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1病例分析病例分析 以以性传播性疾病性传播性疾病性传播性疾病性传播性疾病为例为例 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。1998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。2n 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服服务务员员热热恋恋，有有过过性性接接触触。此此后后约约1010天天左左右右，龟龟头头部部感感到到灼灼热热，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大大，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消消退退。约约1 12 2月月后后，外外生生殖殖器器又又出现小水疱，症状比前更为严重，故来院就诊。出现小水疱，症状比前更为严重，故来院就诊。n n 既往史：身体健康，无其他系统疾患。既往史：身体健康，无其他系统疾患。n n 个人家庭史：无不良生活史，父母健在。个人家庭史：无不良生活史，父母健在。 3n n体体体体格格格格检检检检查查查查：神神志志清清，全全身身倦倦怠怠。体体温温37.637.6，脉脉 搏搏 7272次次 / /分分 ， 呼呼 吸吸 2121次次 / /分分 ， 血血 压压110/70110/70mmHgmmHg。心心肺肺检检查查无无异异常常发发现现，腹腹 ，肝肝脾脾未未及及，无无肾肾区区叩叩击击痛痛。外外生生殖殖器器皮皮肤肤见见阴阴茎茎、龟龟头头部部有有豌豌豆豆、米米粒粒、大大头头针针大大小小不不一一的的小小水水疱疱，部部分分水水疱疱融融合合，破破溃溃，中中央央伴伴糜糜烂烂，微微痛痛。腹腹股股沟沟淋淋巴巴结结稍稍肿肿大大，压压痛痛明明显显，排排尿尿不不适适，下肢疼痛。下肢疼痛。n n辅助检查：辅助检查：辅助检查：辅助检查：旧结核菌素试验弱阳性，肾旧结核菌素试验弱阳性，肾B B超检超检查未见异常，尿液一般检查查未见异常，尿液一般检查WBCWBC（+）、）、RBCRBC（ ），），蛋白（蛋白（- -）疱疹分泌液涂片、革兰）疱疹分泌液涂片、革兰染色、镜检，未见革兰阴性双球菌。染色、镜检，未见革兰阴性双球菌。 4n n 入入 院院 初初 步步 诊诊 断断 ： 性 传 播 性 疾 病 ，（Sexually transmitted diseases,STDs）可疑生殖器疱疹（再发型）。5临床病原体检查目的:n n临床病原体检查目的: 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，防止感染传播造成的危害。6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循以下基本原则：法遵循以下基本原则：1.1.正确、规范采集和运送标本。正确、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、症状或体征，快速作出的病史、症状或体征，快速作出初步诊断。初步诊断。7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循以下基本原则法遵循以下基本原则：3.初步诊断同时，对病原体进行分离与鉴定。4.4.检测机体对病原体的免疫产物。检测机体对病原体的免疫产物。5.5.参与临床选择抗菌药物，指导参与临床选择抗菌药物，指导 和监控微生物的治疗方案，避免和监控微生物的治疗方案，避免 耐药菌株的产生。耐药菌株的产生。8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9检测项目显微镜检查n n阴道、尿道分泌物阴道、尿道分泌物n n下疳、湿疣、脓疱疹液下疳、湿疣、脓疱疹液n n疱疹基底组织刮片疱疹基底组织刮片n n宫颈拭子或刮片宫颈拭子或刮片10检测项目分离、培养、鉴定标本接种：选择合适的培养基、观察菌落性状作生化鉴定n n病毒、立克次体、衣原体、接种细胞或易感动物观察增殖指标和血清学方法鉴定。11检测项目分离、培养、鉴定A、在培养基上1/4的表面滚动棉拭接种B、装淋球菌培养皿的合适罐子12检测项目分离、培养、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试验13检测项目抗体检测 梅毒血清学试验n n非密螺旋体抗原试验：非密螺旋体抗原试验： （venereal disease venereal disease reearch reearch laboratorylaboratory，VDRLVDRL） 不加热血清反应素玻片不加热血清反应素玻片试验（试验（USRUSR） 快速血浆反应素环状卡快速血浆反应素环状卡片试验（片试验（RPRRPR） 自动反应素试验自动反应素试验（ARTART） 14检测项目抗原检测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抗原检测实验原理示意图15检测项目核酸检测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n n4 4、支原体核酸检测、支原体核酸检测16细菌感染检查检验特点n n通过对标本直接显微镜检，病原菌的分离培养鉴定，病原菌的抗原检测，核酸检测和细菌感染后机体免疫应答产物的测定及药物的测定及药物敏感性试验，对细菌感染性疾病可作出及时、准确的病原学诊断。17 检测程序18Diagnosis of bacterial infections n nThe The identification identification and and differentiation differentiation of of bacteria bacteria principally relies:principally 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 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 parallel parallel testing testing of of the the sensitivity sensitivity towards antibiotics is possible.towards antibiotics is possible.19n nn molecular-biological technics that provide rapid identification of infectious agents,both from culture isolates and directly within clinical specimens.n n - on the detection of the antibody response to the pathogen. The concentration of infection-sepcific antibodies is determined in titers or activity units.20n nIn principle,the pathogen should be identified by culture in any acute infection that requires treatment.This,however,is only possible if the pathogen 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.21病毒感染检查检验特点n n标本处理：必须经滤过除菌，标本需迅速冷藏、运送。n n病毒分离培养后，根据细胞病变特征确定病毒的种，对已分离的病毒用已知参考血清作中和试验、补体结合试验、血凝抑制试验。n n新的早期诊断技术：核酸杂交技术、PCR技术。22病实毒验感室染诊性断疾 病 的 23Diagnosis 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. 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.24n n The compare of the advantages and disadvantages of each of these approaches:n nCultureCulture: : TimeTime:Days to weeks:Days to weeks AdvantagesAdvantages:Specificity and sensitivity :Specificity and sensitivity maximum;isolate available for characterizationmaximum;isolate available for characterization DisadvantagesDisadvantages:Cell culture facilities :Cell culture facilities needed;time for diagnosis may be longneeded;time for diagnosis may be long25n nDirect detectionDirect detection: : TimeTime:Hours to 1 day:Hours to 1 day AdvantagesAdvantages:Speed of diagnosis;used for :Speed of diagnosis;used for viruses difficult to cultureviruses difficult to culture Disadvantages Disadvantages:False-positives and :False-positives and negatives;hard to batch testsnegatives;hard to batch testsn nSerologySerology: : TimeTime:Weeks:Weeks AdvantagesAdvantages:Assessment of immunity or :Assessment of immunity or response to virus isolated from response to virus isolated from nonsterile nonsterile site; site; used for viruses difficult to cultureused for viruses difficult to culture DisadvantagesDisadvantages:Potential cross-:Potential cross-reaction;need for acute and convalescent reaction;need for acute and convalescent specimensspecimens26真菌感染检查检验特点n n形态学检查为检测真菌的重要手段n n抗原检测适合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。27Direct Examinationn n It is highly recommended that a direct microscopic It 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 culture 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.28n n菌丝、孢子29