Kifua kikuu : Tofauti kati ya masahihisho

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Pitio la 22:16, 6 Machi 2013

"Kifua kikuu," "MTB," au "TB" (kifupi cha tubercle bacillus) ni ugonjwa unaosambazwa, na mara nyingi ni wa hatari ni ugonjwa wa kuambukiza. Ugonjwa huu husababishwa na aina mbalimbali za vimelea mycobacteria, pia hujulikana kama Mycobacterium tuberculosis.^[1] Kifua kikuu kwa kawaida kinaathiri mapafu, lakini pia kinaweza kuathiri sehemu nyingine za mwili. Kifua Kikuu husambazwa kutoka kwa mtu mmoja hadi mwingine kwa kupitia hewa wakati anapokoa, kupiga chafya, au mate yake yakiwa hewani AP ^[2] Maambukizi mengi hayana dalili hayaleti madhara. Lakini moja kati ya kumi ya maambukizi yasiyoleta madhara hatimaye huendelea na kuwa ugonjwa unaoleta madhara. Kama kifua kikuu kisipotibiwa, kinaua zaidi ya 50% ya watu walioambukizwa.

Dalili za kawaida za maambukizi ya kifua kikuu kinacholeta madhara ni kikohozi sugu na kukohoa damu, Kohozi, homa, kutokwa na jasho usiku, na kukonda. (Kifua kikuu kilikuwa kinaitwa "matumizi" kwa sababu watu walioambukizwa hupunguza uzito.) Maambukizi ya viungo vingine husababisha dalili mbalimbali. utambuzi wa kifua kikuu kwa kutumia eksirei ya kuchunguza ugonjwa hujulikana kama eksirei ya kifua na pia wanatumia maikroskopi} na kufanya uchunguzi wa vimelea maradhi vya majimaji ya mwilini. Uchunguzi wa kifua kikuu kisicholeta madhara hutumia kipimo kiitwacho tuberculin skin test au kipimo cha ngozi (TST) na vipimo vya damu. tiba si rahisi na inabidi kupewa dawa nyingi za kinga mwili kwa kipindi kirefu. Mawasiliano ya kijamii pia yanapimwa na kutibiwa kama inavyotakiwa. Dawa kushindwa kutibu magonjwa ni tatizo kubwa la maambukizi mengi sugu ya kifua kikuu (MDR-TB). Ili kuzuia kifua kikuu, ni lazima watu wapimwe ugonjwa na wachanjwe na chanjo ya bacillus Calmette - Guérin .

Wataalamu wanaamini kwamba theluthi moja ya Idadi ya watu duniani wameambukizwa kifua kikuu, ^[3] na kila sekunde kuna mtu ambaye anaambukizwa ^[3] Mwaka 2007, kadri ya watu 13,700,000 duniani waliambukizwa na kifua kikuu kinacholeta madhara sugu ^[4] Mwaka 2010, kadri ya milioni 8.8 ya watu waliambukizwa na milioni 1.5 ya watu walifariki baada ya kuambukizwa na kifua kikuu, na wagonjwa wengi wanapatikana katika nchi zinazoendelea. ^[5] Idadi halisi ya wagonjwa wa kifua kikuu imekuwa ikipungua tangu mwaka 2006, na kesi mpya zimeshuka tangu mwaka 2002 ^[6] Kifua kikuu sio ugonjwa unaosambazwa kisawasawa duniani kote. Kadri ya 80% ya watu katika nchi nyingi za Asia na Afrika waliofanyiwa kipimo cha ngozi walionekana wameambukizwa, lakini ni asilimia 5-10% tu ya wananchi wa Marekani ambao walionekana na ugonjwa huo <ref. Name= Robbins /> Watu wengi waliopo katika zinazoendelea duniani wanaambukizwa na kifua kikuu kwa sababu ya kutokuwa na kinga. Kwa kawaida, hawa watu wanaambukizwa na kifua kikuu baada ya kuambukizwa na VVU na hatimaye wanapatwa na UKIMWI <ref. Name= Lancet11 />

Dalili na ishara

Faili:. Dalili za kifua kikuu.svg

Dalili kuu na ishara tofauti pamoja na hatua za kifua kikuu zinajulikana ^[7] Dalili nyingi huchanganyika na ishara zingine, ingawa kuna dalili zingine ambazo (ingawa sio lazima) ni za aina fulani ya kifua kikuu. Aina mbalimbali za kifua kikuu zinaweza kuwepo kwa pamoja.

Kuna kadri ya 5-10% ya watu ambao hawana VVU ingawa wameambukizwa na kifua kikuu na wanapatwa na madhara katika maisha yao ^[8] Kwa upande mwingine, 30% ya watu ambao wameambukizwa na VVU pamoja na kifua kikuu, huwa wanapatwa na madhara ya ugonjwa huo ^[8] Kifua Kikuu kinaweza kuambukiza sehemu yoyote ya mwili, lakini kwa kawaida hutokea katika mapafu (na inajulikana kama kifua kikuu cha mapafu) <ref. name= ID10 /> TB Extrapulmonary ni kifua kikuu kinachotokea sehemu yoyote ya mwili yaani nje ya mapafu. TB Extrapulmonary inaweza pia kuwepo pamoja na kifua kikuu cha mapafu <ref. Name= ID10 /> Ishara na dalili ni pamoja na homa, baridi, Kutokwa na jasho usiku, kupoteza hamu ya kula, kukonda , na uchovu. ^[9] Kuna uwezekano mkubwa wa kujikunja kwa kucha pembeni <ref. Name= Pet2005 />

Mapafu

Kifua kikuu kikiambukiza kinaathiri mapafu kwa 90% ya wagonjwa ^[10] ^[11] Dalili zake huweza kuwa maumivu ya kifua na kikohozi cha muda mrefu chenye makohozi.<-! ^[10] -> Kadri ya 25% ya watu hawana dalili yoyote (yaani, wao hawaonyeshi "dalili") ^[10] Wakati mwingine, wagonjwa. wanakohoa damu kwa kiasi kidogo. Wakati mwingine, ugonjwa unaweza kusababisha mshipa wa mapafu imomonyoke, na kusababisha damu nyingi kuvuja hali hii inaitwa Rasmussen's aneurysm.<-! ^[9] -> Kifua kikuu kinaweza kusababishwa na vimelea sugu na kusababisha makovu katika masikio ya juu ya mapafu.<-! ^[9] ->.. Mara nyingi ni mapafu ya juu yanayoathirika ^[9] Sababu haijulikani vizuri ^[1] Labda mapafu ya juu yanaathirika zaidi kwa sababu yanapata hewa kwa njia bora ^[1] au kwa sababu ya ukaushaji mbaya wa limfu . ^[9]

Kifua kikuu katika sehemu nyingine ya mwili

Kadri ya 15-20% ya madhara yanayoletwa na ugonjwa yanaletwa na maambukizi yanayoenea nje ya viungo vya kupumua, na husababisha aina nyingine ya kifua kikuu .^[12]/1} Kifua kikuu kinachotokea nje ya viungo vya kupumua kinaitwa "extrapulmonary tuberculosis" ^[13] Extrapulmonary TB hutokea zaidi kwa wagonjwa wenye upungufu wa kingamwili na watoto wadogo. ExtrapulmonaryTB hutokea kwa zaidi ya 50% ya wagonjwa wenye VVU ^[13] Sehemu zinazoathiriwa na extrapulmonary TB ni pamoja na sehemu za nje ya mapafu pleura (au pleurisy tuberculous), mfumo wa neva (au kifua kikuu cha uti wa mgongo), na mfumo wa limfu (katika scrofula ya shingo).Extrapulmonary TB pia hutokea katika [mfumo wa [mkojo na sehemu za siri]] (au kifua kikuu cha sehemu za siri) katika mifupa na viungo (au Pott's disease wa mgongo), na maeneo mengine. Inapoenea katika mifupa, inajulikana kama "kifua kikuu cha mifupa", ^[14] ambayo ni aina ya maambukizi ya mifupa au osteomyelitis ^[15] Aina hatari zaidi ya Extrapulmonary TB inaitwa TB ya "kueneza", inajulikana kama kifua kikuu inayoenea mwilini <ref. Name= ID10 /> Asilimia 10% ya kifua kikuu kinachotokea nje ya viungo vya kupumua, husababisha kifua kikuu inayosamba mwilini. ^[16] Visababishi

Mycobacteria

IKisababishi kikubwa cha kifua kikuu ni Mycobacterium tuberculosis, ni kiumbe kidogo, [[ | kinachohitaji oksijeni]] na kisichotembea bacillus ^[9] Sifa nyingi za kipekee za kiumbe hiki zinaletwa na ongezeko kubwa la mafuta ^[17] Ina seli inayojigawa [[ | ]] kila baada ya masaa 16 hadi 20. Kiwango hiki si kikubwa ukilinganishwa na bakteria zingine, ambazo kwa kawaida vinajigawa kwa muda usiopungua saa mmoja ^[18] Mycobacteria wana utando wa nje utando wa mafuta ^[19] Kama jaribio la Gramu stain likifanywa, MTB haikolei sana rangi yaani "Gram-positive" haipatikani na rangi haionekani kwa sababu utando wake una mafuta mengi mafuta pamoja na asidi Mycolic acid. ^[20] MTB inaweza kuhimili kemikali dhaifu na hivi vimelea vinaweza kuishi katika sehemu kavu kwa wiki moja. Kwa kawaida, bakteria zinaweza kukua na kuishi tu ndani ya seli ya kiumbe viumbe, lakini M. tuberculosis' inaweza kukuzwa ya maabara. ^[21]/3}

Kwa kutumia vipimo vya kimaabara vya kansa histological kwa kuweka madoa juu ya sampuli ya mate yaliyotoka kwenye makohozi, wanasayansi wanaweza kutambua MTB chini ya makroskopi (nyepesi) ya kawaida. (Phlegm pia inaitwa "kohozi.") MTB huacha madoa hata baada ya kuchanganywa na asidi, na hivyo hujulikana kama Acid-fast bacillus (AFB) ^[1] ^[20] acid-fast bacillus. Kuna njia mbili zinazotumia vipimo vya asidi :. Kipimo kinachojulikana kama Ziehl - Neelsen stain, kinageuza rangi ya vimelea AFB na kuwa vyekundu na vinaonekana wazi wazi dhidi ya sehemu ya bluu, ^[22] na auramine-rhodamine stain ambayo hufuatiwa na makroskopi yenye kuakisi mwanga {{^[23]

Mchangamano wa “M. tuberculosis (MTBC) ni pamoja na bakteria zingine nne zinazosababisha kifua kikuu {mycobacteria: “M. bovis,” “M. africanum,” “M. canetti,” pamoja na “M. microti.”Hitilafu ya kutaja: Closing </ref> missing for <ref> tag^[24] “M. bovis” ndio ilikuwa ni kisababishi kikubwa cha kifua kikuu, lakini baada ya kuanza kutumia maziwa yanayopashwa moto vimelea vya mycobacterium vimeweza kuondolewa na kupuguza matatizo ya kiafya katika nchi zinazoendelea.^[1]Hitilafu ya kutaja: Closing </ref> missing for <ref> tag^[25] "M. microti " pia ni adimu na inawaathiri zaidi watu wenye upungufu wa kingamwili, ingawa ugonjwa huu unaweza kuwa umeenea zaidi kuliko inavyofikiriwa ^[26]

Mycobacteria zingine zinazojulikana ni pamoja na " M. leprae, " " M. avium, " na " M. kansasii ". Hizi aina mbili za mwisho zinajulikana kama " nontuberculous mycobacteria "(NTM). NTM hazisababisha kifua kikuu au ukoma, lakini husababisha magonjwa ya mapafu yanayofanana na kifua kikuu ^[27]

Sababu za hatari

Idadi ya sababu za kufanya watu wahusike zaidi na maambukizi ya TB. Muhimu zaidi ni hatari ya kimataifa Virusi ya Ukimwi ; 13% ya kesi zote TB wameambukizwa na virusi.^[5] Hili ni tatizo hasa katika Afrika kusini mwa Sahara , ambapo viwango vya HIV ni kubwa .^[28]^[29] Kifua Kikuu ni uhusiano wa karibu na wote msongamano na utapiamlo, na kuifanya moja ya magonjwa makuu ya umaskini . This link Wale walio katika hatari ya juu hivyo ni pamoja ugonjwa ya umaskini.^[10] watu ambao hujidunga dawa haramu, wenyeji na wafanyakazi wa locales ambapo watu wanaoishi katika mazingira magumu kukusanya (km magereza na malazi makazi), jamii wasiojiweza kimatibabu na wasio na mtaji, ya hatari kwa makabila madogo, watoto katika mawasiliano ya karibu na hatari ya hali ya juu kwa jamii ya wagonjwa na watoa huduma ya afya ya kuwahudumia wateja.^[30] uvimbe sugu ni sababu nyingine hatari ya ugonjwa. Kwa Silicosis kuongeza hatari kuhusu mara 30. ^[31] Wale ambao moshi sigaras kuwa karibu mara mbili ya hatari ya TB ya wasiovuta sigara.^[32] Baadhi ya dawa hasa yanaweza pia kuongeza hatari ya kifua kikuu katika mataifa yaliyostawi, ulevi ^[10] na Ugonjwa wa kisukari (kuongezeka maratatu ).^[33] Baadhi ya dawa, kama vile corticosteroids na infliximab (an anti-αTNF monoclonal antibody) kuwa inazidi muhimu hatari, hasa katika nchi zilizoendelea.^[10] Kuna pia, upungufu maumbile ^[34] kwa umuhimu ambayo kwa ujumla ni bado siowekwa wazi .^[10]

Mkakati

Uenezaji

Wakati watuwalio na TB hukohoa mapafu , hupiga chafya, kuzungumza, kuimba, au mate, wao hutoa viambukizi erosoli matone 0.5 na 5 µm katika kipenyo. kuchafya moja inaweza kutoa juu ya matone 40,000.^[35] Kila moja ya matone haya wanaweza kuambukiza ugonjwa huo, tangu dozi ya kuambukiza ugonjwa wa kifua kikuu ni ya chini sana. (kuvuta pumzi ya bakteria wachache kuliko Mei 10 kusababisha maambukizi).^[36]

Watu wenye TB kwa muda mrefu akiwa , mara kwa mara, au karibu na watu na TB ni hatari hasa juu ya kuambukizwa, na kiwango cha wastani 22% ya kuambukiza.^[37] Mtu aliye na kifua kikuu hai, lakini hajatibiwa anaweza kuambukiza 10-15 (au zaidi) watu wengine kwa mwaka.^[3] Maambukizi lazima huwepo tu kutoka kwa watu wenye TB hai. Wale wenye maambukizi ya fiche hawadhaniwi kuambukiza. ^[1] uwezekano wa maambukizi kutoka kwa mtu mmoja hadi mwingine inategemea sababu kadhaa , , ikiwa ni pamoja na idadi ya matone ya kuambukiza kufukuzwa na mwenezaji , ufanisi wa uingizaji hewa, muda wa mfiduo, virulence ya M. kifua kikuu strain, kiwango cha kinga katika mtu ambaye hajaambukizwa na wengine .^[38] ili kupunguza maenezi ya mtu-kwa-mtu tenga watu wenye TB hai (" ya wazi ") na kuweka kwenye regimenti dawa za kupambana na TB. Baada ya wiki mbili ya matibabu ya ufanisi, masomo na maambukizi kutokana-upinzani maambukizi kwa ujumla hayazidi kuenea kwa wengine .Hitilafu ya kutaja: Invalid parameter in <ref> tag

Pathojenesisi

Takribani 90% ya watu walioambukizwa ‘‘M. kifua kikuu na Dalili, maambukizi ya TB (wakati mwingine huitwa LTBI). ^[39] na tu 10% maisha nafasi ya kuwa maambukizi fiche itakuwa maendeleo ya ugonjwa ya wazi, kazi ya kifua kikuu. ^[40] Katika wale wanaoishi na H.I.V, hatari ya kupatwa na TB hai inaongezeka hadi 10% karibu mwaka. ^[40] Kama matibabu ya ufanisi hawakujaliwa, kiwango cha kifo kwa kesi kazi TB ni hadi 66%. ^[3]

TB maambukizi huanza wakati mycobacteria TB maambukizi huanza wakati Pulmonary alveolus pulmonary alveoli, ambapo wao kuvamia na kuiga ndani endosomes ya alveolar macrophages tundu la mapafu.^[1]^[41] tovuti ya msingi ya maambukizi katika mapafu, unaojulikana kama "lLengo Ghon focus", ni kwa ujumla iko katika sehemu ama juu ya tundu ya chini, au sehemu ya chini ya tundu juu.^[1] Kifua kikuu cha mapafu pia huweza kutokea kupitia maambukizi kutoka mkondo wa damu, Hii inajulikana kama lengo Simon . A Simon focus na ni kawaida kupatikana katika kilele cha mapafu.^[42] maambukizi haya ya hematogenous yanaweza pia kusambaza maambukizi kwa maeneo ya mbali zaidi, kama vile nodiya limfu ya pembeni, mafigo, ubongo na mifupa.^[1]^[43] Maeneo yote ya mwili yanaweza kuathirika kwa ugonjwa huo, ingawa kwa sababu isiyojulikana ni mara chache tu huathiri moyo, skeletal misuli s, kongosho , au tezi.^[44]

Kifua Kikuu huainishwa kama moja ya magonjwa granuloma ya inflamesheni tatizi. Macrophages, T lymphocytes, B lymphocytes, na fibroblasts ni miongoni mwa seli zinazoungana kuunda limfu granulomas. Lymphocytes na lymphocytes jirani macrophages kwa walioambukizwa. Granuloma huzuia usambazaji wa mycobacteria na hutoa mazingira ya mahali hapo kwa ajili ya mwingiliano wa seli ya mfumo wa kinga. Bakteria ndani ya granuloma inawezalala, kusababisha maambukizi ya fiche. Kipengele kingine cha granulomas ni maendeleo ya kifo isiyo ya kawaida katikati (necrosis) katika kituo cha tubercles. Kwa jicho uchi, hii ina umbo la jibini laini, nyeupe na inaitwa caseous necrosis. ^[45]

Bakteria ya TB inaweza kuingia kwenye mfumo wa damu kutokana na eneo la tishu kuharibiwa. Zinaweza kuenea kwa mwili na kuanzisha maenezi ya  ukimwi, tubercles zote huonekana vidogo, nyeupe katika tishu.  ^[46]Aian hii kali ya ugonjwa wa TB hupatika kawaida zaidi kwa watoto wachanga na wale wanaoishi na VVU, inaitwa kifua kikuu  military .^[47] Watu wenye TB hii  huwa na  kiwango cha juu cha vifo hata kwa matibabu (takriban 30%).^[16]^[48]

Kwa watu wengi, maambukizi ya nta na hafifu. Uharibifu wa tishu na nekrisisi mara nyingi husawazishwa na adilifu. ^[45] Tishu zilizoathirika hubadilishwa kuwa kovu na matundu huujazwa kwa kisiesheni ya nekritiki. Wakati w akuuguaa, baadhi ya mashimo hayo huungana na mapito ya hewa bronchi na nyenzo hii inaweza kutoka kwa kikohozi. Ni ina ya bakteria hai, na hivyo inaweza kueneza maambukizi. Tiba sahihi kiviujasumu inaua bakteria na inaruhusu uponyaji. Juu ya tiba, maeneo yaliyoathirika hatimaye kubadilishwa na tishu kovu. ^[45]

Uaguzi

Kifua Kikuu hai

Ni vigumu kuagua kifua kikuukwa misingi ya ishara na dalilitu^[49]Ni vigumu pai kuagua ugonjwa huo kwawatu wenye wanashida ya kinga.^[50] hata hivyo watu wenye dalili za magonjwa ya mapafu walio na dalili au dalili za kudumu muda mrefu zaidi ya wiki mbili wanaweza kuwa na TB.^[50] kifua X-ray na nyingi sputum utamadumi kwa bacilli asidi haraka ni kawaida sehemu ya tathmini ya awali.^[50] Interferon-γ kutolewa assays na vipimo vya tuberculin ya ngozi hazisaidii katika nchi zinazoendelea.^[51]^[52]IGRAs mapungufu sawa katika wale wanaoishi na VVU.^[53]^[54]

Utambuzi yakinifu wa TB ni yaliyotolewa na kutambua “M. kifua KiKuu” katika sampuli ya kliniki (kwa mfano makohozi, pus, au tishu biopsy). Hata hivyo, ni vigumu kwa utamaduni mchakato huu viumbe polepole-kukua wanaweza kuchukua 2-6 wiki kwa ajili ya damu au utamaduni makohozi.^[55] Hivyo, matibabu ni mara nyingi imeanza kabla ya tamaduni ni alithibitisha.^[56]

Nucleic asidi amplification mithani na kupita Triphosphate deaminase huweza kuruhusu uchunguzi wa haraka wa TB.^[49] Vipimo hivi, hata hivyo, si mara kwa mara ilipendekeza, kama wao mara chache kubadilisha jinsi mtu ni kutibiwa.^[56] Vipimo vya damu ili kuchunguza kingamwili siyo maalum au nyeti kingamwili siyo maalum au nyeti na unyeti na maalum au nyeti , hivyo si ilipendekeza.^[57]

kifua kikuu Sioonekana

Mantoux tuberculin skin test [[Mantoux mithani |Mantoux tuberculin ngozi mithani mara nyingi hutumika kwa watu screen katika hatari kubwa ya TB.^[50] Wale ambao wamekuwa awali chanjo wanaweza kuwa na uongo chanya mtihani matokeo.^[58]mtihani inaweza kuwa uongo hasi katika wale walio na sarcoidosis, Hodgkin's lymphoma, na utapiamlo. au wengi hasa, katika wale ambao kweli kufanya wana kifua kikuu hai. ^[1] [[Interferon assays katika vivuli mbalimbali ya njano lioenea, kuashiria juu ya watu 300 kwa kila 100,000, na kwa Marekani, Canada, Australia, na Ulaya ya kaskazini katika vivuli ya bluu kirefu, kuashiria kiwango cha maambukizi karibu 10 kwa kila watu 100,000. Asia ni njano lakini si hivyo kabisa mkali, kuashiria kiwango cha maambukizi ya kuzunguka 200 per mbalimbali 100,000. Amerika ya Kusini ni ya njano nyeusi. Mwaka 2007, kiwango cha maambukizi ya TB kwa watu 100,000 ilikuwa ya juu katika Afrika Kusini mwa Sahara, na pia alikuwa kiasi katika Asia. >World Health Organization (2009). "The Stop TB Strategy, case reports, treatment outcomes and estimates of TB burden". Global tuberculosis control: epidemiology, strategy, financing. ku. 187–300. ISBN 978-92-4-156380-2. Iliwekwa mnamo 14 November 2009. Check date values in: |accessdate= (help)</ref>kutolewa gamma (IGRAs) juu ya sampuli ya damu, ni ilipendekeza kwa wale ambao ni chanya kwa mtihani Mantoux.

<refname=NICE2011> Kigezo:NICE </ref> IGRAs Haya si walioathirika na chanjo au zaidi mazingira mycobacteria, hivyo wao kuzalisha wachache matokeo ya uongo na HIV. ^[59] hivyo wao kuzalisha wachache matokeo ya uongo na HIV. Hata hivyo wao walioathirika na M. szulgai, M. marinum na M. kansasii.”^[60] IGRAs inaweza kuongeza usikivu wakati kutumika kwa kuongeza mtihani ngozi lakini inaweza kuwa chini zaidi kuliko mtihani nyeti ngozi wakati kutumika peke yake.^[61].

Kuzuia

Kuzuia ya Kifua Kikuu na kudhibiti juhudi kimsingi wanategemea chanjo ya watoto wachanga na kugundua na matibabu sahihi ya matukio hai. ^[10] Shirika la Afya Duniani (WHO) imepata baadhi ya mafanikio mazoezi kuboresha tiba, na kupungua kwa idadi ndogo ya kesi. ^[10]

Chanjo

Chanjo tu sasa inapatikana kama ya 2011 ni bacillus Calmette– Guérin (BCG). Ambayo, wakati ni ufanisi dhidi ya ugonjwa kusambazwa katika utoto, unampa ulinzi dhidi ya kuambukizwa TB haiendani mapafu. ^[62] Hata hivyo, ni wengi sana kutumika chanjo duniani kote, na zaidi ya 90% ya watoto wote kuwa chanjo. ^[10]Hata hivyo, kinga ni kuvuta itapungua baada ya miaka kumi.^[10] Kama kifua kikuu ni kawaida katika zaidi ya Canada, Uingereza, na Marekani, BCG ni tu unasimamiwa na watu katika hatari ya juu. ^[63]^[64]^[65] Sehemu ya hoja akisema dhidi ya matumizi ya chanjo ni kwamba inafanya ngozi tuberculin mtihani uongo chanya, na kwa hiyo, hakuna wa matumizi katika uchunguzi.^[65] idadi ya chanjo mpya ni sasa katika maendeleo^[10]

Afya ya Jamii

Shirika la Afya Duniani alitangaza TB "ya afya ya kimataifa dharura" katika 1993. ^[10] na katika 2006, TB Stop Ushirikiano maendeleo Mpango wa Kimataifa Stop kifua kikuu kwamba lengo la kuokoa maisha ya milioni 14 kati ya uzinduzi wake na 2015.^[66] idadi ya malengo ya wana kuweka si uwezekano wa kupatikana kwa 2015, hasa kutokana na ongezeko katika kifua kikuu HIV-kuhusishwa na kuibuka wa kifua kikuu sugu nyingi (MDR-TB).^[10] [[ mfumo wa kifua kikuu] uainishaji maendeleo na Jamii ya Marekani Thoracic hutumiwa hasa katika mipango ya afya ya umma. .^[67]

Menejimenti

Tiba ya TB anatumia kiuvijasumu na kuua vimelea. Ufanisi kutibu TB ni vigumu, kutokana na muundo wa kawaida na cha kemikali katika ukuta mycobacterial kiini, ambayo inazuia kuingia ya madawa ya kulevya na hufanya kiuvijasumu wengi ufanisi. ^[68] kiuvijasumu mbili ya kawaida kutumika ni isoniazid na rifampicin, na matibabu yanaweza ziongezwe, kuchukua miezi kadhaa. ^[38] kutibu ya sioonekana TB kawaida inaajiri antibiotic moja, ^[69] wakati kazi ugonjwa wa Kifua Kikuu ni bora kutibiwa na mchanganyiko wa kiuvijasumu kadhaa ili kupunguza hatari ya bakteria kuendeleza upinzani antibiotiki. ^[10]. Watu wenye maambukizi ya latent pia kutibiwa kuwazuia inaendelea kwa ugonjwa kazi TB baadaye katika maisha.^[69] Moja kwa moja aliona tiba, yaani kuwa na huduma ya afya mtoa kuangalia mtu kuchukua dawa zao, ni ilipendekeza na WHO katika jitihada za kupunguza idadi ya watu si ipasavyo kuchukua antibiotiki.^[70] ushahidi wa kuunga mkono kitendo hiki juu ya watu tu kutumia dawa zao kwa kujitegemea ni maskini. ^[71] Mbinu ya kuwakumbusha watu kuhusu umuhimu wa tiba wala hata hivyo kuonekana ufanisi.^[72]

Mwanzo mpya

Matibabu ya kifua kikuu ilipendekeza mpya-mwanzo ya mapafu, kama wa 2010, ni miezi sita ya macho ya antibiotiki zenye rifampicin, isoniazidi, pyrazinamide na ethambutol kwa miezi miwili ya kwanza, na tu rifampicin na isoniazidi pyrazinamide, na ethambutol. kwa miezi minne iliyopita. ^[10] Ambapo upinzani isoniazidi ni ya juu, ethambutol inaweza kuongezwa kwa miezi minne iliyopita kama mbadala. ^[10]

Matumizi ya Kawaida ugonjwa

Kama kifua kikuu kurudia, kupima na kuamua ambayo antibiotiki ni nyeti ni muhimu kabla ya kuamua matibabu. ^[10] Kama nyingi TB sugu (MDR-TB) ni wanaona, matibabu na antibiotiki angalau nne madhubuti kwa ajili ya miezi 18 hadi 24 ni ilipendekeza. ^[10]

Upinzani ya Dawa

Upinzani Kanuni hutokea wakati mtu huwa wameambukizwa mnachuja sugu wa TB. Mtu aliye na TB kikamilifu wanahusika inaweza kuendeleza sekondari (alipewa) upinzani wakati wa tiba kwa sababu ya tiba za kutosha, si kuchukua regimen eda ipasavyo (ukosefu wa kufuata), au kwa kutumia chini quality dawa.^[73] Sugu TB ni mbaya ya afya ya umma suala katika nchi nyingi zinazoendelea, kama tiba yake ni tena na inahitaji dawa ghali zaidi. MDR-TB hufafanuliwa kama upinzani kwa mbili ya ufanisi zaidi madawa ya TB ya mstari wa kwanza: rifampicin na isoniazidi. . Sana sugu TB pia ni sugu kwa tatu au zaidi ya madarasa sita ya madawa ya mstari wa pili. .^[74] Kabisa sugu TB, ambayo kwa mara ya kwanza aliona katika 2003 nchini Italia, lakini si sana taarifa mpaka 2012, ni sugu kwa madawa yote kwa sasa kutumika. ^[75]

Ubashiri

Mwendelezo na maambukizi ya TB na ugonjwa wazi ya TB hutokea wakati bacilli kushinda ulinzi mfumo wa kinga na kuanza kuzidisha. Katika ugonjwa wa TB ya msingi (baadhi 1-5% ya kesi), hii hutokea mara baada ya maambukizi ya awali. [219] Hata hivyo, katika matukio mengi ya, maambukizi sioonekana hutokea na hakuna dalili za wazi. ^[1] Hizi bacilli kulala kuzalisha kifua kikuu kazi katika% 5-10 ya kesi hizi sioonekana, mara nyingi miaka mingi baada ya kuambukizwa. ^[8] hatari ya kuongezeka kwa muathiriko immunosuppression, kama vile kuwa husababishwa na maambukizi ya VVU. Katika watu kuambukiza pamoja na M. kifua kikuu na VVU, hatari ya muathiriko inaongezeka hadi 10% kwa mwaka. ^[1] Mafunzo kutumia DNA ya alama ya kidole ya M. kifua kikuu Matatizo umeonyesha kuambukiza tena inachangia zaidi kikubwa kwa TB ya kawaida zaidi kuliko ilivyodhaniwa hapo awali,^[76]na makadirio ili akaunti kwa zaidi ya 50% ya kesi ku hai tena katika maeneo ambapo TB ni ya kawaida.^[77] nafasi ya kifo kutokana na kesi ya kifua kikuu ni kuhusu 4% kama ya 2008, kutoka 8% mwaka 1995.^[10].

Epidemolojia

katika vivuli mbalimbali ya njano lioenea, kuashiria juu ya watu 300 kwa kila 100,000, na kwa Marekani, Canada, Australia, na Ulaya ya kaskazini katika vivuli ya bluu kirefu, kuashiria kiwango cha maambukizi karibu 10 kwa kila watu 100,000. Asia ni njano lakini si hivyo kabisa mkali, kuashiria kiwango cha maambukizi ya kuzunguka 200 per mbalimbali 100,000. Amerika ya Kusini ni ya njano nyeusi. Mwaka 2007, kiwango cha maambukizi ya TB kwa watu 100,000 ilikuwa ya juu katika Afrika Kusini mwa Sahara, na pia alikuwa kiasi katika Asia. >World Health Organization (2009). "The Stop TB Strategy, case reports, treatment outcomes and estimatesofTBburden". Global tuberculosis control: epidemiology, strategy, financing. ku. 187–300. ISBN 978-92-4-156380-2. Iliwekwa mnamo 14 November 2009. Check date values in: |accessdate= (help)</ref>]]Takribani theluthi moja ya idadi ya watu duniani imekuwa kuambukizwa na M. kifua kikuu, na maambukizi mapya ya kutokea kwa kiwango cha moja kwa pili kwa kiwango cha kimataifa. ^[3]Hata hivyo, wengi maambukizi na M. kifua kikuu wala kusababisha ugonjwa wa Kifua Kikuu, ^[78] na 90-95% ya maambukizi ya kubaki bila dalili. ^[39] Mwaka 2007, kulikuwa na wastani wa milioni 13.7 sugu kazi kesi. ^[79] Mwaka 2010, kulikuwa na milioni 8.8 mpya kesi ya TB kukutwa na vifo 1,450,000, zaidi ya haya yanayojitokeza katika nchi zinazoendelea.^[5] Vifo hivi 1,450,000, kuhusu 0,350,000 kutokea katika wale wana ambukizwa pamoja na HIV. ^[80] Kifua Kikuu ni ya pili zaidi ya vifo kutokana na ugonjwa kuambukiza (baada ya wale kutokana na HIV / UKIMWI).^[9]idadi kamili ya kesi kifua kikuu ("maambukizi") imekuwa ikipungua tangu 2005, wakati mpya kesi ("matukio") zimeshuka tangu 2002.^[5]China imepata maendeleo makubwa hasa, pamoja na kupunguza takriban 80% katika kiwango cha TB wake vifo kati ya 1990 na 2010.^[80] Kifua Kikuu ni ya kawaida zaidi katika nchi zinazoendelea; kuhusu 80% ya idadi ya watu katika nchi nyingi za Asia na Afrika mtihani chanya katika vipimo tuberculin, wakati tu 5-10% ya mtihani Marekani idadi chanya.^[1] Matumaini ya kudhibiti ugonjwa huo kabisa wamekuwa kasi unyevunyevu kwa sababu ya mambo kadhaa, ikiwa ni pamoja na ugumu wa kuendeleza chanjo ufanisi, ghali na muda mwingi uchunguzi wa mchakato, umuhimu wa miezi mingi ya matibabu, ongezeko la maambukizi ya virusi-kuhusishwa kifua kikuu , na kuibuka wa kesi sugu katika miaka ya 1980.^[10]

Katika 2007, nchi yenye kiwango cha juu zaidi ya makadirio ya matukio ya TB ilikuwa Swaziland, na kesi 1,200 kwa kila watu 100,000. India ilikuwa kubwa jumla ya matukio, na wastani wa kesi 2.0 milioni mpya. ^[79] Katika nchi zilizoendelea, kifua kikuu ni. ^[79]chini ya kawaida na ni kupatikana hasa katika maeneo ya mijini. Viwango kila watu 100,000 katika maeneo mbalimbali ya dunia ambapo: Kimataifa 178, 332 Kusini, Amerika 36, Bahari ya Mashariki 173, Ulaya 63, Asia ya Kusini 278, na 139 Pacific Magharibi katika 2010 ^[80] Nchini Canada na Australia, kifua kikuu ni mara nyingi zaidi ya kawaida kati ya Watu wa asili,hasa katika maeneo ya kijijini.^[82]^[83]Katika Marekani watu wa asili kuwa vifo vya mara tano zaidi kutoka TB.^[84] matukio ya TB inatofautiana na umri Katika Afrika, kimsingi unaathiri vijana na watu wazima vijana. ^[85]Hata hivyo, katika nchi ambapo matukio viwango zimepungua kasi ( kama vile Marekani), TB ni ugonjwa wa watu hasa wakubwa na kinga iliyoathirika. ^[1]^[86].

Historia

Faili:Maiti katika makumbusho ya Uingereza.jpg

Egyptian maiti katika Makumbusho ya Uingereza - kuoza lioathiriwa na kifua kikuu imekuwa kupatikana katika miiba ya Egyptian mummy=maiti.

Kifua Kikuu imekuwepo kwa binadamu tangu zamani saa ya karibuni Zamani saa ya karibuni .^[10] Mwanzo zisizo na utata kutambua ya M. kifua kikuu inahusisha ushahidi wa ugonjwa huo katika mabaki ya bison tarehe na takriban 17,000 miaka iliyopita.^[87] Hivyo, kama kifua kikuu asili katika mangombe, kisha kuhamishiwa kwa binadamu, au kama ni kuachana kutoka babu ya kawaida, sasa ni wazi. ^[88] kulinganisha genes ya M. kifua kikuu tata (MTBC) kwa binadamu kwa MTBC katika wanyama unaonyesha binadamu hakuwa kupata MTBC kutoka kwa wanyama wakati wa kufuga wanyama kama ilivyoaminika hapo nyuma. Wote Matatizo ya bakteria kifua kikuu kushiriki babu ya kawaida, ambayo ingeweza kuambukizwa binadamu kama mapema kama Mapinduzi Neolithic. ^[89] Mabaki ya kiunzi kuonyesha prehistoric binadamu (4000 KK) BC ) alikuwa TB. Na watafiti wamegundua kuoza enye umbo katika miiba ya Misri ya Egypt mummies kutoka BC 3000-2400.^[90] Phthisis ni neno la Kigiriki kwa ajili ya matumizi, mrefu zamani kwa ajili ya kifua kikuu cha mapafu; ^[91] ] karibu 460 BC, Hippocrates kutambuliwa phthisis kama ugonjwa kuenea zaidi ya nyakati. Ilikuwa alisema kuhusisha homa na kukohoa ya damu, ambayo ilikuwa karibu daima mbaya. ^[92] Masomo ya maumbile zinaonyesha TB alikuwepo katika Amerika kutoka BK mwaka 100. ^[93]

Kabla ya Mapinduzi ya Viwanda, ngano nyingi zinazohusiana na kifua kikuu vampires. Wakati mmoja wa familia walikufa kutokana na hilo, wanachama wengine walioambukizwa bila kupoteza afya yao polepole. Watu waliamini hii kulitokana na mtu awali na TB kuondoa maji maisha kutoka kwa wanachama wengine wa familia.^[94]

Ingawa aina ya mapafu kuhusishwa natubercles ilianzishwa kama patholojia na Dr Richard Morton katika 1689.^[95]^[96] kutokana na aina ya dalili yake, TB ilikuwa si kutambuliwa kama ugonjwa mmoja hadi miaka ya 1820, na haikuitwa kifua kikuu mpaka 1839 na J. L. Schönlein.^[97] Katika miaka 1838-1845, Dk John Croghan, mmiliki wa of Pango Mammoth , kuletwa idadi ya watu wenye kifua kikuu katika pango kwa matumaini ya kutibu ugonjwa na joto mara kwa mara na usafi wa hewa pango; walikufa ndani ya mwaka. ^[98] Hermann Brehmer kufunguliwa kwanza TB sanatorium katika 1859 katika Sokołowsko, Poland.^[99]

Dr. Robert Koch discovered the tuberculosis bacilli.

Kifua kikuu na kusababisha bacillus, ‘’Mycobacterium kifua kikuu ‘’, ilikuwa kutambuliwa na ilivyoelezwa kwenye Machi 24, 1882 na Robert Koch. Alipokea Tuzo ya Nobel katika in Fizilojia au dawa katika 1905 kwa ugunduzi huu. ^[100] Koch hawakuamini bovin (ng'ombe) na kifua kikuu na magonjwa ya binadamu walikuwa sawa. Ambayo kuchelewa utambuzi wa maziwa aliyeambukizwa kama chanzo cha maambukizi. Baadaye, hatari ya maambukizi kutoka chanzo hili kasi kupunguzwa kwa uvumbuzi wa mchakato pasteurishaji. Koch alitangaza dondoo glycerine ya bacilli kinundu kama "dawa" ya kifua kikuu katika 1890, na kuiita 'tuberculin'. Wakati ilikuwa si ufanisi, baadaye mafanikio ilichukuliwa kama mtihani uchunguzi kwa ajili ya uwepo wa kifua kikuu mbele ya dalili. ^[101]

Albert Calmette na Camille Guérin mafanikio ya kwanza ya kweli mafanikio katika utoaji wa chanjo dhidi ya kifua kikuu katika 1906. kwa kutumia mnachuja ya ngombe kufikika kifua kikuu. Ilikuwa inaitwa (bacillus of Calmette and Guérin) (BCG). Chanjo ya BCG mara ya kwanza kutumika juu ya binadamu katika 1921 nchini Ufalansa.^[102] Lakini tu kupokea kukubalika kuenea katika Marekani, Uingereza, and Ujerumani na baada ya Vita Kuu ya II. ^[103]

Kifua Kikuu unasababishwa zaidi kuenea umma wasiwasi katika karne ya 19 na 20 mapema kama ugonjwa wa ndwele maskini wa mijini. Katika 1815, moja katika vifo nne nchini Uingereza ni kutokana na "matumizi". By 1918, moja katika vifo sita katika Ufaransa alikuwa bado unasababishwa na TB. Baada ya kuamua ugonjwa huo kuenea katika miaka ya 1880, TB ilikuwa kuweka liolazimu kujulishwa Ugonjwa katika Uingereza, kampeni walikuwa wameanza kuacha watu kutoka kutema katika maeneo ya umma, na maskini walioambukizwa walikuwa "moyo" kuingia sanatorium sanatoria ambayo inafanana magereza (sanatoria kwa ajili ya madarasa kati na juu inayotolewa huduma bora na matibabu ya mara kwa mara). ^[99] Chochote faida ( kwa kusudi ) ya "hewa safi" na ajira katika sanatoria, hata chini ya hali bora, 50% ya wale waliokuwa wakiingia alikufa ndani ya miaka mitano (circa 1916).^[99]

Katika Ulaya, viwango vya ugonjwa wa kifua kikuu ulianza kupanda katika miaka ya 1600 mapema kwa ngazi kilele katika miaka ya 1800, wakati unasababishwa karibu 25% ya vifo vyote.^[104] Vifo vya kisha ilipungua karibu 90% kwa miaka ya 1950.^[105] Maboresho katika afya ya umma alianza kwa kiasi kikubwa kupunguza viwango vya ugonjwa wa kifua kikuu hata kabla ya kuwasili kwa [[streptomycin] na kiviujasumu nyingine. Ingawa ugonjwa alibakia tishio kubwa kwa afya ya umma ambao vile. Wakati Medical Council Utafiti iliundwa katika Uingereza katika 1913, lengo yake ya awali ilikuwa kifua kikuu utafiti. ^[106]

Katika mwaka 1946, maendeleo yastreptomycin Kiviujasumu alifanya matibabu ya ufanisi na tiba ya TB ukweli. Kabla ya kuanzishwa kwa dawa hii, matibabu tu (isipokuwa sanatoria) alikuwa upasuaji kuingilia, ikiwa ni pamoja na "“mbinu pneumothorax”, ambayo wanaohusika kuanguka uvimbe walioambukizwa na "kupumzika" ni na kuruhusu vidonda tuberculous kuponya. ^[107] kuibuka wa MDR-TB ina tena ilianzisha upasuaji kama chaguo ndani ya kiwango kukubalika kwa ujumla wa huduma katika kutibu magonjwa ya TB. Hali kwa sasa hatua za upasuaji kuhusisha kuondolewa makijishimo ya patholojia ya kifua ("bullae") katika mapafu ya kupunguza idadi ya bakteria na kuongeza mfiduo wa bakteria iliyobaki kwa madawa katika mfumo wa damu, na hivyo ukipungua jumla bakteria mzigo na kuongeza ufanisi wa utaratibu ya tiba ya Kivuijasumu.^[108] Matumaini ya TB kabisa kuondoa (cf. smallpox), walikuwa kwa kimbilio baada ya kupanda ya Matatizo sugu katika miaka ya 1980. Liofufuka baadae ya kifua kikuu ilisababisha tamko la dharura ya afya ya kimataifa na Shirika la Afya Duniani mwaka 1993. ^[109]

Jamii na Ustaarabu

Shirika la Afya Duniani na Bill and Melinda Gates Foundation ni kutoa ruzuku mpya haraka-kaimu uchunguzi mtihani kwa ajili ya matumizi katika nchi chini na kipato cha kati.^[110]^[111] Wengi raslimali maeneo kama ya 2011 bado tu kupata hadubini makohozi.^[112]

India ilikuwa ya juu jumla ya idadi ya wagonjwa wa TB duniani kote katika 2010, kwa sehemu kutokana na usimamizi mbovu ugonjwa ndani ya sekta binafsi ya afya. Mipango kama vile Programu ya Taifa ya Kifua Kikuu karatasi ya kufikiria tena ni kusaidia kupunguza viwango vya TB miongoni mwa watu wanaopata huduma ya afya ya umma.^[113]^[114]

Utafiti

Chanjo ya BCG ina mapungufu, na utafiti wa kuendeleza chanjo ya TB mpya ni unaoendelea.^[115] idadi ya wagombea uwezekano ni sasa katika majaribio ya awamu ya I na II kliniki .^[115] Mbili mbinu kuu ni kuwa kutumika kujaribu kuboresha ufanisi wa chanjo zinapatikana. Moja inahusisha mbinu kuongeza chanjo subunit kwa BCG, wakati mkakati mwingine ni kujaribu kujenga mpya na bora chanjo hai. ^[115] MVA85A, mfano wa chanjo subunit, sasa katika majaribio nchini Afrika Kusini, ni msingi juu ya virusi vya vinasaba kufura ngozi.^[116] Chanjo ni unaotarajiwa kuwa na jukumu muhimu katika matibabu ya wote fiche na ugonjwa hai.^[117]

Kuhamasisha ugunduzi zaidi, watafiti na watunga sera ni kukuza mpya mifano ya kiuchumi ya maendeleo ya chanjo, ikiwa ni pamoja na zawadi, motisha ya kodi, na ahadi mapema Soko .^[118]^[119] Idadi ya makundi, ikiwa ni pamoja na Ushirikiano Stop TB ,^[120] ] Afrika Kifua Initiative Chanjo, na the Aeras TB Duniani Foundation Chanjo , wanahusika na utafiti.^[121] Kati ya hayo, Aeras TB Duniani Chanjo Foundation alipokea zawadi ya zaidi ya $ 280,000,000 (Marekani) kutoka kwa Bill na Melinda Gates Foundation kuendeleza na leseni ya chanjo dhidi ya kifua kikuu bora kwa ajili ya matumizi katika nchi mzigo mkubwa. ^[122]^[123]

Katika wanyama wengine

Mycobacteria kuambukiza wanyama mbalimbali, ikiwa ni pamoja na ndege,^[124]panya,^[125] na wanyama watambaao. ^[126] subspecies Mycobacterium kifua kikuu, ingawa, ni mara chache sasa katika wanyama wa porini. ^[127] jitihada za kutokomeza kifua kikuu ng’ombe unasababishwa na “Bovis Mycobacterium ” kutoka kwa ng'ombe na mifugo kulungu waNew Zealand New Zealand imekuwa na mafanikio.^[128] Jitihada katika Uingereza wamekuwa chini ya mafanikio.^[129]<ref>Kigezo:Cite journal last=Ward</ref

Rejea

↑ ^1.00 ^1.01 ^1.02 ^1.03 ^1.04 ^1.05 ^1.06 ^1.07 ^1.08 ^1.09 ^1.10 ^1.11 ^1.12 ^1.13 Kumar V, Abbas AK, Fausto N, Mitchell RN (2007). Robbins Basic Pathology (toleo la 8th). Saunders Elsevier. ku. 516–522. ISBN 978-1-4160-2973-1.
↑ Konstantinos A (2010). "Testing for tuberculosis". Australian Prescriber 33 (1): 12–18.
↑ ^3.0 ^3.1 ^3.2 ^3.3 ^3.4 "Tuberculosis Fact sheet N°104". World Health Organization. November 2010. Iliwekwa mnamo 26 July 2011. Check date values in: |date=, |accessdate= (help)
↑ World Health Organization (2009). "Epidemiology". Global tuberculosis control: epidemiology, strategy, financing. ku. 6–33. ISBN 978-92-4-156380-2. Iliwekwa mnamo 12 November 2009. Check date values in: |accessdate= (help)
↑ ^5.0 ^5.1 ^5.2 ^5.3 World Health Organization (2011). "The sixteenth global report on tuberculosis".
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↑ Schiffman G (15 January 2009). "Tuberculosis Symptoms". eMedicineHealth. Check date values in: |date= (help)
↑ ^8.0 ^8.1 ^8.2 al.], edited by Peter G. Gibson ; section editors, Michael Abramson ... [et (2005). Evidence-based respiratory medicine (toleo la 1. publ.). Oxford: Blackwell. uk. 321. ISBN 978-0-7279-1605-1.
↑ ^9.0 ^9.1 ^9.2 ^9.3 ^9.4 ^9.5 ^9.6 Dolin, [edited by] Gerald L. Mandell, John E. Bennett, Raphael (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases (toleo la 7th). Philadelphia, PA: Churchill Livingstone/Elsevier. ku. Chapter 250. ISBN 978-0-443-06839-3.
↑ ^10.00 ^10.01 ^10.02 ^10.03 ^10.04 ^10.05 ^10.06 ^10.07 ^10.08 ^10.09 ^10.10 ^10.11 ^10.12 ^10.13 ^10.14 ^10.15 ^10.16 ^10.17 ^10.18 ^10.19 ^10.20 ^10.21 Lawn first=SD; Zumla, AI (2 July 2011). "Tuberculosis journal=Lancet" 378 (9785). ku. 57–72. PMID 21420161. doi:10.1016/S0140-6736(10)62173-3. Check date values in: |date= (help)
↑ Behera, D. (2010). Textbook of pulmonary medicine (toleo la 2nd ed.). New Delhi: Jaypee Brothers Medical Pub. uk. 457. ISBN 978-81-8448-749-7.
↑ Jindal, editor-in-chief SK. Textbook of pulmonary and critical care medicine. New Delhi: Jaypee Brothers Medical Publishers. uk. 549. ISBN 978-93-5025-073-0.
↑ ^13.0 ^13.1 Golden MP, Vikram HR (2005). "Extrapulmonary tuberculosis: an overview". American family physician 72 (9): 1761–8. PMID 16300038.
↑ Kabra, [edited by] Vimlesh Seth, S.K. (2006). Essentials of tuberculosis in children (toleo la 3rd ed.). New Delhi: Jaypee Bros. Medical Publishers. uk. 249. ISBN 978-81-8061-709-6.
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↑ ^16.0 ^16.1 Ghosh, editors-in-chief, Thomas M. Habermann, Amit K. (2008). Mayo Clinic internal medicine : concise textbook. Rochester,MN: Mayo Clinic Scientific Press. uk. 789. ISBN 9781420067491.
↑ Southwick F (10 December 2007). "Chapter 4: Pulmonary Infections". Infectious Diseases: A Clinical Short Course, 2nd ed. McGraw-Hill Medical Publishing Division. uk. 104 Extra |pages= or |at= (help). ISBN 0-07-147722-5. Check date values in: |date= (help)
↑ Jindal, editor-in-chief SK. Textbook of pulmonary and critical care medicine. New Delhi: Jaypee Brothers Medical Publishers. uk. 525. ISBN 978-93-5025-073-0.
↑ Niederweis M, Danilchanka O, Huff J, Hoffmann C, Engelhardt H (March 2010). "Mycobacterial outer membranes: in search of proteins". Trends in Microbiology 18 (3): 109–16. PMC 2931330. PMID 20060722. doi:10.1016/j.tim.2009.12.005. Check date values in: |date= (help)
↑ ^20.0 ^20.1 Madison B (2001). "Application of stains in clinical microbiology". Biotech Histochem 76 (3): 119–25. PMID 11475314. doi:10.1080/714028138.
↑ Parish T, Stoker N (1999). "Mycobacteria: bugs and bugbears (two steps forward and one step back)". Molecular Biotechnology 13 (3): 191–200. PMID 10934532. doi:10.1385/MB:13:3:191.
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