骨结核英文七年制培训课件.pptx

1、IntroductionIntroductionEpidemiology and Etiology(流行病学及病因学)v Pathology(病理)v Diagnosis and Differential Diagnosis (诊断与鉴别诊断)v Prophylaxis and Treatment (预防与治疗)Tuberculosis of bones and joints Generally to be a chronic inflammatory and infectious disease caused by Myobacteriumtuberculosis.Extrapulmonar

2、y secondary diseases Approximately 95%cases of tuberculosis of bones and joints are due to pulmonary tuberculosis,but pulmonary tuberculosis is evident in only half the patients with skeletal involvement.EpidemiologyEpidemiology In general,most patients with this disease are in the age of 30 or belo

3、w at diagnosis in developing countries with this disease is in the elderly in developed countries.EpidemiologyLocationIncidenceIn Summary 脊柱结核最常见 Etiology Acid-fast bacilli Mycobacterium tuberculosisnHuman tubercle bacilli（人型结核杆菌）commonnBovine tubercle bacilli (牛型结核杆菌)rareEtiology On March 24,1882,R

4、obert Koch announced his discovery of the tubercle bacillus.He discovered a staining technique that enabled him to see Mycobacterium tuberculosis.（结核杆菌）Dr.Robert KochEtiology Transmission Routes Hematogenous dissemination（血液传播）（血液传播）to long bones and vertebrae Direct spread to bone from adjacent tub

5、erculous lymphadenitis（结核性淋巴腺炎）（结核性淋巴腺炎）Single or multi centric（单发或多中心）（单发或多中心），particularly in AIDS Predilection for synovium（偏好滑膜）（偏好滑膜）-higher oxygen pressure Pathology(病理)Initial pathological changes are tuberculous osteomyelitis(结核性骨髓炎结核性骨髓炎,单纯骨结核单纯骨结核)and synovial tuberculosis(滑膜结核滑膜结核)。The ar

6、ticular cartilages remain intact at this stage.The lesion will be healed through proper treatment in time,and joint function will be reserved thoroughly or partially.If the original focus remains active and untreated,the lesion will exacerbate,involved bone,cartilage and synovia,developing to tuberc

7、ulous panarthritis（全关节结核）（全关节结核）.PathologySimple Seletal TB Pathology (Simple Sekeltal TB)calcaneusPathology(Simple Skeletal TB)TB of the Cancellous Bone Peripheral type abundant blood supply local bone defect without forming sequestrum Pathology(Simple Skeletal TB)TB of the Cortical Bone Localized

8、destroy without forming sequestrum onion-like proliferation;the quantity of new bone formation of periosteum is determined by the age.Pathology(Simple Skeletal TB)TB of the metaphysis(干骺端结核）forming sequestrua(死骨片）(cancellous bone)new bone formation of periosteum （骨膜）(compact bone)Pathology(TB of the

9、 Synovial membrane滑膜结核滑膜结核)vEarly stage:vHyperaemia 充血充血vSynovial hypertrophy 肿胀肿胀vExudate increasing 渗出增多渗出增多vPannus formation（血管翳）（血管翳）&Rice bodies 米粒体米粒体(small,free white bodies composed of compact masses of fibrin,necrotic synovial villi,or cartilage fragments)vLate stage:hyperplasia of synovium

10、 滑膜肥厚增生滑膜肥厚增生 The risk of joints involve knee,hip,elbow and ankle.Pathology(Tuberculous panarthritis)全关节结核全关节结核 Due to SimpleTB Due to synovial TBComplications of Late Stage TB of Bones and Joints Abscess 脓肿 Pathological subluxation,dislocation or fracture 病理性半脱位、脱位或骨折 Articular deformity or stiffne

11、ss 关节畸形强直 Shortening of extremities 肢体短缩 (epiphyses erosion)骨骺受损 Paraplegia(spinal cord compressed)截瘫Complications of Late Stage TB of bones and jointsParaspinal abscess椎旁脓肿椎旁脓肿Calcification of the paraspinal abscess is essentially pathognomonic for tuberculosis 椎旁脓肿钙化是结核椎旁脓肿钙化是结核的基本特征的基本特征Normal sh

12、adow of psoas major 正常腰大肌影Psoas abscess腰大肌脓肿Deep gravitation abscess of groin 腹股沟深部流注脓肿腹股沟深部流注脓肿Articular stiffness and deformity 关节强直畸形关节强直畸形Limb Shortening肢体短缩肢体短缩Kyphosis（脊柱后凸）（脊柱后凸）Paraplegia（截瘫）（截瘫）掌握要点 骨与关节结核的发展阶段和分型及其骨与关节结核的发展阶段和分型及其X线特点线特点 松质骨结核：中心型松质骨结核：中心型 坏死型坏死型 边缘型边缘型 溶骨型溶骨型 密质骨结核：层状骨膜增生

13、，梭型膨大密质骨结核：层状骨膜增生，梭型膨大 干骺端结核：兼有松质骨和密质骨结核特性干骺端结核：兼有松质骨和密质骨结核特性 滑膜结核：无特殊。仅骨质疏松滑膜结核：无特殊。仅骨质疏松 全关节结核：早期；晚期全关节结核：早期；晚期 骨与关节结核晚期并发症：骨与关节结核晚期并发症：不同部位的寒性脓肿不同部位的寒性脓肿 关节畸形、强直关节畸形、强直Diagnosis and Differential DiagnosisDiagnosis Medical history Insidious onset 隐匿起病 Symptoms:pain 疼痛 low fever 低热 night sweats 盗汗

14、anorexia 厌食 anemia 贫血 weight loss 体重减轻 local swelling 局限肿胀 morbid night crying of babies 夜啼 contact history 接触史Diagnosis Diagnosis Radiographic Findings (6-8 weeks after)Skeletal TB TB of the cancellous bone:Central lesion:bone necrosis Peripheral lesion:bone lysis TB of the cortical bone:layer peri

15、osteum proliferation&shuttle-like inflation TB of the metaphysis:DiagnosisRadiographic Findings TB of the synovial membrane:The earliest findings in the radiograms are regional bone atrophy,soft-tissue swelling,and capsular distention.These changes are due to synovitis and are nonspecific.Tuberculou

16、s panarthritis:The above changes are followed by peripheral erosion of the bone and destruction of the subchondral bone,with the joint space narrowing.Diagnosis Lab test blood rt.10%pt.white cell The sedimentation rate:non-pathognomonic for tuberculosis but alters early than X-ray(male 15mm/h;femal1

17、yr.ESR,CRP Normal.)Osteotomy,Arthrodesis and arthroplastyCase report 74 yrs,female,low back pain,radiate to the rt.leg,6 months with hip pain limited in bed 2 months progressive weight loss,anorexia,no fever,Tenderness at the rt.groin of the hip Limited rang of motion of rt.hip,Thomas sign(-)Lab tes

18、t:Wbc normal,CRP ,ESR Oct.26,2006Feb.23,2007March 2,2007March 2,2007Hip joint aspiration Pus-like liquid 5ml Culture(-)Q&A Diagnosis?Treatment?TB-Controversy&tendency Pathogenesis immunologic research need to be go farther farther study in gene level:(HLA allele,ethnic differance;IL-6,IL8,IL-10,TNF-

19、a)TB-Controversy&tendency Early diagnosis:the molecular biology technic is still a developmental tendency of study.Gene probe technic（基因探针技术）,Polymerase chain reaction（多聚酶链反应）PCR Nucleic acid amplification(核酸扩增）in vitroTB-Controversy&tendency Searching more ideal drug for TB with less side effectTha

20、nks Etiology On March 24,1882,Robert Koch announced his discovery of the tubercle bacillus.He discovered a staining technique that enabled him to see Mycobacterium tuberculosis.（结核杆菌）Dr.Robert KochPathology(Simple Skeletal TB)TB of the Cancellous Bone Peripheral type abundant blood supply local bone

21、 defect without forming sequestrum Diagnosis Medical history Insidious onset 隐匿起病 Symptoms:pain 疼痛 low fever 低热 night sweats 盗汗 anorexia 厌食 anemia 贫血 weight loss 体重减轻 local swelling 局限肿胀 morbid night crying of babies 夜啼 contact history 接触史Diagnosis 掌握要点 骨与关节结核的诊断要点：骨与关节结核的诊断要点：分四步骤：分四步骤：病史与临床表现病史与临床

22、表现 结菌素皮肤实验结菌素皮肤实验 X X线片检查（胸部和患肢）线片检查（胸部和患肢）;MRI 细菌学检查（痰培养、脓肿穿刺液培养）细菌学检查（痰培养、脓肿穿刺液培养）主要鉴别的疾病：主要鉴别的疾病：结缔组织病结缔组织病骨关节感染性疾病骨关节感染性疾病骨肿瘤骨肿瘤Prophylaxis and TreatmentFeb.23,2007TB-Controversy&tendency Early diagnosis:the molecular biology technic is still a developmental tendency of study.Gene probe technic（基因探针技术）,Polymerase chain reaction（多聚酶链反应）PCR Nucleic acid amplification(核酸扩增）in vitro