Transcript 1.＜肺結核合併愛滋病之治療＞ 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
國立陽明大學愛滋病預防及研究中心
王永衛 醫師
Worldwide Adult Prevalence of HIV Infection
1,000,000 -1,200,000
HIV-infected individuals in
USA, 2007, 57% on ART
HIV-infected Persons
• Total: 18386 (in 2009)
• AIDS: 5811
• Deaths: 2418
On ART 5000 (33%)
TAIWAN
0.08 %
(0.03-0.14)
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
Synovate Healthcare U.S. HIV Monitor Q2, 2007; Centers for Disease Control and Prevention (CDC) :
http://www.cdc.gov ; Taiwan Center for Disease Control (2009 report)
Natural History of HIV Infection
Primary
infection
1200
1100
1000
Opportunistic
diseases
900
1:512
600
1:64
500
1:32
400
1:16
300
1.8
200
1.4
100
1.2
0
0
0
3
6
9
Weeks
12
1
2
3
4
5
6
Years
7
8
9
10
11
)
1:128
Constitutional
symptoms
(
)
Clinical latency
700
Plasma Viremia Titer
1:256
800
(
CD4 T Cells/mm3
Death
Possible acute HIV syndrome
Wide dissemination of virus
Seeding of lymphoid organs
Pulmonary Complications 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
Streptococcus 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 ～ 10μm〈微米〉，寬約0.2～0.6
μm，生長期約 4～8 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）
典型分枝桿菌
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
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 (15–49yrs) is
2.03% in 2006
18000
2.50%
16472
16000
16758
15042
15378
16784
14486
14000
2.03%
2.00%
12000
1.50%
10000
8000
0.95%
2000
0
1.13%
1.00%
0.76%
6000
4000
1.01%
0.53%
0.25%
0.36%
61
36
0.73%
0.45%
68
0.45%
75
0.56%
0.50%
112
92
0.00%
2001
HIV(+)-TB
2002
2003
all TB
2004
HIV/TB %
2005
2006
HIV/TB %15-49 y/o
Clinical manifestation 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)
AIDS
1998;12:1301-7
 Splenomegaly
2 (9.1)
7
CXR finding
TB in HIV infected patients
 CD4>200
CD4 <200
Upper lobes involvement
Lower lobe pneumonia
Cavity
 Normal CXR
Hilar or mediastinal LNP
Miliary TB
Normal
8-20%
28 Y/O MSM
Productive cough for 1 months, BW loss
CD4 38 HIV virus load 460000
Sputum AFS (-), Lung biopsy: granulomatous inflammation, 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 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
Sputum
Bronchoscopy
Bronchoalveolar larvage
Transbronchial biopsy
Urine
Blood
Lymph nodes
Bone marrow
CSF
Pleural specimen
Pleural fluid
Pleural biopsy
Microscopy % Culture %
40-67
74-95
7-20
10-39
22
52-89
42-85
45-77
26-64
37-90
18-52
0-27
3-6
52-55
40-95
25-67
Comparison of HIV Disease Progression in TBTC
Study 23 vs. CPCRA 019/ACTG 222
TBTC 23
CPCRA/ACTG
1999-2002
1993-1995
Baseline CD4 cell count
90
86
Use of HAART during TB
treatment
80%
0
Death within 1 year of start
of TB therapy
4.5%
20%
Death or new OI within 1
year of start of TB therapy
15.7%
38.9%
Years of enrollment
Overlapping Side Effect Profiles of First-line
Antituberculosis Drugs and Antiretroviral Drugs
Side effect
Possible causes
Antituberculosis
drugs
Antiretroviral
drugs
Skin rash
PZA, RIF, INH
NVP, EFZ, ABC
Nausea, vomiting
PZA, RIF, RBT, INH
ZDV, RTV, AMP, IDV
Hepatitis
PZA, RIF, RBT, INH
NVP, PIs, Immune
reconstitution
Leukopenia, anemia
RBT, RIF
ZDV
IRS response 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
 Pulmonary
 Lymphadenitis
 Cutaneous
 Disseminated
Textbook of AIDS Medicine 1999
NTM
MAC
M. kansasii
M. chelonae
M. xenopi
MAC
M. scrofulaceum
M. marinum
M. fortuitum
M. chelonae
M. ulcerans
MAC
M. genovense
M. kansasii
M. chelonae
M. haemophilum
M. malmoense
Mycobacteriual species causing Disseminated
NTM infection in AIDS patients






Species
Number (%)
MAC
1906
(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;139:4-7
Clinical Syndromes of
Disseminated MAC in AIDS
 Gastrointestinal
 Generalized
Chronic diarrhea
Fever
Abdominal pain
Fatigue
Chronic malnutrition
Weight loss
Periportal LNP
Pancytopenia
Extrabiliary
obstructive
jaundice
MAC pneumonia