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肺結核合併愛滋病治療台北榮民總醫院感染科國立陽明大學愛滋病預防及研究中心王永衛醫師TAIWAN0.08%(0.03-0.14)WorldwideAdultPrevalenceofHIVInfectionHIV-infectedPerso

ns•Total:18386(in2009)•AIDS:5811•Deaths:2418OnART5000(33%)1,000,000-1,200,000HIV-infectedindividualsinUSA,2007,57%onARTSyno

vateHealthcareU.S.HIVMonitorQ2,2007;CentersforDiseaseControlandPrevention(CDC):http://www.cdc.gov;TaiwanCenterforDisease

Control(2009report)目前愛滋病毒感染存活人數:4000萬人每年新感染HIV人數:500萬人每年愛滋病患死亡人數:300萬人120011001000900800700600500400300200

10001:5121:2561:1281:641:321:161.81.41.20WeeksYears0369123456789101112CD4TCells/mm3PlasmaViremiaTiter

PrimaryinfectionPossibleacuteHIVsyndromeWidedisseminationofvirusSeedingoflymphoidorgansClinicallatencyDeathOpportunisticdiseasesConstitu

tionalsymptoms()()NaturalHistoryofHIVInfection結核病~三千年歷史的古老疾病埃及時代西元前3700-1000年誰是肺結核病人?魯迅李叔同林徽音林黛玉身邊隨時都有機會接觸病人，與其排斥逃避，不如主動關懷，幫助病人好好治療。R

obertKoch結核病防治全球每年約有300萬人死於結核病，約300萬人死於愛滋病，其中愛滋病人死於結核病約佔1/3。全球約有1/3人口已受結核菌感染，每年約有800萬人新發生結核病，其中台灣約佔15,000人

。何謂結核病（TBtuberculosis）？慢性傳染性疾病由結核分枝桿菌（結核桿菌）所引起的由飛沫（空氣）傳染病情進展緩慢，早期症狀不明顯人體之任何器官都可能得結核病，以肺部居多認識結核桿菌（t

uberclebacillus）嗜氧菌、抗酸菌，喜潮濕、陰暗處長約1～10μm〈微米〉，寬約0.2～0.6μm，生長期約4～8週最適宜之生存溫度是37℃怕熱、怕火，100℃，5分鐘；65℃，15分鐘即可殺菌

怕陽光；紫外線照射迅速死亡認識結核桿菌（tuberclebacillus）典型分枝桿菌非典型分枝桿菌人型結核桿菌鳥型、牛型分枝桿菌具傳染性不具傳染性菌落粗糙菌落較散，平滑HIVprevalenceinadults,andTB

notificationrates,forKisumu,KenyaNatRevImmunol2005;5:819-26.TB-HIVco-infectioninTaiwanHIV帶原者中有5.6%曾罹患結核

病2006年確診結核病與HIV資料庫進行勾稽◼HIV(+)/TB的比率為0.71%（112人）◼PrevalenceofHIVinadultTBpatients(15–49yrs)is2.03%in200614486366168

759211216758150421678416472153780.25%0.36%0.45%0.45%0.56%0.73%0.53%0.76%0.95%1.01%1.13%2.03%0200040006000800010000120001400016000180002001

200220032004200520060.00%0.50%1.00%1.50%2.00%2.50%HIV(+)-TBallTBHIV/TB%HIV/TB%15-49y/oClinicalmanifestationi

nAIDSwithdisseminatedmycobacterialinfectioninNTUHS/SDTB(22)DMAC(15)Fever21(95.5)14(93.3)Nightsweating15(68.2)4(26.7)BWloss10

(45.5)11(73.3)Diarrhea5(22.7)7(46.7)LNP15(68.2)1(6.7)Hepatosplenomegaly3(13.3)6(40)Splenomegaly2(9.1)7(467)AIDS1998;12:1301-7CX

RfindingTBinHIVinfectedpatientsCD4>200CD4<200UpperlobesinvolvementLowerlobepneumoniaCavityHilarormediastinalLNPMiliaryTBNormalN

ormalCXR8-20%28Y/OMSMProductivecoughfor1months,BWlossCD438HIVvirusload460000SputumAFS(-),Lungbiopsy:granulomatousinflammation,

Caseousnecrosis,Multinucleargiantcell2006040420060928TBTBempyemaPulmonaryTBwithTBlymphadenitis42y/oMSMIntermittent

fever,nightsweatingfor2monthsCD4215CD81175HIVvirusload486000LNaspirateAFS(+)SputumTBculture:MTBExtra

-pulmonarytuberculosisPJPandTB38y/oMSMDOEfor2weeks,BWloss11KgCD464CD8345HIVvirusload67300WBC2840,SputumTBculture:MTB,Bloodc

ulture:Salmonellacholeraesuis2006020720060214DiagnosisHIVinfectionwithTBSpecimenMicroscopy%Culture%Sputum40-6774-95BronchoscopyBronchoal

veolarlarvage7-2052-89Transbronchialbiopsy10-3942-85Urine2245-77Blood26-64Lymphnodes37-9040-95Bonemarrow18-5225-67CSF0-2

7PleuralspecimenPleuralfluid3-6Pleuralbiopsy52-55TextbookofAIDSMedicine1999;Chapter16ComparisonofHIVD

iseaseProgressioninTBTCStudy23vs.CPCRA019/ACTG222YearsofenrollmentBaselineCD4cellcountUseofHAARTduringTBtreatmentDeathwithin1yearofstarto

fTBtherapyDeathornewOIwithin1yearofstartofTBtherapyTBTC231999-20029080%4.5%15.7%CPCRA/ACTG1993-199586020%3

8.9%OverlappingSideEffectProfilesofFirst-lineAntituberculosisDrugsandAntiretroviralDrugsSideeffectPossiblecausesAntituberculosisdrugsAntiretro

viraldrugsSkinrashNausea,vomitingHepatitisLeukopenia,anemiaPZA,RIF,INHPZA,RIF,RBT,INHPZA,RIF,RBT,INHRBT,RIFNVP,EFZ,ABCZDV,RTV,AMP,IDV

NVP,PIs,ImmunereconstitutionZDVIRSresponsetopathogensMycobacteriumtuberculosis(TB)Mycobacteriumaviumcomplex(MAC)Cytomegalovirus(CMV),C

ryptococcusPneumocystisToxoplasmaHepatitisBVaricellazostervirus.ClinicalDiseasesandNTMinHumansClinicalDisease

NTMPulmonaryMACM.kansasiiM.chelonaeM.xenopiLymphadenitisMACM.scrofulaceumCutaneousM.marinumM.fortuitumM.chelonaeM.ulcerans

DisseminatedMACM.genovenseM.kansasiiM.chelonaeM.haemophilumM.malmoenseTextbookofAIDSMedicine1999Mycobact

eriualspeciescausingDisseminatedNTMinfectioninAIDSpatientsSpeciesNumber(%)MAC1906(96.1)M.kansasii57(2.9)M.gordonae11(0

.6)M.fortuitum5(0.3)M.chelonae5(0.3)AmRevRespirDis1989;139:4-7ClinicalSyndromesofDisseminatedMACinAIDSGeneraliz

edFeverFatigueWeightlossPancytopeniaGastrointestinalChronicdiarrheaAbdominalpainChronicmalnutritionPeriportalLNPExtrabiliaryobstructivejaundiceMACp

neumonia