Tuberculosis in the elderly

Introduction to tuberculosis in the elderly Tuberculosis of lung is a chronic infectious disease of the lung caused by Mycobacterium tuberculosis invading the body under certain conditions. The sterilized patient is the main source of infection in society. Since Robert Koch discovered tubercle bacilli in 1882, modern medicine has invented medical X-ray technology and the development of anti-tuberculosis chemotherapy technologies such as streptomycin and isoniazid. It has formed a relatively complete and mature prevention and control technology to make tuberculosis popular. The pathological and clinical conditions have changed significantly. In the 1950s, the tuberculosis epidemic in China decreased significantly. However, in the last 10 years of the 20th century, the incidence of tuberculosis has rebounded. As the population ages, the number of tuberculosis in the elderly is relatively rising. The clinical symptoms of human tuberculosis are atypical, the rate of misdiagnosis is high, and the curative effect is poor. If treatment is not appropriate, the disease progresses rapidly and the prognosis is poor. The elderly tuberculosis is often the main source of infection for family tuberculosis. Therefore, prevention and treatment of tuberculosis in the elderly is not only for the elderly. Physical health, but also to eliminate or reduce the source of infection, is important for the prevention and treatment of tuberculosis. basic knowledge The proportion of the disease: the incidence rate of the elderly over 60 years old is about 0.03% - 0.08% Susceptible people: the elderly Mode of infection: droplet spread Complications: emphysema, massive hemoptysis, adult respiratory distress syndrome, pulmonary heart disease

Causes of tuberculosis in the elderly

(1) Causes of the disease

The infection rate and morbidity rate of the elderly are on the rise, and the relevant factors are considered:

1. Endogenous re-ignition

The elderly were infected with tuberculosis in adolescence, because the body's disease resistance was strong, and it did not cause disease. In the old age, due to the decline of immunity, the latent physical tuberculosis was multiplied and the disease occurred, and most of the disease occurred.

2. Delayed lesions

The elderly suffer from tuberculosis in the young and middle-aged period and the disease is delayed until the old age.

3. Recurrence

In young and middle-aged patients with tuberculosis, the treated lesions are stable, and the unkilled tuberculosis bacteria are in a temporary dormant state. In the old age, due to age, the immune function is reduced, and the elderly often suffer from various diseases or malnutrition. The immune function is more reduced, or some elderly people use corticosteroids or immunosuppressive agents in the treatment of other diseases, which also reduces immune function, causing the tuberculosis bacteria to reproduce and grow under dormancy, leading to the recurrence of tuberculosis.

4. In the old age, the disease resistance is low, and the tuberculosis invade repeatedly and the disease occurs.

(two) pathogenesis

1. Immunology and pathogenesis

(1) Koch phenomenon: Injecting uninfected guinea pigs with tuberculosis, localized swelling occurred after 10 to 14 days, and ulcers gradually formed, hilar lymphadenopathy, and death due to dissemination of tuberculosis, but to 3 6 weeks of guinea pigs infected with sputum, the same amount of tuberculosis, after 2 to 3 days, local violent reaction, rapid formation of superficial ulcers, and soon healed, no lymphadenopathy and dissemination of the body, Animals also have no death. This is the so-called Koch phenomenon. After the infection, the severe local focal reaction indicates the allergic reaction of the body, while the lesion tends to be limited, and there is no dissemination. It is evidence of immunity, and this initial infection and The so-called Koch phenomenon, which re-infects different responses, has been used to explain the different mechanisms of human primary and secondary tuberculosis.

(2) Anti-tuberculosis immunity: If the T lymphocyte-mediated macrophage immune response, when the tiny droplet nucleus containing tuberculosis enters the alveoli, the initially invaded tuberculosis can grow and grow in macrophages, The antigen is released by lysin treatment or by macrophage death, presented to the helper T lymphocytes, sensitized, and proliferated to form a monoclonal cell line. When attacked again by the antigen, the lymphocytes produce multiple kinds of lymphocytes. Lymphokines, including macrophages and lymphocyte chemokines (CF), macrophage activating factors, especially interferon-r (IF-r), interleukin-1 (IL-1, formerly known as lymphocyte stimulating factor) , tumor necrosis factor- and - (TNF- and TNF-) and the aforementioned mobile inhibitory factor (MIF), mitogenic factor (MF), lymphocyte transfer factor (LTF), etc., resulting in a single core Cells chemotaxis, local retention, activation, division and reproduction, and unsensitized lymphocytes are directly converted to sensitized lymphocytes.

Activated macrophage metabolism, phagocytosis, digestion, secretion and antigen handling are significantly enhanced, and produce a large number of reactive oxygen metabolites, various oxidative and digestive enzymes and other bactericidin, which effectively kills Mycobacterium tuberculosis The special immunity, this immunity is specific in lymphocytes, but non-specific to macrophages as effector cells. Once activated, in addition to tuberculosis, some other intracellular parasites and some Some tumor cells also have a role, and the specific anti-tuberculosis immunity obtained causes the body to become confined after infection with tuberculosis. On the contrary, if the immunity is insufficient or the amount of invading bacteria is large, the virulence is strong, especially when accompanied by allergic reactions. It leads to the spread of clinical signs and lesions.

(3) Delayed allergic reaction is an abnormal immune response to bacteria and its main body after infection with tuberculosis. It is also mediated by T cells, and macrophages are used as effector cells, which belong to the type of delayed allergic reaction. Under certain conditions, if the amount of locally aggregated antigen is low, delayed allergic reaction can effectively prevent reinfection of exogenous tuberculosis and local organs to extinguish blood-borne disseminated tuberculosis, because of the inhalation of exogenous tuberculosis. Endogenous bloodstream dissemination is always limited in certain time and certain local TB counts, but in most cases this allergic reaction is harmful to the body, due to the direct and indirect effects of delayed allergic reactions. Cell necrosis and cheeseization cause tissue damage. Once the cavity is formed, the tuberculosis bacteria multiply and cause dissemination.

With the research progress of monoclonal antibody technology, it provides favorable conditions for the study of T lymphocyte subsets and their functions in peripheral blood of patients with pulmonary tuberculosis. The research data show that there is indeed a change in T lymphocyte subsets in patients with tuberculosis, and T3 and T4 are decreased. The increase in T8 and the decrease in the ratio of T4/T8 constitute the characteristics of T lymphocyte subsets in tuberculosis, and the mechanism is still unclear. Interleukin-2 (IL-2) and interleukin-2 receptor (IL) in tuberculosis patients Studies of -2R) expression suggest that IL-2 levels are decreased and IL-2R expression is decreased.

2. Pathology

(1) Basic lesions:

1 exudative lesions: this type of lesion is often a large amount of bacteria, strong allergic reaction, showing tissue edema, followed by neutrophils, lymphocytes, monocyte infiltration and fibrin exudation, there may be a small number of classes Epithelial cells and multinucleated giant cells, tuberculosis can be found by acid-fast staining. The evolution process depends on the balance between immunity and allergic reaction. The reaction leads to necrosis of the lesion, followed by liquefaction. If the immunity is strong, the lesion is completely absorbed. Or become a proliferative lesion.

2 proliferative lesions: when the amount of bacteria in the lesion is small and the number of sensitized lymphocytes is large, the tuberculous nodules characteristic of tuberculosis are formed. The central part is the Langhansian giant cell derived from macrophages, with large cell bodies and many nuclei. Up to 5 to 50, arranged in a ring or horseshoe shape at the edge of the nucleus, sometimes concentrated in the two poles or the center of the cell body; the epithelial cells surrounded by macrophages are surrounded by layers, and lymphocytes are surrounded by it. And plasma cells scattered and covered, a single nodule diameter of about 0.1mm, can be fused to form a fusion type nodule, tuberculosis granulation is a diffuse proliferative lesion, more common in the cavity wall, sinus and its surroundings and cheese necrosis Surrounded by epithelial cells and neonatal capillaries, there are Langhan giant cells, lymphocytes and a small number of neutrophils. There are few tuberculosis in proliferative lesions, and macrophages are activated, reflecting the occupation of immunity. leading position.

3 caseous necrosis: the deterioration of the lesion, the first turbid swelling of the tissue, followed by cytoplasmic steatosis, nuclear fragmentation, dissolution, until complete necrosis, the appearance of necrotic tissue is yellow, like a cheese-like semi-solid or solid density, around the necrotic area Gradually the granulation tissue hyperplasia, and finally become fiber-wrapped fiber cheese lesions, necrotic lesions can be unchanged for many years, among which tuberculosis is rare, but if the local antigen concentration increases sharply, severe allergic reaction occurs, the cheese necrosis is liquefied, and the bronchial discharge is The cavity is formed, and its inner wall contains a large number of metabolically active, vigorous extracellular tuberculosis bacteria, which become a source of bronchial dissemination.

(2) Pathological evolution:

1 improved, recovered:

A. Dissipative absorption: In the exudative lesions, the lung tissue structure remains largely intact, and the blood supply is abundant. When the body's immunity is improved, especially through effective chemotherapy, the lesions can be completely absorbed without leaving traces. Light cheese necrosis or proliferative lesions can also be used. After treatment, it absorbs and shrinks, leaving only tiny fibrous scars.

B. Fibrosis: As the inflammatory component of the lesion is absorbed, fibroblasts and argyrophilic fibers in the nodular lesions proliferate, producing collagen fibers, forming fibrosis, and epithelial cells can also be transformed into fibroblasts, indirectly involved in fibers. During the process, fibrosis mostly begins around the lesion and occasionally appears in the center of the lesion, eventually becoming a non-specific strip or stellate scar.

C. Calcification and ossification: The confined cheese lesions gradually dehydrate, dry, and calcium deposits inside, forming calcification, fibrosis and calcification are the enhancement of the body's immunity, the disease is still and healing, but sometimes a variety The lesions coexist, partially fibrotic or calcified, while the other part is still active or even progressing. Even if the lesions of complete calcification do not fully reach the biological healing, the residual residual bacteria still have the possibility of reactivation. In children, tuberculosis calcification can Further ossification.

D. The outcome of the cavity: the elimination and disease and absorption of the tuberculosis in the cavity make the cavity wall thin and gradually shrink. Finally, due to the centripetal contraction of the fibrous tissue, the cavity is completely closed, and only the star-shaped scar is seen. Under the action of effective chemotherapy, Some cavities cannot be completely closed, but the specific lesions of tuberculosis have disappeared. The bronchial epithelial cells extend into the cave wall and become a cleansing cavity. It is also a good form of hollow healing. Sometimes the cavity drains the bronchial obstruction, the necrotic material in the cavity is concentrated, and the air Absorption, the surrounding is gradually wrapped around the fibrous tissue to form a fibrous cheese lesion or tuberculosis ball, the lesion shrinks and is relatively stable, but once the bronchus is recanalized, the cavity reappears and the lesion re-activates.

2 worsening progress:

A. Caseous necrosis and liquefaction: as already mentioned.

B. Diffusion: including local spread, bronchial, lymphatic and hematogenous dissemination, as well as lymph node-bronchial, lymphatic-blood dissemination, more common in patients with severe immunosuppression and tuberculous cavity long-term treatment, children with primary pulmonary tuberculosis through lymphatic drainage Lymph node spread, hilar lymph nodes can be broken to form lymph nodes - bronchospasm, causing bronchial dissemination; hilar lymph nodes can be introduced into the thoracic duct, into the superior vena cava and cause lymphatic-blood dissemination; cheese stove directly erodes adjacent pulmonary artery or its branches Lead to blood line spread, mainly in the bronchial dissemination of adults from the cavernous necrosis; occasionally the blood line spread mainly from the cheese necrosis cavity; occasionally the blood line spread, often due to other parts, such as genitourinary tract or bone and joint tuberculosis The stove is broken and invaded by the body vein system.

C. Re-activity: stagnation of quiescent TB in calcification or other forms of inactive lesions, which can cause disintegration and ulceration due to severe damage to the body's immunity or lung-damaged lesions (such as suppurative inflammation). Re-ignition, but in the case of adhering to regular chemotherapy medications and completing prescribed treatments, this situation is rare.

3 The effect of chemotherapy on pathological morphology: A prominent effect of chemotherapy on the pathology of tuberculosis is the appearance of cleansing cavities. It is not seen in the pre-chemotherapy era. The formation of subpleural bullae after chemotherapy is thought to be a special kind of purification cavity. Morphology, compared with unchemotherapy cases, tuberculous bronchitis is significantly reduced in chemotherapy cases. For the basic pathological changes of tuberculosis, chemotherapy will undoubtedly promote the absorption and dissipation of exudative lesions; proliferative lesions can have many changes, epithelial cells and Langhanse giant cells. Nuclear enrichment, deep solution, cytoplasmic swelling and degeneration, and finally become irregular coarse mesh and destruction, lesion absorption, can also cause changes in the arrangement of cells in the nodules, lymphocytes turn to the center of the nodules, epithelial cells are located around , or completely replaced by lymphocytes, and some converted to non-specific granulomatous tissue, and then fibrosis and transparency, cheese lesions shrink after chemotherapy, fresh small cheese lesions can form non-specific fiber scars and completely cured Different chemotherapeutic drugs have different effects on pathological morphology, and isoniazid can promote cheese stove Dissolved and cleared, easy to form a cleansing cavity; streptomycin causes epithelial cells and giant cells to shrink, deform and disappear, inhibiting fibrosis.

Elderly tuberculosis prevention

Primary prevention

(1) Establish a prevention and control system: establish and improve the prevention and control institutions at all levels, be responsible for organizing and implementing the system of management, management, and overall management, and formulate prevention and treatment plans according to the epidemic and epidemiological characteristics of the region, and carry out education and training. Good living habits, training and technical personnel in the prevention and control, and promoting social forces to participate in and support the planning and implementation of tuberculosis prevention and control.

(2) Early detection and thorough treatment of patients who have been discovered: Case finding mainly relies on symptomatic treatment, timely detection and diagnosis of tuberculosis patients to avoid missed diagnosis and misdiagnosis, must be "detected must cure, the rule must be thorough", must be thoroughly Treating patients, especially infectious patients, can greatly reduce the infection source density and effectively reduce the infection rate and reduce the incidence.

2. Secondary prevention

Early detection of tuberculosis patients and timely treatment to prevent the bacteria and slow down.

(1) Early detection: Strengthen health promotion, popularize knowledge about tuberculosis prevention, and make the people do self-examination and mutual supervision. Once suspicious persons are found, they will immediately go to the hospital for examination. This is beneficial to the patients themselves and the whole society. An effective means of early detection and early treatment.

(2) Early treatment: The treatment of tuberculosis includes the following aspects: rational use of anti-tuberculosis drugs to kill and inhibit bacteria, so that the lesions heal; surgical removal of destructive lesions, prevention and treatment of disease dissemination or infection; symptomatic treatment .

3. Three levels of prevention

The prevention is based on secondary prevention. Timely treatment can reduce the incidence of complications. The complications of tuberculosis are:

1 large area of double tuberculosis function is extensively damaged, leading to bronchiectasis secondary to secondary lung infection, both of which can lead to further impairment of function and even respiratory failure.

2 Chronic fibrovascular tuberculosis caused by long-term recurrent episodes further affects pulmonary function.

3 large area of pleural adhesion is caused by improper treatment of tuberculous pleurisy, can cause restrictive ventilation dysfunction, and even pulmonary heart disease and respiratory failure. Therefore, the prevention of recurrence of tuberculosis is the key to tertiary prevention, which requires clinicians to treat Strictly follow the principles of early, regular, appropriate, combined, and full use of sensitive drugs, treat patients, and strengthen supervision, so that the tuberculosis patients' disease procedures are minimized, and the serious adverse consequences caused by recurrence are prevented. Due to the lack of timely or inappropriate diagnosis and treatment, the tuberculosis patients should be reduced in disease procedures as much as possible. On the basis of preventing further development of the lesions, the existing pulmonary heart function should be preserved, and the potential compensatory capacity should be fully utilized to enable the patients to reach Functional rehabilitation.

For those who are sick and disabled due to tuberculosis, the society should take care of and guide them. Firstly, they should properly isolate and supervise the use of drugs, and strive to control the bacteria in the intensive treatment process. On this basis, it is necessary to publicize to the society and the family. Enlisting social and family care and help, strengthening patient function training and nutritional support are long-term and complicated tasks, which require the participation of family members. Psychological rehabilitation is an easily overlooked problem for tuberculosis patients. Medical workers It is the responsibility to explain the pathogens, pathogenesis, transmission routes, treatment intended and current treatment effects of tuberculosis to patients in order to eliminate some unnecessary psychological concerns of patients, and to explain to them the purpose of appropriate isolation measures Limit, and explain that tuberculosis is a communicable disease that can be basically controlled, and build confidence in patients to overcome the disease, which is beneficial for patients to actively cooperate with early rehabilitation.

Elderly tuberculosis complications Complications emphysema hemoptysis adult respiratory distress syndrome pulmonary heart disease

Complicated emphysema, pulmonary heart disease, massive hemoptysis, and even adult respiratory distress syndrome.

Symptoms of pulmonary tuberculosis in the elderly Common symptoms Immunity reduces appetite loss systemic failure cough reflexes fatigue cough relaxation heat cacao disease face detection negative chronic face

1. Incidence process and clinical type

(1) Primary tuberculosis: extremely rare in elderly patients, tuberculosis that is the first infection, also known as primary tuberculosis. Typical lesions include primary pulmonary lesions, tuberculous inflammation of draining lymphatic and hilar or mediastinal lymph nodes. The three are collectively referred to as the primary compound syndrome, and sometimes only the hilar or mediastinal lymph nodes are enlarged on the X-ray, also known as bronchial lymph node tuberculosis.

(2) Hematogenous disseminated pulmonary tuberculosis: mostly accompanied by primary tuberculosis, which is more common in children. In adults, tuberculosis in the latent infection of the primary infection enters the bloodstream, occasionally due to lung or other organ secondary. Active tuberculosis lesions are caused by erosion of adjacent lymphatic vessels. Invasion of the pulmonary veins leads to systemic disseminated tuberculosis; pulmonary, bronchial and venous system invaders mainly cause miliary tuberculosis in the lungs; in rare cases, lung lesions The tuberculosis in the lungs breaks into one side of the pulmonary artery or its branches, causing miliary tuberculosis in one or a part of the lung area. This type of tuberculosis occurs in patients with extremely low immunity. The causes include immunosuppression caused by drugs and diseases, measles, whooping cough, Diabetes, childbirth, etc., acute hematogenous disseminated pulmonary tuberculosis caused by a large number of bacterial invasions in a single or short-term, clinical manifestations are complex and variable, often accompanied by tuberculous meningitis or other organ tuberculosis, when a small number of tuberculosis intermittently When the invading bloodstream or the body's immunity is relatively good, subacute or chronic hematogenous disseminated pulmonary tuberculosis is formed, and the lesion is confined. Or a portion thereof, relatively rare clinically.

(3) secondary tuberculosis: due to the reactivation and release of tuberculosis in the latent lesions after initial infection, very few may be exogenous recurrent infections, this type is the most common type of adult tuberculosis, but adult tuberculosis is not Limited to this type, often chronic recurrent infection or chronic onset and after, but there are also acute onset and clinical process, called chronic tuberculosis is not very accurate, and the name of invasive tuberculosis is only focused on pathological X-ray Morphology, also the accurate expression of this type of tuberculosis, according to the pathogenesis called secondary or primary post-tuberculosis is logical, secondary tuberculosis can occur at any age after the primary infection, more common in adults, the cause In addition to the reduction of systemic immunity, local pulmonary factors can induce quiescent fibrotic lesions or calcification lesions, but most of the clinically successful tuberculosis has no clear incentives, due to overlapping of immune and allergic reactions. And the effects of treatment measures, followed by pathological and X-ray morphology of exudative invasive pulmonary tuberculosis, proliferative tuberculosis, fiber stem Sexual tuberculosis, caseous pneumonia, empty tuberculosis, etc., but the pattern of tuberculosis is rarely single, often multiple forms coexist, and only one is the main, with the implementation of strong and effective chemotherapy, Many of them have little clinical significance. Following the appearance of tuberculosis, the pulmonary tuberculosis occurs in the posterior segment of the upper and lower back of the lungs. The hilar lymph nodes are rarely enlarged, and the lesions tend to be limited, but they are prone to caseous necrosis and cavities. Formation, more bacteria, different from most of the original tuberculosis incurable self-healing, the characteristics of few bacteria, more important in epidemiology.

2. Symptoms and signs

The clinical manifestations of tuberculosis are diverse. Although different types and nature of lesions, the range can be an important determinant, but the body's reactivity and lung function reserve capacity also have important effects. For example, some cases have a wide range of lesions on the X-ray, tissue destruction. Very heavy, and the clinical symptoms are mild.

(1) systemic symptoms: fever is the most common systemic toxicity symptoms of tuberculosis, mostly long-term low fever, starting in the afternoon or evening, the next morning to normal, can be associated with fatigue, fatigue, night sweats, and some patients show body temperature Unstable, the body temperature rises slightly after a slight activity, although it is still difficult to calm down after half an hour of rest; when the lesion spreads rapidly, it will have high fever. Although the heat type or relaxation heat type can be chilled, it is rare. In the chills, there is not much sweating. Patients with high fever of tuberculosis may not improve because they may not be diagnosed in time, but the systemic condition is relatively good, which is different from the extreme debilitation and wilting of other infections such as Gram-negative bacilli. Other systemic symptoms include loss of appetite, weight loss, irritability, palpitations, cheek flushing and other mild toxicity and autonomic dysfunction.

(2) respiratory symptoms

1 cough and expectoration: infiltrative lesions cough slightly, dry cough or only a small amount of mucus sputum, increased sputum volume when there is a hole, if accompanied by secondary infection, sputum is purulent, accompanied by bronchial tuberculosis irritating cough, with limitations Snoring or wheezing.

2 hemoptysis: 1/3 ~ 1/2 patients have hemoptysis in different stages, destructive lesions are easy to hemoptysis, and healing lesions fibrosis and calcification can also cause hemoptysis directly or indirectly (secondary bronchiectasis), tuberculosis Inflammation increases capillary permeability, often showing blood stasis; lesions damage small blood vessels, blood volume increases; if the cavity wall of the pulmonary aneurysm rupture, it causes massive hemoptysis; extensive lesions involving the bronchial artery can also lead to massive hemoptysis, hemoptysis clinical Symptoms and severity, in addition to hemoptysis, depend to a large extent on airway clearance and systemic status, including chronic airway disease, cardiopulmonary dysfunction, aging, cough reflex inhibition, systemic failure, etc. The state of impaired clearance mechanism is easy to cause asphyxia, hemoptysis is easy to cause tuberculosis, especially in the case of a large number of hemoptysis, continuous high fever after hemoptysis is often a powerful suggestion.

3 chest pain: the insidious pain of the site is often caused by nerve reflex, fixed acupuncture-like pain, with the increase of respiratory and cough and the symptoms of the lateral position are relieved, often due to pleural involvement, the pleura is stimulated, the pain can be radiated to Shoulder or upper abdomen.

4 shortness of breath: severe toxic symptoms and high fever can cause respiratory rate increase, but the real urgency is only seen in extensive lung tissue destruction, pleural thickening or emphysema, pulmonary heart disease.

(3) Signs: depending on the nature, location, extent or extent of the lesion, when the lesion is mainly exudative or caseous with pneumonia and the lesions are wide, there are signs of consolidation, percussion dullness, auscultation and bronchial breath sounds and fine Wet snoring, followed by hair tuberculosis occurs in the posterior segment of the upper tip, so the scapular region and the fine wet voice have great value for diagnosis. The location of the cavity is superficial and the bronchial patency is smooth when there is bronchial breath or accompanying Wet snoring; signs of huge hollow tuberculosis have thoracic collapse, tracheal and mediastinal shift, percussion turbidity, auscultation of respiratory sounds reduced or wet vomiting and emphysema signs, miliary tuberculosis rarely lung signs, even Concurrent with adult respiratory distress syndrome, see severe dyspnea and cyanosis, bronchial tuberculosis has a local wheezing sound, especially at the end of expiration or coughing.

3. The performance of tuberculosis in the elderly is atypical, and asymptomatic patients are as high as 26%. Compared with young adults, they have the following characteristics:

(1) There are more males than females in the elderly, and males are 4 to 8 times more likely to be females.

(2) The symptoms are not typical. Because the immune function of the elderly is low, the symptoms of tuberculosis poisoning are not obvious. The onset is insidious, the systemic symptoms are mainly, and the respiratory symptoms are mild. As usual, it is anemia, weight loss, loss of appetite, lethargy, etc. The incidence of night sweats is significantly lower than that of young and middle-aged patients. A small number of patients have unconsciousness and incontinence as the first symptom, or low proteinemia, low sodium and hypokalemia, and are easily misdiagnosed.

(3) The number of patients with chronic fibrosis and hematogenous disseminated pulmonary tuberculosis increased significantly.

(4) There are a wide range of lesions, and there are many cases of cavities. It is reported that in the X-ray manifestations of senile pulmonary tuberculosis, the caliber is 53%.

(5) There are many patients with bacteria.

(6) The course of disease is long, refractory, and there are many cases of retreatment. The tuberculosis in the elderly is mostly delayed from the youth, or has been treated in the youth. In the elderly, relapse due to low immune function, long course and difficult treatment.

(7) Complications and comorbidities, 86.6% of tuberculosis in the elderly have comorbidities, mainly diabetes, pulmonary heart disease, coronary heart disease, hypertension and so on.

Elderly tuberculosis examination

1. Tuberculosis test

In order to diagnose the most specific method of tuberculosis, thick smear acid-fast staining microscopy is quick and simple, with high positive rate and few false positives. It is generally recommended, and the initial diagnosis is positive for acid-fast bacilli. It is estimated that the sputum-positive tuberculosis is the lowest. The concentration of 10 / ml, 50% ~ 80% of tuberculosis patients with sputum coating positive, tuberculosis culture can be identified with other acid-fast bacilli, unless the chemotherapeutic can be smear positive culture test negative, in the untreated tuberculosis The sensitivity and specificity of the culture are higher than the smear test. The culture strain is further used for drug susceptibility determination, which can provide an important reference for the treatment, especially the re-treatment. The smear-positive (smear-positive) case is treated within 7 to 10 days of chemotherapy. The growth of tuberculosis is rarely affected, and only a very small number of cases of smear (negative smear test) chemotherapy quickly affect the culture results, so specimens must be taken before the start of chemotherapy, in the absence of sputum and will not cough In the early morning, children take gastric juice to check for tubercle bacillus. If necessary, it is still a method worthy of adoption. It is also an alternative method for attracting sampling by atomization in the adult or by tracheal puncture. Methods, the biggest disadvantage of tuberculosis culture is that it grows slowly. It takes 4-6 weeks to see the colonies. If the drug sensitivity test is continuously performed, it takes 3 to 4 months, and there are still problems such as the unsatisfactory positive rate and difficulty in standardization. Due to the structural abnormality of the enzymes required for DNA synthesis of tuberculosis, there has been no breakthrough in the research on rapid culture for a long time. At present, the Bactec 460TB system is used to solve the problem of rapid detection of tuberculosis, which uses 7H12 branches containing radioactive 14C palmitic acid as a substrate. Bacillus medium, when the test specimen is inoculated into the medium, if there is mycobacteria, the metabolite and the substrate react to form 14CO2, and the latter is sent to the ionization chamber, and the measurement result is automatically displayed, and NAP (P-nitro) is added. -acetylamino--hydroxypropiophenone) drugs can be distinguished from atypical mycobacteria. This system can also be used to measure the sensitivity of anti-tuberculosis drugs. Most applications show that the Bactec system is used for detection of mycobacteria for an average of 9 days. After 5 days of identification, the susceptibility test can be completed in 6 days, the detection time is significantly shortened, and the compliance rate with the conventional method is extremely high. The disadvantage is that the equipment and reagents are expensive. And may underestimate the drug-resistant tuberculosis misdiagnosed the elderly, a wide range of diseases, easy to form hollow, so check high TB sputum positive rate can be as high as 85.9%.

2. Lignin test

The sputum is a metabolite of Mycobacterium tuberculosis. The main component is tuberculosis protein. It is prepared from the human tuberculosis filtrate grown in liquid medium. The old OT antigen is impure and can cause non-specific reaction. Pure protein derivative. (PPD) is better than OT. PPD-S made by precipitation with sulfuric acid is designated as the international standard for mammals by WHO, and WHO has appointed the salt of PPF-RT-32 (plus Tween80 stabilizer) produced in Denmark. It is widely used in the world, but the PPD antigen is still relatively complicated. The intraceretic injection method is usually performed by intradermal injection. The injection of 0.1 ml of sputum into the medial side of the left forearm is used to observe and record after 48~72h. As a result, the corresponding titers and contents of 0.1 ml of different nodule preparations are shown in Table 1. The epidemiological investigation and clinical general use 5 TU as the standard dose, and the results were judged based on the local swelling diameter of 72 h: 4 mm negative (-) 59mm weak positive reaction (+), 1019mm moderate positive reaction (++), 20mm or although it does not exceed this diameter but no blister, necrosis, strong positive reaction (+++), short-term repeated test Can cause re-intensity effect, so the clinical application directly uses the standard dose, no It is advocated to gradually increase from a small dose, repeated trials, the elderly due to low immune function, the positive rate of tuberculin test is low and only 70 years old is only about 10% lower.

3. Serological diagnosis

The development of non-invasive new diagnostic techniques has always been an urgent need of clinical and epidemiological studies. There are many studies on the immunological techniques for detecting anti-tuberculosis IgG antibodies by ELISA. However, the significance of humoral immunity in tuberculosis is still unclear. Species specificity is not easy to determine, and monoclonal antibodies with specific antigens are still needed to improve the sensitivity and specificity of ELISA immunology in the diagnosis of tuberculosis. Gene diagnosis is to detect the DNA gene of tuberculosis, which is different from traditional For phenotypic diagnostic techniques, the prior art has various nucleic acid probes, chromosomal nucleic acid transfer fingerprinting techniques and polymerase chain reaction (PCR), which are sensitive, specific, fast, and independent of culture and convenience. The characteristics of low-viability bacteria are detected, but they are still in the research stage. There are still many obstacles to overcome from practical promotion. With the rapid development of molecular biology research and technology, it is expected to open up new avenues for the diagnosis of tuberculosis.

4. Most elderly patients with active tuberculosis have accelerated erythrocyte sedimentation rate. Patients with hematogenous disseminated pulmonary tuberculosis may have abnormal liver function, anemia, leukopenia, etc. Occasionally, leukemia-like reactions may occur, but lack of specific diagnostic significance.

5. Chest X-ray examination

X-ray examination is the main means of diagnosing tuberculosis. It has reference significance for understanding the location, extent, nature, evolution and treatment of the lesion. The typical X-ray changes have diagnostic value. The characteristic signs of primary pulmonary tuberculosis are the primary lesions in the lung. Tumor-like lesions composed of lymphangiitis and enlarged hilar or mediastinal lymph nodes. The primary lesions in the lungs can be found in the posterior part of the lung field, but the upper part of the lower part of the leaf or the lower part of the lower part of the lower part of the pleura is mostly exudative. Floc-like blurred shadows, when the cheese is changed, the density is deepened, but often accompanied by obvious inflammation around the lesion, the edges are extremely blurred. In severe cases, acute cavities can occur, and the extent of the lesion is uncertain. The larger ones occupy several lung segments or the entire lung lobe. Lymphadenitis is one or several strip-like shadows that extend from the lesion to the hilum. The edges are often blurred. The enlarged lymph nodes are more common in the ipsilateral hilar or mediastinum, occasionally affecting the contralateral side, and the edges or smoothing ("knots" Section type ") or fuzzy ("inflammatory type"), most lymph nodes are lobulated or wavy edges, acute hematogenous disseminated tuberculosis on the chest X-ray showed scattered in the two lung fields, more uniform distribution Miliary shadows with similar density and size. This kind of microscopic nodule fluoroscopy is usually not found. It is sometimes difficult to distinguish the film in the early stage of the disease (3~4 weeks ago). Often, the diagnosis is delayed, and high-quality chest radiographs must be taken. Or add lateral flakes to make the small lungs of the two lungs overlap each other to facilitate the display of the lesions. Subacute and chronic hematogenous disseminated pulmonary tuberculosis have different sizes and densities, and tend to be proliferative, with a limited range, usually located in the two upper lungs. The X-ray findings of the tuberculous tuberculosis are complex and variable, or the flakes are flaky, or the spots (slices) are nodular. The density of the cheese lesions is high and uneven, often there are translucent areas or cavities, and the tuberculosis cavities are "none." Wall "empty cavity" (acute cavity), thick-walled cavity, thin-walled cavity, tension cavity, chronic fiber cavity and other different forms, generally speaking, the cavity wall of tuberculosis is relatively smooth, liquid level is less wind or only shallow liquid level, slightly sick At the same time, fibrosis or calcification occurs at the same time. The characteristic X-ray signs of chronic secondary pulmonary tuberculosis are mixed with polymorphic lesions, which occur in the posterior segment of the upper tip or the lower segment of the lower lobe, which has diagnostic significance. It is not specific for X-ray diagnosis of tuberculosis, and it is affected by factors such as the level and experience of the readers and the variable X-ray findings of the tuberculosis, especially when the lesion is located in a non-perfect location or is not typical and lacks characteristic morphology. , qualitative diagnosis is very difficult.

6. Chest CT

For cases with no abnormal findings or atypical findings on chest X-ray examination, chest CT examination should be performed, and small or concealed lesions can be found to understand the extent and composition of the lesion.

Diagnosis and diagnosis of pulmonary tuberculosis in the elderly

Diagnostic criteria

Although the main diagnostic method for tuberculosis is X-ray examination, it is necessary to combine the medical history and clinical manifestations, sputum bacteriological examination and some necessary special examination data for comprehensive analysis, and insist on pathogenic diagnosis and pathological diagnosis to get the correct one. Diagnosis, such as highly suspected tuberculosis, but without a definitive basis for a feasible anti-tuberculosis drug trial treatment to confirm the diagnosis.

Differential diagnosis

The X-ray manifestations of different types of tuberculosis vary, and the diseases that need to be identified are also different.

1. Primary tuberculosis

X-ray features manifested as mediastinal and hilar lymphadenopathy, requiring lymphoma, including lymphosarcoma, Hodgkin's disease and lymphocytic leukemia, intrathoracic sarcoidosis, central bronchogenic carcinoma, mediastinal lymph node metastasis and various types Mediastinal tumor identification.

2. Hematogenous disseminated tuberculosis

Severe venom symptoms and early X-ray features are unclear when differentiated from typhoid and sepsis, lung miliary lesions must be associated with bronchioloalveolar carcinoma, pulmonary lymphangiogenesis, pulmonary metastases, hemosiderosis, each Identification of alveolitis and the like.

3. Infiltrating pulmonary tuberculosis is easily confused with various bacterial and non-bacterial pneumonia. The tuberculosis cavity must be distinguished from lung abscess and cancerous cavity. The thin wall cavity of tuberculosis must be differentiated from pulmonary cyst and cystic bronchiectasis. Tuberculosis should be differentiated from lung cancer, benign lung tumors, lung metastases, pulmonary inflammatory pseudotumor, hydatidosis, arteriovenous fistula, etc.

4. Chronic fibrous cavity tuberculosis

The main X-ray showed pulmonary fibrosis, irregular cavities, local lung volume reduction, tracheal mediastinal shift, etc., and should be differentiated from chronic lung abscess, atelectasis, obvious pleural hypertrophy and radiation pneumonitis.

5. Special population and atypical tuberculosis

Some special people with tuberculosis can have different characteristics from the general tuberculosis patients in terms of symptoms, signs and chest X-ray findings and clinical course, which is called "atypical tuberculosis" and is easy to delay diagnosis.

(1) Non-reactive tuberculosis: also known as fulminant tuberculous sepsis, a serious mononuclear-macrophage system tuberculosis, found in patients with extreme immunodeficiency, first with persistent high fever, myelosuppression or leukemia-like response, Liver, spleen, lymph nodes, lung, kidney, bone marrow, severe caseous necrotic lesions, containing a large number of MTB, and X-ray findings are often very inconspicuous, prolonged appearance or long-term performance of atypical miliary lesions, homogeneous Sexual patchy shadows, often located in non-tuberculosis areas.

(2) Allergic manifestations such as tuberculous rheumatic rheumatism and nodular erythema: more common in young women, multiple joint pain or inflammation of the extremities, recurrent erythema and ring erythema near the extremities and ankle joints, good spring Hair, anti-tuberculosis treatment is effective.

(3) AIDS complicated with pulmonary tuberculosis can be manifested as hilar, mediastinal lymphadenopathy, middle and lower lung infiltrating lesions, and lack of cavities, similar to primary pulmonary tuberculosis, and more common with pleurisy and extrapulmonary tuberculosis, PPD The test is negative and so on.

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