與其排斥逃避，不如主動關懷，幫助病人好好治療。誰是肺結核病人?魯迅李叔同林徽音林黛玉身邊隨時都有機會接觸病Robert KochRobert Koch結核病防治全球每年約有300萬人死於結核病，約300萬人死於愛滋病，其中愛滋病人死於結核病約佔1/3。全球約有1/3 人口已受結核菌感染，每年約有 800 萬人新發生結核病，其中台灣約佔 15,000 人。結核病防治全球每年約有300萬人死於結核病，約300萬

5、人死於何謂結核病（TB tuberculosis）？慢性傳染性疾病由結核分枝桿菌（結核桿菌）所引起的由飛沫（空氣）傳染病情進展緩慢，早期症狀不明顯人體之任何器官都可能得結核病，以肺部居多何謂結核病（TB tuberculosis）？慢性傳染性疾認識結核桿菌（tubercle bacillus）嗜氧菌、抗酸菌，喜潮濕、陰暗處長約1 10m微米，寬約0.20.6 m，生長期約 48 週最適宜之生存溫度是37怕熱、怕火，100，5分鐘；65，15分鐘即可殺菌怕陽光；紫外線照射迅速死亡認識結核桿菌（tubercle bacillus）嗜氧菌、認識結核桿菌（tubercle bacillus）典型分枝桿

6、菌非典型分枝桿菌人型結核桿菌鳥型、牛型分枝桿菌具傳染性不具傳染性菌落粗糙菌落較散，平滑認識結核桿菌（tubercle bacillus）典型分枝HIV prevalence in adults, and TB notification rates, for Kisumu, Kenya Nat Rev Immunol 2005;5:819-26.HIV prevalence in adults, and TB-HIV co-infection in TaiwanHIV帶原者中有5.6%曾罹患結核病2006年確診結核病與HIV資料庫進行勾稽HIV(+) / TB 的比率為 0.71%（112人）P

7、revalence of HIV in adult TB patients (1549yrs) is 2.03% in 2006TB-HIV co-infection in TaiwanHClinical manifestation in AIDS with disseminated mycobacterial infection in NTUHS/SDTB (22)DMAC (15)Fever21 (95.5)14 (93.3)Night sweating15 (68.2) 4 (26.7)BW loss10 (45.5)11 (73.3)Diarrhea 5 (22.7) 7 (46.7)

8、LNP15 (68.2) 1 (6.7)Hepatosplenomegaly 3 (13.3) 6 (40)Splenomegaly 2 (9.1) 7 (46.7)AIDS 1998;12:1301-7Clinical manifestation in AIDSCXR findingTB in HIV infected patientsCD4200CD4 200Upper lobes involvementLower lobe pneumoniaCavity Hilar or mediastinal LNPMiliary TBNormalNormal CXR8-20%CXR findingT

9、B in HIV infected28 Y/O MSMProductive cough for 1 months, BW lossCD4 38 HIV virus load 460000Sputum AFS (-), Lung biopsy: granulomatous inflammation, Caseous necrosis, Multinuclear giant cell200604042006092828 Y/O MSMProductive cough foTBTB肺结核合并爱滋病治疗课件肺结核合并爱滋病治疗课件TB empyemaTB empyemaPulmonary TB wit

10、h TB lymphadenitis42 y/o MSMIntermittent fever, night sweating for 2 monthsCD4 215 CD8 1175 HIV virus load 486000LN aspirate AFS (+)Sputum TB culture : MTBPulmonary TB with TB lymphadenExtra-pulmonary tuberculosisExtra-pulmonary tuberculosisPJP and TBPJP and TB38 y/o MSMDOE for 2 weeks, BW loss 11 K

11、gCD4 64 CD8 345 HIV virus load 67300 WBC 2840, Sputum TB culture: MTB, Blood culture: Salmonella choleraesuis 200602072006021438 y/o MSMDOE for 2 weeks, BWDiagnosis HIV infection with TBSpecimenMicroscopy %Culture %Sputum40-6774-95BronchoscopyBronchoalveolar larvage 7-2052-89Transbronchial biopsy10-

12、3942-85Urine2245-77Blood26-64Lymph nodes37-9040-95Bone marrow18-5225-67CSF0-27Pleural specimenPleural fluid3-6Pleural biopsy52-55Textbook of AIDS Medicine 1999; Chapter16Diagnosis HIV infection with Comparison of HIV Disease Progression in TBTC Study 23 vs. CPCRA 019/ACTG 222Years of enrollmentBasel

13、ine CD4 cell countUse of HAART during TB treatmentDeath within 1 year of start of TB therapyDeath or new OI within 1 year of start of TB therapy TBTC 231999-20029080%4.5%15.7%CPCRA/ACTG1993-199586020%38.9%Comparison of HIV Disease ProgOverlapping Side Effect Profiles of First-lineAntituberculosis Dr

14、ugs and Antiretroviral DrugsSide effectPossible causesAntituberculosis drugsAntiretroviral drugsSkin rashNausea, vomitingHepatitisLeukopenia, anemiaPZA, RIF, INHPZA, RIF, RBT, INHPZA, RIF, RBT, INHRBT, RIFNVP, EFZ, ABCZDV, RTV, AMP, IDVNVP, PIs, ImmunereconstitutionZDVOverlapping Side Effect ProfilI

15、RS response to pathogens Mycobacterium tuberculosis (TB) Mycobacterium avium complex (MAC)Cytomegalovirus (CMV),CryptococcusPneumocystisToxoplasmaHepatitis BVaricella zoster virus. IRS response to pathogens MycoClinical Diseases and NTM in HumansClinical DiseaseNTMPulmonaryMACM. kansasiiM. chelonaeM

16、. xenopiLymphadenitisMACM. scrofulaceumCutaneousM. marinumM. fortuitumM. chelonaeM. ulceransDisseminatedMACM. genovenseM. kansasiiM. chelonaeM. haemophilumM. malmoenseTextbook of AIDS Medicine 1999Clinical Diseases and NTM in HMycobacteriual species causing Disseminated NTM infection in AIDS patientsSpecies Number (%)MAC1906(96.1)M. kansasii 57(2.9)M. gordonae 11 (0.6)M. fortuitum 5(0.3)M. chelonae 5(0.3) Am Rev Respir Dis 1989;139:4-7Mycobacteriual species causing