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,TAIWAN 0.08 % (0.03-0.14),Worldwide Adult Prevalence of HIV Infection,HIV-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 ART,Synovate Healthcare U.S. HI
2、V Monitor Q2, 2007; Centers for Disease Control and Prevention (CDC) : http:/www.cdc.gov ; 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,1200 1100 1000 900 800 700 600 500 400 300 200 100 0,1:512 1:256 1:128 1:64 1:32 1:16 1.8 1.4 1.2 0,Weeks,Y
3、ears,0,3,6,9,1,2,3,4,5,6,7,8,9,10,11,12,CD4 T Cells/mm3,Plasma Viremia Titer,Primary infection,Possible acute HIV syndrome Wide dissemination of virus Seeding of lymphoid organs,Clinical latency,Death,Opportunistic diseases,Constitutional symptoms,(,),(,),Natural History of HIV Infection,Pulmonary C
4、omplications of HIV Infection,Fungi Pneumocystis carinii Penicillium marneffei Cryptococcus neoformans Aspergillus fumigatus Histoplasma capsulatum Protozoa Toxoplasma gondii Cryptosporidium spp. Virus CMV HSV Adenovirus HIV,Bacteria Mycobacterium tuberculosis MAC M. kansasii Nocardia asteroides Str
5、eptococcus pneumoniae Staphylococus aureus Legionella pneumophilia Rhodococcus equi Hemophilus influenzae Lymphocytic interstitial pneumonitis,Tuberculosis,結核病三千年歷史的古老疾病 埃及時代,西元前 3700-1000年,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。,Robert 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
6、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。,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,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（tub
7、ercle bacillus）,HIV prevalence in adults, and TB notification rates, for Kisumu, Kenya,Nat Rev Immunol 2005;5:819-26.,TB-HIV co-infection in Taiwan,HIV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） Prevalence of HIV in adult TB patients (1549yrs) is 2.03% in 2006,Clinical manifes
8、tation in AIDS with disseminated mycobacterial infection in NTUH,S/S DTB (22) DMAC (15) Fever 21 (95.5) 14 (93.3) Night sweating 15 (68.2) 4 (26.7) BW loss 10 (45.5) 11 (73.3) Diarrhea 5 (22.7) 7 (46.7) LNP 15 (68.2) 1 (6.7) Hepatosplenomegaly 3 (13.3) 6 (40) Splenomegaly 2 (9.1) 7 (46.7),AIDS 1998;
9、12:1301-7,CXR finding TB in HIV infected patients,CD4200 CD4 200 Upper lobes involvement Lower lobe pneumonia Cavity Hilar or mediastinal LNP Miliary TB Normal Normal CXR 8-20%,28 Y/O MSM Productive cough for 1 months, BW loss CD4 38 HIV virus load 460000 Sputum AFS (-), Lung biopsy: granulomatous i
10、nflammation, Caseous necrosis, Multinuclear giant cell,20060404,20060928,TB,TB empyema,Pulmonary TB with TB lymphadenitis,42 y/o MSM Intermittent fever, night sweating for 2 months CD4 215 CD8 1175 HIV virus load 486000 LN aspirate AFS (+) Sputum TB culture : MTB,Extra-pulmonary tuberculosis,PJP and
11、 TB,38 y/o MSM DOE for 2 weeks, BW loss 11 Kg CD4 64 CD8 345 HIV virus load 67300 WBC 2840, Sputum TB culture: MTB, Blood culture: Salmonella choleraesuis,20060207,20060214,Diagnosis HIV infection with TB,Specimen Microscopy % Culture % Sputum 40-67 74-95 Bronchoscopy Bronchoalveolar larvage 7-20 52
12、-89 Transbronchial biopsy 10-39 42-85 Urine 22 45-77 Blood 26-64 Lymph nodes 37-90 40-95 Bone marrow 18-52 25-67 CSF 0-27 Pleural specimen Pleural fluid 3-6 Pleural biopsy 52-55,Textbook of AIDS Medicine 1999; Chapter16,Comparison of HIV Disease Progression in TBTC Study 23 vs. CPCRA 019/ACTG 222,Ye
13、ars of enrollment Baseline CD4 cell count Use of HAART during TB treatment Death within 1 year of start of TB therapy Death or new OI within 1 year of start of TB therapy,TBTC 231999-2002 90 80%4.5%15.7%,CPCRA/ACTG1993-1995 86 020%38.9%,Overlapping Side Effect Profiles of First-line Antituberculosis
14、 Drugs and Antiretroviral Drugs,Side effect,Possible causes,Antituberculosis drugs,Antiretroviral drugs,Skin rash Nausea, vomiting HepatitisLeukopenia, anemia,PZA, RIF, INH PZA, RIF, RBT, INH PZA, RIF, RBT, INHRBT, RIF,NVP, EFZ, ABC ZDV, RTV, AMP, IDV NVP, PIs, Immune reconstitution ZDV,IRS response
15、 to pathogens,Mycobacterium tuberculosis (TB) Mycobacterium avium complex (MAC) Cytomegalovirus (CMV), Cryptococcus Pneumocystis Toxoplasma Hepatitis B Varicella zoster virus.,Clinical Diseases and NTM in Humans,Clinical Disease NTM Pulmonary MAC M. kansasii M. chelonae M. xenopi Lymphadenitis MAC M
16、. scrofulaceum Cutaneous M. marinum M. fortuitum M. chelonae M. ulcerans Disseminated MAC M. genovense M. kansasii M. chelonae M. haemophilum M. malmoense,Textbook of AIDS Medicine 1999,Mycobacteriual species causing Disseminated NTM infection in AIDS patients,Species Number (%) MAC 1906 (96.1) M. k
17、ansasii 57 (2.9) M. gordonae 11 (0.6) M. fortuitum 5 (0.3) M. chelonae 5 (0.3),Am Rev Respir Dis 1989;139:4-7,Clinical Syndromes of Disseminated MAC in AIDS,Generalized Fever Fatigue Weight loss Pancytopenia,Gastrointestinal Chronic diarrhea Abdominal pain Chronic malnutrition Periportal LNP Extrabiliary obstructive jaundice,MAC pneumonia,
