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1、临床病原学检查临床病原学检查上海第二医科大学上海第二医科大学 附属瑞金临床医学院检验系附属瑞金临床医学院检验系 洪秀华洪秀华 卫蓓文卫蓓文病例分析病例分析 以性传播性疾以性传播性疾病为例病为例 n n【病史摘要】n n 一入院病历n n 患者：陈某，男性，25岁，音响推销员，未婚。2019年3月8日入院。住院号32334。n n 主诉：龟头部长“疱疮，反复不愈。n n 现现病病史史：阴阴茎茎、包包皮皮两两侧侧、龟龟头头部部出出现现小小水水疱疱，疼疼痛痛难难忍忍。患患者者2 2年年前前曾曾与与一一酒酒店店效效力力员员热热恋恋，有有过过性性接接触触。以以后后约约1010天天左左右右，龟龟头头部部感
2、感到到灼灼热热，不不久久即即感感疼疼痛痛，并并出出现现几几个个小小水水疱疱。很很快快破破溃溃渗渗水水。经经某某医医院院诊诊治治，按按“ “性性病病治治疗疗，注注射射“ “利利福福平平、“ “淋淋必必治治等等药药物物，未未见见好好转转，反反而而创创面面扩扩展展，水水疱疱溃溃破破相相连连成成片片，2020余余天天后后相相继继衰衰退退。约约1 12 2月月后后，外外生生殖殖器器又又出出现现小水疱，病症比前更小水疱，病症比前更为严为严重，故来院就重，故来院就诊诊。n n 既往史：身体安康，无其他系既往史：身体安康，无其他系统统疾患。疾患。n n 个人家庭史：无不良生活史，父母健在。个人家庭史：无不良生
3、活史，父母健在。 n n体体体体格格格格检检查查：神神神神志志志志清清清清，全全全全身身身身倦倦倦倦怠怠怠怠。体体体体温温温温37.637.6，脉脉脉脉搏搏搏搏7272次次次次/ /分分分分，呼呼呼呼吸吸吸吸2121次次次次/ /分分分分，血血血血压压110/70mmHg110/70mmHg。心心心心肺肺肺肺检检查查无无无无异异异异常常常常发发现现，腹腹腹腹 ，肝肝肝肝脾脾脾脾未未未未及及及及，无无无无肾肾区区区区叩叩叩叩击击痛痛痛痛。外外外外生生生生殖殖殖殖器器器器皮皮皮皮肤肤肤肤见见阴阴阴阴茎茎茎茎、龟龟头头部部部部有有有有豌豌豌豌豆豆豆豆、米米米米粒粒粒粒、大大大大头头针针大大大大小小小
4、小不不不不一一一一的的的的小小小小水水水水疱疱疱疱，部部部部分分分分水水水水疱疱疱疱交交交交融融融融，破破破破溃溃，中中中中央央央央伴伴伴伴糜糜糜糜烂烂，微微微微痛痛痛痛。腹腹腹腹股股股股沟沟沟沟淋淋淋淋巴巴巴巴结结稍稍稍稍肿肿大，大，大，大，压压痛明痛明痛明痛明显显，排尿不适，下肢疼痛。，排尿不适，下肢疼痛。，排尿不适，下肢疼痛。，排尿不适，下肢疼痛。n n辅辅助助助助检检查查：旧旧旧旧结结核核核核菌菌菌菌素素素素实实验验弱弱弱弱阳阳阳阳性性性性，肾肾B B超超超超检检查查未未未未见见异异异异常常常常，尿尿尿尿液液液液普普普普通通通通检检查查WBCWBC+、RBCRBC ，蛋蛋蛋蛋白白白白-
5、 -疱疱疱疱疹疹疹疹分分分分泌泌泌泌液液液液涂涂涂涂片片片片、革革革革兰兰染色、染色、染色、染色、镜检镜检，未，未，未，未见见革革革革兰兰阴性双球菌。阴性双球菌。阴性双球菌。阴性双球菌。 n n 入院初步诊断：性传播性疾病，Sexually transmitted diseases,STDs可疑生殖器疱疹再发型。临床病原体检查目的:n n临床病原体检查目的:n n 是确定感染的发生和性质，在疾病早期提供恰当的治疗方案，并采取有效的预防措施，防止感染传播呵斥的危害。各种不同病原体的实验诊断方各种不同病原体的实验诊断方法遵照以下根本原那么：法遵照以下根本原那么：1.1.正确、规范采集和运送标本。正
6、确、规范采集和运送标本。2.2.直接显微镜查见病原体或检出直接显微镜查见病原体或检出病原体抗原，借助分子生物学的病原体抗原，借助分子生物学的方法检测病原体核酸，结合病人方法检测病原体核酸，结合病人的病史、病症或体征，快速作出的病史、病症或体征，快速作出初步诊断。初步诊断。各种不同病原体的实验诊断方各种不同病原体的实验诊断方法遵照以下根本原那么：法遵照以下根本原那么：3.初步诊断同时，对病原体进展分别与鉴定。4.检测机体对病原体的免疫产物。5.参与临床选择抗菌药物，指点 和监控微生物的治疗方案，防止 耐药菌株的产生。姬姆萨染色衣原体包涵体HSV病毒被支原体感染的精子梅毒螺旋体检测工程显微镜检查n
7、 n阴道、尿道分泌物阴道、尿道分泌物n n下疳、湿疣、下疳、湿疣、脓脓疱疹液疱疹液n n疱疹基底疱疹基底组织组织刮片刮片n n宫颈宫颈拭子或刮片拭子或刮片检测工程分别、培育、鉴定标本接种：选择适宜的培育基、察看菌落性状作生化鉴定病毒、立克次体、衣原体、接种细胞或易打动物察看增殖目的和血清学方法鉴定。检测工程分别、培育、鉴定A、在培育基上1/4的外表滚动棉拭接种B、装淋球菌培育皿的适宜罐子检测工程分别、培育、鉴定C、巧克力琼脂上淋病奈瑟菌菌落D、几种奈瑟菌的快碳水化合物降解实验检测工程抗体检测 梅毒血清学实验n n非密螺旋体抗原实验：非密螺旋体抗原实验：n n venereal disease
8、venereal disease reearch laboratoryreearch laboratory，VDRLVDRLn n 不加热血清反响素不加热血清反响素玻片实验玻片实验USRUSRn n 快速血浆反响素环快速血浆反响素环状卡片实验状卡片实验RPRRPRn n 自动反响素实验自动反响素实验ARTARTn n 检测工程抗原检测n n1、单纯疱疹病毒抗原检测n n2、HIV抗原检测n n3、衣原体抗原检测HIV抗原检测实验原理表示图检测工程核酸检测n n1 1、HIVHIV核酸检测核酸检测n n2 2、梅毒螺旋体、梅毒螺旋体PCRPCR检测检测n n3 3、衣原体核酸探针、衣原体核酸探针
9、n n4 4、支原体核酸检测、支原体核酸检测细菌感染检查检验特点n n经过对标本直接显微镜检，病原菌的分别培育鉴定，病原菌的抗原检测，核酸检测和细菌感染后机体免疫应对产物的测定及药物的测定及药物敏感性实验，对细菌感染性疾病可作出及时、准确的病原学诊断。 检测程序Diagnosis of bacterial infections n nThe The identification identification and and differentiation differentiation of of bacteria bacteria principally relies:principally
10、 relies:n n -on -on microbial microbial morphology morphology and and growth growth variables variables on on culturing culturing the the organisms organisms on on non-non-selective selective and and selective selective media. media. Culture Culture remains remains the the standard standard for for
11、diagnosis diagnosis of of bacterial bacterial infection infection because because it it is is the the simplest,the simplest,the most most reliable reliable and and the the most most cost cost efficient efficient method. method. Another Another advantage advantage is is the the fact fact that that pa
12、rallel parallel testing testing of of the the sensitivity sensitivity towards antibiotics is possible.towards antibiotics is possible.n nn molecular-biological technics that provide rapid identification of infectious agents,both from culture isolates and directly within clinical specimens.n n - on t
13、he detection of the antibody response to the pathogen. The concentration of infection-sepcific antibodies is determined in titers or activity units.n nIn principle,the pathogen should be identified by culture in any acute infection that requires treatment.This,however,is only possible if the pathoge
14、n is still detectable in excretions,secretions,blood or tissue at the time when the clinical symptoms occur,e.g. salmonellae in feces in the case of diarrhea or gonococci from endocervical canal in genital tract infection.病毒感染检查检验特点n n标本处置：必需经滤过除菌，标本需迅速冷藏、运送。n n病毒分别培育后，根据细胞病变特征确定病毒的种，对已分别的病毒用知参考血清作中
15、和实验、补体结合实验、血凝抑制实验。n n新的早期诊断技术：核酸杂交技术、PCR技术。病实毒验感室染诊性断疾 病 的 Diagnosis of viral infectionsn n The primary diagnostic technique for most viral infections is the isolation of the virus in cell culture. Serologic techniques may also be useful, especially if the virus was isolated from a nonsterile site.
16、In some instances, serologic diagnoses is the only practical approach in a clinical laboratory. Direct detection of antigen in body fluids or tissues has also been effective for some viruses. The list of agents for which direct detection of antigen is useful will undoubtedly continue to expand.n n T
17、he compare of the advantages and The compare of the advantages and disadvantages of each of these approaches:disadvantages of each of these approaches:n nCulture:Culture:n n Time:Days to weeks Time:Days to weeksn n Advantages:Specificity and sensitivity Advantages:Specificity and sensitivity maximum
18、;isolate available for characterizationmaximum;isolate available for characterizationn n Disadvantages:Cell culture facilities Disadvantages:Cell culture facilities needed;time for diagnosis may be longneeded;time for diagnosis may be longn nDirect detection:Direct detection:n n Time:Hours to 1 day
19、Time:Hours to 1 dayn n Advantages:Speed of diagnosis;used for Advantages:Speed of diagnosis;used for viruses difficult to cultureviruses difficult to culturen n Disadvantages:False-positives and Disadvantages:False-positives and negatives;hard to batch testsnegatives;hard to batch testsn nSerology:S
20、erology:n n Time:Weeks Time:Weeksn n Advantages:Assessment of immunity or Advantages:Assessment of immunity or response to virus isolated from nonsterile site; response to virus isolated from nonsterile site; used for viruses difficult to cultureused for viruses difficult to culturen n Disadvantages
21、:Potential cross- Disadvantages:Potential cross-reaction;need for acute and convalescent reaction;need for acute and convalescent specimensspecimens真菌感染检查检验特点n n形状学检查为检测真菌的重要手段n n抗原检测适宜血清和脑脊液中隐球菌、念珠菌、夹膜组织胞浆菌。n n血清学诊断适用于深部真菌感染。Direct Examinationn n It is highly recommended that a direct microscopic I
22、t is highly recommended that a direct microscopic examination be made on most this provide an examination be made on most this provide an immediate presumptive diagnosis for the physician, but immediate presumptive diagnosis for the physician, but it may also aid in the selection of an appropriate c
23、ulture it may also aid in the selection of an appropriate culture medium.medium.n n A phase-contrast microscope is a valuable adjunct in A phase-contrast microscope is a valuable adjunct in the direct examination of specimens. The advantages the direct examination of specimens. The advantages include the following:1)mounts can be made and include the following:1)mounts can be made and examined quickly;2)there is no need for direct examined quickly;2)there is no need for direct staining;and3)the objects can be clearly visualized.staining;and3)the objects can be clearly visualized.n n菌丝、孢子
