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رخدادهایی که در سطح آزمایشگاه رخ می دهد و نتایجی که در پی
:دارد س�اله در بیمارس�تانی پ�ذیرش ش�د در حالیک�ه تب، ک�اهش وزن 83ی�ک م�رد و� س�رفه �د�اش�ت.� ا�ین� م�ر�د �م�ش�کوک� �ب�ه د�ا�ش�تن ت�وم�ور� �ش�ناخت�ه� ش�د. آ�زم�ایش م ش�د �ام�ا د�ر آز�مایش�ات �بع�دی� ک�ه انج�ام ت�وب�رکل�وز�یس خل�ط� آن م�ر�د، م�ثب�ت اعال�نق�ض را قب�لی ن�تیج�ه �ی گ�ز�ار�ش �گردی�د �و م�ن�فی تو�بر�کل�وزی�س ت�س�ت گ�ر�فت د�اده �ب�ود.� رخ� آ�زمایش�گاه� محیطی �د�ر ال�و�دگی� ع�لت ب�ه� ا�ی�ن �ام�ر ک�ه ن�م�ود
م�و�ر�د از ب�یم�ا�ران 14بر�ر�س�ی �ه�ا�ی بیش�ت�ری �ک�ه ان�ج�ام گ�ر�فت �نش�ان� د�اد �ک�ه �در �د�یگر ن�یز ه�مین اش�تباه رخ �داده بود.�
تاخیر در تشخیص صحیح–مداخالت درمانی غیر الزم–عوارض نامطلوبی که در نتیجه ی در مان رخ داده بود–انواعی از دیگر آلودگیها، یافت شد– 200 ماه6ه ای ب6ود ک6ه در این بررس6ی 6حل این مش6کل نیازمن6د بررس6ی –
ا6ش6عه ی6 دو6ب6ار6ه 6آ6زمایش6ات ق6ر6ار 6دار6ن6د 6ت6ا6 تحت 6مداخل6ه ر6ا را xبیم6ا6ر انجام دهند.
تغییر در رویه های آزمایشگاه، مشکل را رفع نمود.–اش�تباهاتی ک�ه در آزمایش�گاهها رخ میدهن�د منج�ر ب�ه اتالف وقت، ان�رژی،
ن�ی�روی پر�س�نل میش�و�د و ن�ی�ز ب�ه ن�ت�ایج� آزم�ایش�ات اش�تب�اه را� ب�رای بیم�اران .ب��������ه ��������د�نب��������ال ��������خ�و�اه��������د� ��������دا�ش��������ت
Mycobacterium tuberculosis
Mycobacterium leprae (uncommon)
Mycobacterium avium-intracellulaire Complex (MAC) or (M. avium)
Important Human Pathogens
MYCOBACTERIUM• Aerobic bacilli –non spore forming
non motile
• Cell wall –rich in lipids
• Acid-fast bacilli
• Very slow growing
MYCOBACTERIA ASSOCIATED WITH HUMAN DISEASE
Mycobacterium Environmental contaminant Reservoir
M tuberculosis No Human
M bovis No Human, cattle
M leprae No Humn
M kansasii Rarely Water, cattle
M marinum Rarely Fish, water
M scrofulaceum Possibly Soil, water
M avium intracellulare
Possibly Soil, water, birds
M ulcerans No Unknown
M fortuitum Yes Soil, water, animals
M chelonae Yes Soil, water, animals
CLASSIFICATION OF MYCOBACTERIA ASSOCIATED WITH HUMAN DISEASE
Mycobacterium Clinical significance Pigmentation Growth
Unclassified
M Tuberculosis , M bovis
M ulcerans
Strict pathogens No No
M leprae Strict pathogen - -
Runyon Group 1
M marinum , kansasii
Runyon Group 2
Usually pathogenic Photochromogens slow
M scrofulaceum Rarely pathogenic Scotochromogens slow
Runyon Group 3
M avium intracellulare Pathogenic in immunocompromised
No slow
Runyon Group 4
M fortuitum, M chelonae Rarely pathogenic No ‘rapid’
Lipid-Rich Cell Wall of MycobacteriumMycolic acids
CMN Group: Unusual cell wall lipids (mycolic acids,etc.)
(Purified Protein Derivative)
Acid-Fast (Kinyoun) Stain of Mycobacterium
NOTE: cord growth (serpentine arrangement) of virulent strains
Photochromogenic Mycobacterium kansasii on Middlebrook Agar
NOTE: Mycobacteria pathogenic for humans can be differentiated (Runyon Groups) by:
speed of growth (all are slower than most other pathogens) and by
production of chromogenic pigments (in light, in dark, or none)
• Causes tuberculosis• Classic human disease• Pathogenesis• Transmission• Clinical presentations• Diagnosis• Treatment• Prevention
Mycobacterium tuberculosis
Mycobacterium tuberculosis
Infections (cont.)
BCG (bacille Calmette-Guerin) = attenuated M. bovis
Positive PPD + Chest X-Ray +
MDR-TB a serious global health threat
Pneumonia
Granuloma formation with fibrosis
Caseous necrosis• Tissue becomes dry & amorphous (resembling cheese)• Mixture of protein & fat (assimilated very slowly)
Calcification• Ca++ salts deposited
Cavity formation• Center liquefies & empties into bronchi
Typical Progression of Pulmonary Tuberculosis
Diagram of a
Granuloma
NOTE: ultimately a fibrin layer develops around granuloma (fibrosis), further “walling off” the lesion.
Typical progression in pulmonary TB involves caseation, calcification and cavity formation.
Symptoms of Tuberculosis…
• may appear years after contracting the disease
• Fever
• Night-Time Sweating
• Loss of Weight
• Persistent Cough
• Constant Tiredness
• Loss of Appetite
Pathogenesis• Inhaled aerosols
Engulfed by alveolar macrophages Bacilli replicate Macrophages die
• Infected macrophages migrate local lymph nodes• Develop Ghon’s focus Primary complex• Cell mediated immune response
stops cycle of destruction and spread• Viable but non replicating bacilli present in macrophages
EVIDENCE OF INFECTION WITH M TUBERCULOSISChest x-ray / positive skin test
Case Finding
Most common tools for case finding include:
• History taking
• Physical examination
• Sputum examination
• X-ray examination
• Tuberculin skin testing
CLINICAL PRESENTATION
Pulmonary tuberculosisPulmonary tuberculosis
Primary complexAsymptomaticHEALS
REACTIVATIONPost-primary tuberculosis
Acute pulmonary diseaseSystemic spread
Asymptomatic /symptomatic
LATER DISEASERenal / CNS etc
MILIARY TUBERCULOSISPulmonarymeningitis
DIAGNOSIS
Pulmonary tuberculosisPulmonary tuberculosis
Primary complexAsymptomaticHEALS
REACTIVATIONPost-primary tuberculosis
Acute pulmonary diseaseSystemic spread
Aymptomatic /symptomatic
LATER DISEASERenal / CNS etc
MILIARY TUBERCULOSISPulmonarymeningitis
11
23
33
1. Evidence of infection
a. Chest x-ray - hilar lymphadenopathy calcification of primary focus/LN
b. Delayed hypersensitivity response to purified protein derivative (PPD) MANTOUX /HEAF TEST
2. Evidence of active disease
a. Sputum for AFB positive
3. Evidence of active disease
a. Indirect evidence of infection (Mantoux)
b. Direct evidence of infection PCR / culture
c. Histo-pathological evidence
DIAGNOSIS
Recording Sputum Smear Microscopy Results
Number of Acid-fast Bacilli
(AFB)
# of Oil Immersion Fields
Examine
Reported as:
No AFB Per 100 fields No AFB seen
(No AFB per 100 fields)
1-9 AFB Per 100 fields Scanty, record exact figure
(1-9 AFB per 100 fields)
10-99 AFB Per 100 fields 1+ (10-99 AFB per 100 fields)
1-10 AFB Per field 2+ (1-10 AFB per field in 50 fields)
More than 10 AFB Per field 3+ (>10 AFB per field in 20 fields)
Why the Emphasis on Sputum Smears?
Direct Microscopy is the most reliable and cost effective way to identify persons who are most likely to transmit TB
to others
© ITECH, 2006© University of Alabama at Birmingham, Department of Pathology
• Receipt of specimens: from clinics • Preparation and staining of smears• ZN microscopy /recording• Reporting of results• Maintenance of lab register• Management of reagents and supplies• Internal Quality Control (QC)• Collect specimen for culture and DST, send to
NTRL • Participation in EQA
Primary and District LabServices in TB control (Level 1)
Nyangagbwe Referral lab (Level 2)
• Activities: receive specimen for AFB and culture
• Services to clinics: FM/ZN smear microscopy (smear microscopy and send results)
• Support activities: (supply of reagents/ materials, training; EQA for smear microscopy including supervision)
• Inoculate specimen and refer to NTRL for incubation and DST
Role of NTRL in TB Control
• Identify mycobacterium other than MTB • DST of M. Tuberculosis• TB laboratory equipment services and
maintenance• Develop TB Lab manuals and guidelines• Primary link with NTP• Supervision of intermediate QA of culture and
microscopy• Operational and applied research• Provide EQA and monitor peripheral labs
Mycobacterial Culture (1)
• “Gold Standard” of TB diagnosis
• More expensive and more time consuming than microscopy
• Requires specialised training and media to perform
• Not recommended for routine case detection in Botswana
Courtesy of: Kubica G, 2007.
Mycobacterial Culture (2)
Reasons to request mycobacterial culture:• Patient previously on anti-TB treatment• Still smear-positive after intensive phase of
treatment or after finishing treatment• Symptomatic and at high-risk of MDR-TB• To test fluids potentially infected with M.
tuberculosis• Investigation of patients who develop active PTB
during or after IPT• TB in health workers
• DST performed on all cultures– Tests for isoniazid, rifampicin, ethambutol,
and streptomycin
• If found to be multi-drug resistant, then send for additional testing for susceptibility to second-line medicines
TB Drug Susceptibility Testing (DST)
TREATMENT
• Anti-tuberculous drugs– INAH– Rifampicin– Ethambutol– Pyrazinamide
• DOT
• Multi-drug resistant tuberculosis
PREVENTION
• Incidence declined before availability of anti-tuberculous drugs
• Improved social conditions - housing /nutrition• Case detection & treatment• Contact tracing• Evidence of infection / disease• Treatment of infected / diseased contacts
ROLE OF IMMUNIZATIONBCG (bacillus Calmette Guerin)
ROLE OF IMMUNIZATIONBCG (bacillus Calmette Guerin)
حا 12 کیفی سیستم عاملهمیت ا ئز
کیفیت سیستماز ای مجموعه
هماهنگ های فعالیتعنوان به که شده
می عمل هایی بلوکی سازنده و کنندسیستم ساختار
باشند می .کیفیت
کنترل فرایند، کنترل
کیفیت و نیز کنترل نمونه های آزمایشگاه
ی
خرید و موجودی
مدیریت ارزیابیبحران
مدیریت اطالعات
ارتقاء و بهبود فرایند
خدمات مشتری مدار
تسهیالت و ایمنی
سازمان پرسنل تجهیزات
اسناد و مدارک
کنترل فرایند، کنترل
و کیفیتمدیریت
های نمونهآزمایشگاهی
و خریدی ذخیرهموجودی
ارزیابیمدیریت
رخداد
مدیریت
اطالعات
ی توسعهفرایند
خدمات مشتری
مدار
و تسهیالتایمنی
تجهی پرسنل سازمانزات
مدارو کاسناد
کاری جریان مسیر