結核病的診斷 - 中華民國防疫學會 · 2016/2/17 1 結核病的診斷...
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2016/2/17 1 結核病的診斷 衛福部 疾病管制署 中區傳染病防治醫療網 王任賢 指揮官 前言 • 在結核病的防治上有二個大的方向 • 第一個方向 – 偵測及治療有傳染性的結核 • 第二個方向 – 偵測出高風險無症狀的潛伏性結核以預防其產 生有活性的結核病 結核病的診斷方法 • 診斷潛伏性結核病 – 結核菌素皮膚試驗(TST) – 血液檢查(IGRA) 目前美國FDA只通過QuantiFERON®–TB Gold In‐Tube test (QFT‐GIT)及T‐SPOT®.TB test (T‐Spot) • 診斷活動性結核病 – 痰塗片與結核菌培養 – 影像學檢查 – 分子生物學檢查 診斷潛伏性結核 Risk of TB infection and disease among exposed individuals Exposure (close contact) No infection 70% Early progression (recent TB<2 years) (close contact) Infection ~30% 5-10% Containment 90-95% Late progression (reactivation TB) 5% Continued containment 85-90% 結核菌素皮膚試驗(TST) • 到目前為止結核病的免疫診斷金標準仍為結核 菌素皮膚試驗 • 可以偵測出潛伏性及有活性的結核 • 但擔心的是其敏感性與特異性不夠完善所造成 的假陰性與假陽性結果
Transcript of 結核病的診斷 - 中華民國防疫學會 · 2016/2/17 1 結核病的診斷...
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(TST) (IGRA)
FDAQuantiFERONTBGoldInTubetest(QFTGIT)TSPOT.TBtest(TSpot)
Risk of TB infection and diseaseamong exposed individuals
Exposure(close contact)
No infection 70% Early progression
(recent TB
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OT(oldtuberculin)
OTPPD(Mantoux skintesting)
Oldtuberculin(OT) 1908:
Purifiedproteinderivative(PPD) 1939:(FlorenceSiebert)OT
PPDS (SiebertsLot49608) :1TU,5TU,250TU
OT(oldtuberculin)PPD(purifiedproteinderivative)
PPD S PPDSPPDRT23PPDRT232TUPPDS5TU201191PPDRT231TU 2TU
0 1 cc
(Mantoux test)
0.1cc8mm
PPD0.04gmcg2TU
100
4872
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PPD: PPD:
PPD: : I
>5(mm) X
: II
>10(mm) ,
: III
>15(mm)
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(Boosting)
13
(+),( ), (),13 (+), (),
:/
PPD
(
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(IGRAs) QuantiferonTBGoldInTubeAssay
ESAT6,CFP 10,TB7.7 ELISA
Tspot.TB Assay ESAT6,CFP 10
QuantiFERONTBGold
(ESAT6,CFP10)
ESAT6CFP10
QFTTspot.TB assay
83232
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TspotTB QuantiFERONTBGold
ESAT6/CFP10
ESAT6CFP10
216,, =98%(213/216 =QFT)
Mori,etal.AJRCCM2004;170:5964 532 532
=99.8%(531/532 = QFT) CDC;publicationinpreparation
99,, =96%(95/99=QFT)
Kang,etal.JAMA2005;293:27562761
118,85%,15%
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QFTTST,
60
70
80
90
100
60
71
7881
Percentpositive
0
10
20
30
40
50
Low Risk/BCG Casual Contacts Close Contacts TB patients
51
410
44
TST
QFT
Increase agreement with increased chance of infectionKang, 2005
:
60
70
80
90
100
Percentpositive
No BCG BCG
0
10
20
30
40
50
Casual contact Close contact Casual contact Close contact
TST
QFT
Good test agreement between TST & QFTBrock, 2004
QFTTSTQFT boosting
TST PPD Boosting
23
IGRA QFTG QFTG
IntubeQFTGIntube
TSPOT
ELISA ELISA ELISA ELISPOT ELISA ELISA ELISA ELISPOT
($) 29.22 26.74 25.09 57.79
Costs include facility space, equipment, consumables and staff timeTST$1214
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IGRAs
TSTIGRA TST+/IGRA :
IGRAs IGRAs
CCDRVol36June2010
6,530
InfectionControlandHospitalEpidemiology2010:31,12791285
IGRAs?
QFTTST25 TSTIGRA(TST/IGRA+)( / )
TSTIGRA(TST+/IGRA+)
IGRAs
IGRAsTSTTST
IGRAsTST
TSTIGRAs
CTSIGRAs IGRAs
IGRAsTSTs IGRAsTSTs
TST TSTIGRA TST/IGRA+ TSpot.TB
: IClin Microbiol Infect2011;17:806814
25233 IGRAs
(i)TSTIGRA TST (,) TST (,)
(ii)TSTIGRA, (iii)IGRATST (); (iv)IGRA,TST
IGRAs
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: IIClin Microbiol Infect2011;17:806814
IGRA
IGRAs IGRAs
TST(+)? ?
IGRA IGRAs
PCRDNA
+ +
+
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PCR
(>3) / /
81%
93%
100%
100%
ve P
osi
tivi
ty
0%
50%
First Second Third
Cu
mu
lati
v
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AFB(showninred)aretuberclebacilli
Number of bacilli seen Result reported
None per 100 oil immersion fields Negative
1-9 per 100 oil immersion fields Scanty, reportexact number
10-99 per 100 oil immersion fields 1+
1-10 per oil immersion field 2+
> 10 per oil immersion field 3+
60
70 HIVNegative
EarlyHIV
AFBpositivityinTBpatients
0
10
20
30
40
50
LateHIV
:
414
ColoniesofM.tuberculosis growingonmedia
:
MDRTB
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X 31,
2/3:
1014
:
/
:1.2.3.
NTM
NTMTST
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98%
Interobserveragreement
70%
AFB Microscopy X-ray
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98%
Specificity
50%
AFB Microscopy X-ray
Over-diagnosis
100%
Diagnosed by X-ray alone Actual cases
NTI, Ind J Tuberc, 1974
30%
1015%
40%
TomanK.Tuberculosiscasefindingandchemotherapy.WHO,1979
X
X
Arrowpointstocavityinpatient'srightupperlobe.
Early HIVLate HIV
(severe immuno-compromise)
420
1015
Rouillon A. Tubercle 1976;57:275-99
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70%
60
70
80
h la
b co
nfirm
atio
n
Expectedrange
27%
0
10
20
30
40
50
Non-DOTS DOTS
% o
f cas
es w
ith
1.
2.
3.
4.
5.
GuidanceofNationalTbProgrammes fortheManagementofTBinChildrenWHO/HTM/TB/2006.371
:
:
(..)
PCR
NAAT(NucleicAcidAmplificationTest)NAATPCR
FDANAAT 1995FDAMTD1995 FDAMTD
1999FDAMTD2
(OSPHL)GenProbeMTD2
NAAT
35 NTB
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NAAT
NAAT=95%,=98%
NAAT=66%,=98%
NAAT
+,NAAT+
+,NAAT
NAAT
,NAAT+
NAAT NAAT
,NAAT NAAT NAAT
NAAT
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NAAT
NAAT(:) NAATNAAT
