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大家好
-Hi.

我是Christophe Delacourt
I am Christophe Delacourt.

我是一名小儿肺病专家
I am a pediatric pulmonologist

我在法国巴黎内克尔儿童医院的
and I am working at the Unit of Pediatric Pulmonology

小儿肺病科工作
in the Hospital Necker-Enfants Malades in Paris, France.

在这次的慕课中
In this MOOC course,

我们将着重于包括活动性
we will focus on pediatric tuberculosis

和潜伏性感染在内的儿科结核病
including active disease and latent infection.

从怀疑一个儿童患有结核病
There is a long way to go from TB suspicion

到确诊和开始治疗
in a child to the confirmation of TB diagnosis

中间过程十分漫长
and the initiation of treatment.

第一步是怀疑
The first step is suspicion.

这个孩子是否与结核病病人有亲密接触
Has the child had a known close contact with a pulmonary case

是否有明显的症状
and/or does he have suggestive symptoms

如持续咳嗽
such as a persistent cough,

体重减轻
weight loss,

发育停滞
failure to thrive?

有没有持续的原因不明的发烧
Is there a persistent unexplained fever?

或是不知为何异常嗜睡 缺乏活力
Or is there an unexplained lethargy or reduced playfulness?

第二步是收集样本通过微生物方法确认
The second step is the collection of samples for microbiological confirmation.

如果结果是肯定的
If the response is yes,

就要开始治疗
a treatment will be initiated.

但如果确定不了
But if there is no confirmation,

您就需要进行第三步
you will have to go to the third step

X光检查和免疫试验
with the realization of X-rays and immune tests.

最后一步
Finally,

是评估对治疗的积极反应
the last step will be the evaluation of the positive response to treatment.

胸部X光检查是儿童结核病诊断的关键步骤
A chest X-ray is a key step in the evaluation for TB diagnosis in children.

淋巴结肿大是在X光检查中一个非常频繁
Hypertrophy of lymphadenopathies is a very frequent sign on X-rays

且典型的征兆
and a very typical sign on X-rays.

您能观察到右侧肺门淋巴结肿大
Here you can observe a hypertrophy of the right hilar adenopathies

并在CT扫描中发现淋巴结坏死的典型特征
and on this CT scan the typical aspect of necrotic adenopathy.

这些淋巴结会肿大
These adenopathies may enlarge

压迫临近的气道
and compress adjacent airways to

诱发肺不张或肺内气体潴留
induce atelectasis or lung air trapping.

X光检查中其他典型影像学
Other typical signs on X-rays

表现有提示支气管播散的 树芽征
are a budding tree attesting for bronchial dissemination,

弥漫性粟粒状小结节影
diffuse micronodular Miliary disease,

以及在青春期更常见的胸膜炎征
or pleurisy which is more frequent in adolescents.

由于气道中的杆菌数量非常少
Very frequently,TB disease in children will remain unconfirmed microbiologically

儿童中的结核病在微生物学方面依然很难诊断
because of the very low number of bacilli in the airways.

从怀疑患有结核病的儿童收集到的痰标本中
Among samples collected in children suspected of TB,

少于5％为涂阳
less than 5% will be smear-positive

少于10％为培养阳性
and less than 10% will be culture-positive.

无论痰标本采集方法是什么
The positive culture ratewill remain below 10% whatever the method of collection,

自发性排痰
either spontaneous expectoration,

胃吸出物
gastric aspirate,

鼻咽吸出物还是诱导痰
nasopharyngeal

阳性培养率都保持在10％以下
aspirate, or induced sputum.

特别是有粘液吸引器的话
If achievable, especially if a mucus aspirator is available,

鼻咽吸出物是胃吸出物很好的替代品
nasopharyngeal aspirates are a good alternative to gastric aspirates.

儿童中也会进行Xpert试验
Xpert was also evaluated in children.

当与培养比较时
When compared to culture,

特异性评估在98%-99％之间
the specificity is evaluated between 98 and 99%.

涂片阳性样本的灵敏度约为100％
The sensitivity in smear-positive samples is approximately 100%.

但涂片阴性且培养阳性的样本的灵敏度
But the sensitivity in smear-negative but culture-positive samples

仅在50％至60％之间
is only between 50 and 60%.

因此
Thus,

对疑似患结核病的儿童的诊断价值很低
the diagnostic gain is quite low in children suspected of TB.

如果阳性Xpert样本
If a positive Xpert sample

是可做为治疗这种情况的一个指标
is an indication to treat this situation

那么只有不到10％的儿童会有影响
will concern less than 10% of children.

更重要的是
Very importantly,

Xpert结果阴性并不能排除结核病的可能
a negative Xpert result does not exclude TB diagnosis.

根据世界卫生组织的推荐
As recommended by the World Health Organization,

Xpert可以成为疑似患有耐多药结核病
Xpert can be the initial diagnostic test in children suspected

或艾滋病相关结核病儿童的初步诊断测试
of having MDR-TB or HIV-associated TB.

对于儿童活动性结核病治疗
There are clear recommendations for treatment

有明确的建议
of active pulmonary TB in children.

在持续两个月的第一阶段中
Most children with active TB should be treated

大部分活动性结核病患儿
with only 3 drugs initially

最开始只需使用3种药物进行治疗
during the first phase of 2 months.

但有些患儿一开始就要使用4种药物
But some children should receive a 4-drug

进行治疗
regimen initially,

像是有肺部广泛性病变的患儿
especially children with extensive pulmonary disease

特别是涂阳结核病患儿
and especially those with smear-positive TB,

还有艾滋病患儿
HIV children,

和生活在耐异烟肼
and children living in countries

高流行国家的患儿
with a high prevalence of resistance to isoniazid.

识别和治疗潜伏性结核感染
（latent tuberculous infection，简称"LTBI"）
Identification and treatment of LTBI

是预防接触了活动性结核病患者的儿童
is a key step to prevent progression

患上活动性结核病的关键步骤
to active disease in children exposed to active pulmonary cases.

接触结核病人后
Following exposure,

在没有活动性结核病的证据的情况下
latent infection could be defined by the demonstration

潜伏感染可通过对结核抗原的免疫应答
of an immune response to tuberculosis antigens

来确认
without evidence of active disease.

在有接触史的儿童中
In an exposed child,

当接触距离越近
the risk of infection is higher

时间越长
when the contact is close,prolonged

并且病例的传染性越高时 感染的风险越高
and when the contagiousness of the index case is high.

年龄较小的儿童
The risk of progression of infection towards disease

尤其是5岁以下儿童和有免疫抑制的儿童
is greater in younger children, especially in children under 5,

由感染发展成为疾病的风险更大
and in immunosuppressed children.

根据各国的人均收入
Strategies to test for LTBI will differ

检测潜伏性结核感染
（latent tuberculous infection，简称"LTBI"）的策略也有所不同
according to the income of the countries.

在高收入国家
In high-income countries,

所有感染HIV病毒
testing for LTBI is recommended in children living with HIV,

接触过肺结核病人
in all children in contact with pulmonary TB cases,

或是有特殊情况的儿童都建议接受LTBI检测
and in children with specific conditions.

但在低收入国家
In low-income countries,however,

建议把重点放在和HIV感染者同住的幼儿
it is recommended to focus on children living with HIV and young children

或与结核病病人亲密接触过的儿童身上
who are in a household or in close contact with people with TB.

γ干扰素释放试验分析技术（interferon gamma release assay，简称“IGRA”）或皮肤结核菌素试验（tuberculin skin test，简称“TST”）检测都可以使用
Either IGRA or TST may be used.

有几个针对潜伏性结核感染（latent tuberculous infection，简称"LTBI"）患儿的推荐治疗方案
There are several regimens recommended for LTBI in children.

与长期方案相比 短期的更受欢迎
Shorter-duration regimens are preferred over longer-duration regimens.

最常见的推荐方案是服用6个月的异烟肼
The most frequent recommended regimens are either 6-month isoniazid

或3到4个月的异烟肼
or 3 to 4-month isoniazid

加利福平
plus rifampicin.

儿童的肝损伤风险很低
The risk of hepatotoxicity is considerably low in children.

HIV阳性的儿童要避免使用
Rifampicin-containing regimens

有利福平的治疗方案
should be avoided in HIV-positive children.

至于接触耐多药肺结核的案例
In case of contact with MDR-TB,

开展预防性治疗要基于个案的具体情况
the initiation of a preventive treatment is a case-by-case discussion based on:

儿童特定风险
child specific risks,

当地资源能提供多高质量药物敏感性测试
local resources to provide high quality drug-susceptibility testing,

可获得的必要药物
availability of all the necessary medications,

以及对治疗效果或副作用的密切监控能力
and ability to closely monitor the treatment, either efficacy or side-effects.

感谢您的关注
Thank you for your attention.