肠系膜淋巴结结核

　　肠系膜淋巴结结核的发生是由结核杆菌感染所致的。本病多见于儿童和青少年，分原发性和继发性，原发性常因饮用受结核杆菌污染的牛奶或乳制品而发病；继发性较原发性多见，多继发于开放性肺结核或肠结核。病变淋巴结若破溃可引起结核性腹膜炎。

　　Mesenteric lymph node tuberculosis often complicates with diseases such as open pulmonary tuberculosis or intestinal tuberculosis, tuberculous peritonitis, varicose veins of the abdominal wall, pyloric obstruction, and incomplete intestinal obstruction. Mesenteric lymph node tuberculosis can also lead to malnutrition and intestinal adhesions in children.

　　Patients with mesenteric lymph node tuberculosis manifest persistent low fever, fatigue, and discomfort. There is often persistent, hidden pain in the umbilical or lower right abdomen, which may sometimes worsen acutely, or it may manifest as acute abdominal pain, similar to colic, accompanied by nausea and vomiting, and may have diarrhea or constipation. On physical examination, enlarged lymph nodes can be palpated around the umbilicus or in the upper left abdomen and lower right abdomen, with tenderness, often suspected to be acute appendicitis and surgery is performed. In chronic mesenteric lymph node tuberculosis, symptoms of chronic intoxication and malnutrition may occur, manifested as long-term irregular low fever, decreased appetite, weight loss, anemia, fatigue, and diarrhea. Sometimes, nodular, enlarged lymph nodes can be palpated, which are relatively fixed and not easily movable. Enlarged lymph nodes can compress the portal vein, causing obstruction of venous return, leading to ascites and varicose veins of the abdominal wall; compress the inferior vena cava to cause lower limb edema; compress the pylorus to cause pyloric obstruction; and compress the intestines to cause incomplete intestinal obstruction. Adults may lack clinical symptoms and manifest as palpable abdominal masses around the umbilicus, which are discovered to be lymph node tuberculosis only when laparotomy is performed.

　　The prevention of mesenteric lymph node tuberculosis mainly involves controlling the source of infection, cutting off the route of transmission, and protecting susceptible populations. The specific preventive measures are described as follows.

　　1. Control the source of infection

　　1. The main source of tuberculosis transmission is tuberculosis patients Early rational chemotherapy for sputum-positive tuberculosis patients can reduce the sputum tuberculosis bacteria in a short period of time, even to disappear, and almost 100% can be cured. Therefore, early detection of patients, especially those with positive cultures, and timely rational chemotherapy are the central links in the modern prevention and treatment of tuberculosis. The method of early detection of patients is to perform X-ray chest films and bacteriological examinations on suspected patients in a timely manner.

　　2. Reduce the opportunity for transmission Positive sputum tuberculosis patients are the main source of infection for pediatric tuberculosis. Early detection and rational treatment of sputum-positive tuberculosis patients are fundamental measures for preventing pediatric tuberculosis. For families of infants and young children with active tuberculosis, detailed examinations, chest X-rays, and tuberculin tests should be conducted. Regular physical examinations should be conducted for staff in primary schools and kindergartens to timely detect and isolate the source of infection, which can effectively reduce the chance of pediatric tuberculosis infection.

　　3. Popularize BCG vaccination Practice has proven that BCG vaccination is an effective measure for preventing pediatric tuberculosis. BCG vaccine can be administered on the same day as the hepatitis B vaccine during the neonatal period.

　　2. Cut off the route of transmission

　　Tuberculosis bacteria are mainly transmitted through the respiratory tract, therefore, spitting on the ground is prohibited. The sputum of positive patients, daily necessities, and surrounding items should be disinfected and properly disposed of. Indoor air can be disinfected with ultraviolet light, the utensils used by patients can be boiled, bedding can be exposed to the sun, and痰盒、便器 can be soaked in 5% to 10% Lysol. In daily life, it is necessary to maintain indoor ventilation and clean air, take frequent showers, and change clothes regularly.

　　3. Protect susceptible populations

　　1. Vaccination with BCG vaccine, which is a non-pathogenic live vaccine, can provide specific immunity against tuberculosis to uninfected individuals after administration, with a protection rate of about 80%, and can last for 5 to 10 years; the main targets for vaccination are newborns, infants, children, and adolescents, as well as ethnic minorities entering cities; however, the immunity produced by the BCG vaccine is relative, and other preventive measures should be emphasized.

　　2. Enhance the ability to resist infection and self-protection, establish good hygiene and living habits, do not smoke, do not overindulge in alcohol, take frequent showers, ensure adequate sleep, maintain a balanced diet and reasonable nutrition, strengthen physical exercise, prevent colds, and use antibiotics rationally; reduce contact with tuberculosis patients, and when visiting patients, take preventive measures such as wearing masks, only when allowed by the doctor.

　　Four, preventive chemotherapy is mainly used for the following objects.

　　1. Children under 13 years old who have not been vaccinated with BCG and have a positive tuberculin test.

　　2. Those who are in close contact with patients with open pulmonary tuberculosis, usually family members.

　　3. The tuberculin test has recently changed from negative to positive.

　　4. Tuberculin test shows a strong positive reaction.

　　5. Tuberculin test is positive, children need to use adrenal cortical hormones or other immunosuppressants for a relatively long period of time.

　　The examination of mesenteric lymph node tuberculosis includes blood tests, tuberculin test, barium meal, abdominal flat film, and other specific examination methods are described as follows.

　　1. Erythrocyte sedimentation rate

　　It is significantly accelerated, which can be one of the indicators for evaluating the degree of activity of tuberculosis.

　　2. Blood routine

　　White blood cell count is normal, lymphocytes are increased. Hemoglobin is slightly decreased.

　　3. Plasma protein

　　About 20% of chronic patients have hypoalbuminemia.

　　4. Tuberculin test

　　The tuberculin test at a concentration of 1:10,000 shows a positive reaction, which has reference value.

　　5. Abdominal flat film

　　There are scattered calcified shadows outside the mesentery, especially at the distal end of the ileum.

　　6. Barium meal

　　If intestinal tuberculosis is present, there may be rapid intestinal motility, stimulation of the lesion segment causing contraction, and poor filling. When the lesion involves the small intestine, barium meal may show irritation, the small intestine's motility is enhanced, and narrowing may occur.

　　7. Chest X-ray

　　It can be found that there are tuberculosis foci in the lungs.

　　8. Smear and culture

　　Finding acid-fast bacilli in pleural effusion is an important means of diagnosing tuberculosis, but the positive rate is low, only 20% to 30%.

　　9. Detection of Mycobacterium tuberculosis antibody

　　In the past, antibodies (PPD-IgG, PPD-IgM) were detected using natural antigens such as PPD, with poor sensitivity and specificity. Due to the preparation of purified or semi-purified antigens of Mycobacterium tuberculosis, there has been significant progress in the detection of specific antibodies against Mycobacterium tuberculosis. Commonly used purified antigens include recombinant 38kD tuberculosis protein antigen.

　　10. Enzyme-linked immunosorbent assay (ELISA)

　　Used to detect anti-tuberculosis antibodies in the serum, cerebrospinal fluid, and pleural effusion of tuberculosis patients, which can serve as an auxiliary diagnostic indicator.

　　11. Enzyme-linked immunoelectrophoresis technique (ELIEP)

　　A type of immunological technique combining ELISA with electrophoresis, it is a serological method for auxiliary diagnosis of various tuberculosis diseases.

　　12. Detection of Mycobacterium tuberculosis antigen

　　Methods such as ELISA, latex agglutination test, and reverse passive hemagglutination test are used to detect the antigen of Mycobacterium tuberculosis in body fluids.

　　13. Mixed lymphocyte culture + interferon determination.

　　Patients with mesenteric lymph node tuberculosis should consume foods high in calories, high in protein, high in vitamins, and high in dietary fiber. Patients should avoid smoking and drinking; when taking isoniazid, they should avoid eating fish without scales and foods containing lactose; and when taking rifampicin, they should avoid milk.

　　The treatment of mesenteric lymph node tuberculosis includes anti-tuberculosis treatment, symptomatic treatment, and laparotomy, and the specific methods of treatment are described as follows.

　　1. Treatment principles

　　Attention should be paid to nutrition, and more protein, vitamin, and iron-rich foods should be eaten, and anti-tuberculosis drugs should be used for treatment. The method is basically the same as that for tuberculous peritonitis, and the course of treatment is 1-1.5 years. When the enlarged lymph nodes compress abdominal organs and produce corresponding symptoms, and medical treatment is ineffective, surgical treatment can be considered to relieve the compression. The caseous necrotic lymph nodes can have the caseous material removed. The other lymph nodes that do not produce compression symptoms are generally not treated.

　　2. Anti-tuberculosis treatment

　　The selection of anti-tuberculosis drugs: the treatment of tuberculous mesenteric lymphadenitis is similar to that of other parts of tuberculosis, but the course of treatment must be 1-1.5 years. For initial cases, streptomycin, isoniazid, pyrazinamide, rifampin, and other first-line drugs are the first choice. In order to delay or prevent the development of drug resistance, it is currently emphasized that 2-3 drugs be used in combination therapy, and the recurrence rate after 6 months of combined treatment with rifampin, isoniazid, and streptomycin is only 3%. If it is secondary tuberculous mesenteric lymphadenitis, the patient may have received anti-tuberculosis drug treatment and developed some drug resistance to first-line drugs, and second-line drugs such as ethambutol, ethionamide, kanamycin, and ciprofloxacin can be considered. Generally, the patient's自觉 symptoms can improve within 1-2 weeks after the start of treatment, appetite increases, body temperature and stool tend to be normal. However, if treatment is not timely and the disease has reached the later stage, even if reasonable and sufficient anti-tuberculosis treatment is given, it cannot prevent the occurrence of complications.

　　3. Symptomatic treatment

　　1. Diarrhea Laxatives such as attapulgite powder (Simeta) and bismuth subcarbonate (bismuth subcarbonate) can be used.

　　2. Abdominal pain Atropine, atropine, and other drugs can be given, and intravenous infusion and potassium salts can be given to severe cases.

　　3. Incomplete obstruction In addition to the above symptomatic treatment, gastrointestinal decompression should be performed.

　　4. Laparotomy

　　This disease is often suspected to be acute appendicitis and surgery is performed. During the operation, it can be found that the appendix is mostly normal, but the mesenteric lymph nodes are often enlarged, and there may be a small amount of fluid in the abdominal cavity. At this time, the appendix can be removed as usual, one lymph node can be removed for histological examination, the abdominal cavity can be sutured but not drained, and most patients can recover.