本文選題：非結(jié)核分枝桿菌　切入點(diǎn)：糖尿病　出處：《浙江大學(xué)》2015年博士論文

【摘要】：第一部分浙江地區(qū)非結(jié)核分枝桿菌在疑似肺結(jié)核患者中的流行研究背景非結(jié)核分枝桿菌(Nontuberculous mycobacteria, NTM)是抗酸染色陽性的分枝桿菌,在近幾年獲得了越來越多的關(guān)注。因?yàn)槭澜绺鞯貐^(qū)的研究發(fā)現(xiàn),NTM的發(fā)病率在普遍上升；而且作為環(huán)境中廣泛存在的細(xì)菌,NTM可以在免疫缺陷患者中引起嚴(yán)重的感染性疾病,累及肺部,皮膚,軟組織,骨髓等部位,并常常被誤診為結(jié)核病。作者所在課題組,從2011年初開始在浙江省傳染病防治示范區(qū)收集從疑似肺結(jié)核患者的痰標(biāo)本中培養(yǎng)得到的分枝桿菌菌株,到2013年底已收集了1831位患者的1953株抗酸染色陽性細(xì)菌,從中鑒定出113株NTM,來自于100位患者。本研究據(jù)此對這些分枝桿菌標(biāo)本中的NTM菌株和患者進(jìn)行了研究。目的為了調(diào)查疑似肺結(jié)核患者中的NTM感染的流行情況,以及患者的一般情況、臨床表現(xiàn)、死亡相關(guān)因素、社會經(jīng)濟(jì)學(xué)因素和NTM菌株的耐藥情況,在位于我國東南沿海地區(qū)的浙江省展開了本研究。方法從2011年1月1日起到2013年12月31日止,通過浙江省示范區(qū)的結(jié)核病監(jiān)測網(wǎng)絡(luò),收集到來源于100位患者的113株NTM菌株。所有菌株均進(jìn)行了分枝桿菌菌種鑒定芯片的鑒定和基因測序以獲得確認(rèn),并進(jìn)行了相關(guān)抗生素的體外液體微量稀釋法藥敏試驗(yàn)。結(jié)果2011年NTM從抗酸染色陽性的分枝桿菌標(biāo)本中的檢出率為5.0%,2012年為6.1%,2013年為6.2%(P0.5)。2011年、2012年及2013年浙江省示范區(qū)的NTM肺部感染的發(fā)生率分別為3.29/10萬(95%CI：1.12-9.69),4.24/10萬(95%CI：1.64-10.98),3.33/10萬(95%CI：1.14-9.75)。感染者主要包括三類人群：中低收入的中老年男性,流動的從事體力勞動的年輕男性,患有肺氣腫等基礎(chǔ)肺部疾病的中老年女性。分離和鑒定得到的主要菌種包括胞內(nèi)分枝桿菌,鳥分枝桿菌,堪薩斯分枝桿菌和膿腫分枝桿菌。經(jīng)體外藥敏試驗(yàn)發(fā)現(xiàn),膿腫分枝桿菌對多種抗生素有很高的耐藥比率,所有的堪薩斯分枝桿菌都對利福平敏感,所有的胞內(nèi)分枝桿菌和烏分枝桿菌都對克拉霉素敏感。結(jié)論浙江地區(qū)流行的NTM主要包括四種：胞內(nèi)分枝桿菌,鳥分枝桿菌,堪薩斯分枝桿菌和膿腫分枝桿菌。三類主要的感染人群說明,NTM的肺部感染的發(fā)生可能和個體的工作環(huán)境、生活環(huán)境以及肺部基礎(chǔ)疾病具有密切聯(lián)系。因?yàn)檎憬貐^(qū)的膿腫分枝桿菌對常用抗生素具有較高的耐藥率,所以在對NTM肺病的患者進(jìn)行抗分枝桿菌的抗生素治療以前,需要對致病的NTM進(jìn)行菌種鑒定,并進(jìn)行體外藥敏試驗(yàn),采用敏感抗生素的聯(lián)合治療方案進(jìn)行治療。第二部分浙江地區(qū)胞內(nèi)分枝桿菌的ERIC-PCR基因圖譜分析背景ERIC-PCR (Enterbacterial Repetitive Intergenic Consensus-Polymerase Chain Reaction)擴(kuò)增得到的細(xì)菌DNA主要包含基因間的重復(fù)保守性序列,可以結(jié)合聚類分析方法用來研究同種不同株的細(xì)菌間的同源性關(guān)系。目的目前沒有胞內(nèi)分枝桿菌可以直接在人與人之間傳播和感染的研究證據(jù)。因此我們假設(shè)在浙江地區(qū)流行的胞內(nèi)分枝桿菌具有高度不同源性,并通過ERIC-PCR對收集的38株胞內(nèi)分枝桿菌進(jìn)行了研究和分析。方法從2011年1月1日起到2012年12月31日止,收集到來源于36位患者的37株胞內(nèi)分枝桿菌和1株胞內(nèi)分枝桿菌標(biāo)準(zhǔn)株并進(jìn)行ERIC-PCRo結(jié) 果每株細(xì)菌都有擴(kuò)增產(chǎn)物,產(chǎn)物大小介于100bp-2000bp,條帶數(shù)目介于3-12條。38株胞內(nèi)分枝桿菌的ERIC-PCR指紋圖譜具有程度不一的差異,沒有條帶完全相同的指紋圖譜結(jié)論ERIC-PCR是可以被用來對胞內(nèi)分枝桿菌進(jìn)行分子分型和同源性檢測的實(shí)驗(yàn)技術(shù)。浙江地區(qū)流行的胞內(nèi)分枝桿菌的同源性程度很低。第三部分多重耐藥非結(jié)核分枝桿菌致多發(fā)性骨髓炎病例的研究報道非結(jié)核分枝桿菌(Nontuberculous mycobacteria, NTM)是近年來獲得重視和關(guān)注的一類重要的機(jī)會性致病菌,不僅可以感染肺部,還可以累及骨髓、皮膚、淋巴結(jié)等全身多處器官,在免疫缺陷患者中造成后果嚴(yán)重的感染。但是因?yàn)榘l(fā)病率低,所以長期未獲得重視和了解。糖尿病患者也屬于免疫缺陷的人群,因此由各種病原菌引起的骨髓炎也是糖尿病患者中一類重要的并發(fā)癥,但是世界范圍內(nèi)的已發(fā)表文獻(xiàn)中只有很少的病例報道是關(guān)于糖尿病患者中發(fā)生的NTM骨髓炎。在這個病例報道中,我們報告了一例69歲的來自浙江地區(qū)的男性糖尿病患者,先被診斷為結(jié)核性骨髓炎。后來借助基因芯片技術(shù)被確診為胞內(nèi)分枝桿菌感染引起的全身多發(fā)性的骨髓炎,并通過體外藥敏試驗(yàn)和23S-rDNA直接測序技術(shù)確認(rèn)發(fā)生了對大環(huán)內(nèi)酯類抗生素耐藥的突變。盡管如此,多種抗生素的聯(lián)合治療方案在這個病人身上仍然取得了控制感染的效果。在討論部分我們進(jìn)行了文獻(xiàn)檢索,根據(jù)目前世界范圍內(nèi)的英語文獻(xiàn)情況對糖尿病患者中的NTM骨髓炎的發(fā)生情況進(jìn)行了綜述。
[Abstract]:Non Mycobacterium tuberculosis in a suspected epidemic background of pulmonary tuberculosis patients in non Mycobacterium tuberculosis in Zhejiang area the first part (Nontuberculous mycobacteria NTM) is a positive acid fast stain Mycobacterium, get more and more attention in recent years. Because the study area around the world found that the incidence of NTM in general increase; and as the environment is widely existed in bacteria, NTM can cause serious infectious disease in immunodeficient patients involving the lungs, skin, soft tissue, bone marrow, and is often misdiagnosed as tuberculosis. The author's research group, began collecting the infectious disease prevention and treatment demonstration area in Zhejiang province from sputum samples of suspected pulmonary tuberculosis patients in the culture of Mycobacterium strains obtained from early 2011 to the end of 2013, has collected 1831 patients with 1953 strains of acid fast stain positive bacteria, 113 strains of NTM from identified from 100 Patients in this study. The study of these specimens in Mycobacterium strains and NTM patients. Objective to study the prevalence of suspected pulmonary tuberculosis in NTM infected patients, and in general, patients with clinical manifestations, death related factors, social economic factors and drug resistance of strain NTM, located in the southeast coastal area China's Zhejiang Province carried out this study. Methods from January 1, 2011 to December 31, 2013, the TB monitoring network demonstration zone in Zhejiang Province, collected from 113 NTM strains from 100 patients. All strains were identified and sequenced Mycobacterium species identification chip to be confirmed, and in vitro microdilution susceptibility test of antibiotics were carried out. The results of 2011 NTM from Mycobacterium detection acid fast stain positive specimens in the rate of 5%, 6.1% in 2012, 2013 Year 6.2% (P0.5).2011, 2012 and 2013 in Zhejiang Province demonstration area NTM lung infection incidence rate was 3.29/10 million (95%CI:1.12-9.69), 4.24/10 million, 3.33/10 million (95%CI:1.64-10.98) (95%CI:1.14-9.75). The infection mainly includes three groups: low-income older men, the flow of manual labor a young man suffering from emphysema of lung disease in elderly women. The main strain was separated and identified including Mycobacterium intracellulare and Mycobacterium avium, Kansas Mycobacterium tuberculosis and Mycobacterium abscessus. The drug sensitivity test in vitro showed that Mycobacterium abscessus has a high rate of resistance to multiple antibiotics, all Kansas Mycobacterium are sensitive to rifampin, all Mycobacterium intracellulare and Mycobacterium Ukraine are sensitive to clarithromycin. Conclusion epidemic in Zhejiang area NTM mainly includes four kinds: intracellular Mycobacterium Coli, Mycobacterium avium and Mycobacterium abscessus and Kansas. Three main types of infections that may occur and the individual working environment of NTM pulmonary infection, living environment and lung diseases are closely linked. Because the resistance of Mycobacterium abscessus in Zhejiang area has a high rate of antibiotics, antibiotic treatment and so anti Mycobacterium pulmonary disease in NTM patients before, the need for pathogenic NTM strain identification, and drug sensitivity test in vitro, using combination therapy of sensitive antibiotic treatment. ERIC-PCR gene of Mycobacterium intracellular region analysis of the second part of the Zhejiang ERIC-PCR (Enterbacterial Repetitive Intergenic Consensus-Polymerase background Chain Reaction) amplification of bacteria DNA mainly includes repeat conserved sequences between genes, can be combined with clustering analysis The method used to study the different strains of bacteria homology relationship. There is no purpose of m.intracellulare can be directly transmitted from person to person and the infection of evidence. So we hypothesized that popular in the Zhejiang area of m.intracellulare highly different sources, and through the ERIC-PCR 38 cell lines to collect in mycobacteria were studied and analyzed. Methods from January 1, 2011 to December 31, 2012, were collected from 36 patients with 37 m.intracellulare and 1 m.intracellulare standard strain and ERIC-PCRo results of each strain has amplified products, product size is 100bp-2000bp, ERIC-PCR fingerprint bands ranged from 3-12.38 m.intracellulare have different degrees of bands, not exactly the same conclusion ERIC-PCR fingerprint that can be used for the m.intracellulare Molecular typing and homology detection experiment technology. Zhejiang area popular m.intracellulare homology degree is very low. The third part multi drug resistant studies reported multiple osteomyelitis cases caused by Mycobacterium tuberculosis non Mycobacterium tuberculosis (Nontuberculous mycobacteria NTM) is a kind of important opportunistic get attention and concern in recent years the pathogens of pulmonary infection, not only can, but also can affect the skin, bone marrow, lymph node and multiple body organs, causing serious consequences of infection in immunocompromised patients. But because of the low incidence, so long did not get attention and understanding. Diabetic patients also belong to immunocompromised people, therefore caused by various pathogenic bacteria osteomyelitis is an important type of diabetes complications, but the world has published only a few cases reported in the literature on diabetes patients In the NTM in the osteomyelitis. Case report, we report the case of a 69 year old from the Zhejiang area men with diabetes, first diagnosed as tuberculous osteomyelitis. Then by means of gene chip technology was diagnosed with Mycobacterium intracellulare infection caused by systemic multiple osteomyelitis, and the drug sensitivity in vitro test and 23S-rDNA sequencing confirmed that mutations of macrolide resistance. However, combination therapy of antibiotics still achieved control effect of infection in this patient. In the discussion section we conducted a literature search, according to the current situation of English literature in the world of diabetic patients. NTM osteomyelitis was reviewed.

【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2015
【分類號】：R181.3

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本文編號：1719601