Pulmonary Tuberculosis

By: Dave Jay S. Manriquez RN.

February 1, 2009
Pulmonary Tuberculosis
• Tuberculosis
(abbreviated as TB for
tubercle bacillus or
Tuberculosis) is a
common and often
deadly
infectious disease
caused by
mycobacteria, mainly
Mycobacterium tuberc
ulosis
. Tuberculosis usually
attacks the lungs (as
pulmonary TB).
Pulmonary Tuberculosis

• Scanning
electron
micrograph of
Mycobacterium t
uberculosis
Epidemiology
• According to the World Health Organization (WHO),
nearly 2 billion people—one third of the world's
population—have been exposed to the tuberculosis
pathogen.
• Annually, 8 million people become ill with
tuberculosis, and 2 million people die from the
disease worldwide.
• In 2004, around 14.6 million people had active TB
disease with 9 million new cases.
• The annual incidence rate varies from 356 per
100,000 in Africa to 41 per 100,000 in the Americas.
• Tuberculosis is the world's greatest infectious
killer of women of reproductive age and the leading
cause of death among people with HIV/AIDS.
Epidemiology

• Most common infectious cause

of death worldwide
• Latent phase of TB enabled it to
spread to one third of the world
population
• 8,000,000 new cases each year
• 3,000,000 infected patients die
Epidemiology
Epidemiology
• Major changes in trends secondary
to HIV
- 1953-1985 cases decreased from
84,304 to 22,201
- during this period cases were
reactivation of old infection and
elderly
- TB and AIDS registries suggests
that HIV-infected pts account for 30-
50% increase in cases of TB
Epidemiology

• World TB incidence. Cases per 100,000; Red => 300,

orange = 200–300, yellow = 100–200, green = 50–
100, blue =< 50 and grey = n/a. Data from WHO,
2006
Incidence
• 1985-1990 TB cases increased 55% in
Hispanics and 27% in African Americans
• Populations at risk
- Foreign-born individuals
- Low socioeconomic status
- Cancer pts
- Celiac disease
- Cigarette smokers
- TNF-a antagonists
- Corticosteroids
• - HIV
Transmission

• When people suffering from active pulmonary TB

cough, sneeze, speak, or spit, they expel infectious
aerosol droplets 0.5 to 5 µm in diameter.
• A single sneeze can release up to 40,000 droplets.
• People with prolonged, frequent, or intense contact
are at particularly high risk of becoming infected,
with an estimated 22% infection rate.
• A person with active but untreated tuberculosis can
infect 10–15 other people per year.
• Others at risk include people in areas where TB is
common,
Transmission
Transmission
• people who inject drugs using unsanitary needles,
• residents and employees of high-risk congregate
settings,
• medically under-served and low-income
populations,
• high-risk racial or ethnic minority populations,
• children exposed to adults in high-risk categories,
• patients immunocompromised by conditions such
as HIV/AIDS, people who take immunosuppressant
drugs,
• and health care workers serving these high-risk
clients.
Pathogenesis
Pathogenesis

Hyperlink to Microsoft Word

• Pathophysiology of Pulmonary
Tuberculosis.doc
• Pathogenesis of TB infection
and disease.doc
Diagnostics
• Inject
intradermally
0.1 ml of 5TU
PPD tuberculin
• Produce wheal 6
mm to 10 mm in
diameter
• Represent DTH
(delayed type
hypersensitivity)
Reading of Mantoux test

• Read reaction
48-72 hours
after injection
• Measure only
induration
• Record reaction
in mm
Classifying the Tuberculin
Reaction
• >5 mm is classified as positive
in
• HIV-positive persons
• Recent contacts of TB case
• Persons with fibrotic changes on
CXR consistent with old healed TB
• Patients with organ transplants
and other immunosuppressed
patients
Classifying the tuberculin
reaction
• >10 mm is classified as positive in
• Recent arrivals from high-prevalence
countries
• Injection drug users
• Residents and employees of high-risk
settings
• Mycobacteriology laboratory personnel
• Persons with clinical conditions that
place them at high risk
• Children <4 years, or children and
adolescents exposed to adults in high-
risk categories
Classifying the tuberculin
reaction
• >15 mm is classified as positive
in
• Persons with no known risk
factors for TB
Factors may affect TST
• False negative
• Faulty application
• Anergy
• Acute TB (2-10 wks to convert)
• Very young age (< 6 months old)
• Live-virus vaccination
• Overwhelming TB disease
• False positive
• BCG vaccination (usually <10mm by
adulthood)
• Nontuberculous mycobacteria infection
Chest Radiography
• Abnormalities often
seen in apical or
posterior segments
of upper lobe or
superior segments
of lower lobe
• May have unusual
appearance in HIV-
positive persons
• Cannot confirm
diagnosis of TB!!
Chest radiography

• No chest X-ray pattern is

absolutely typical of TB
• 10-15% of culture-positive TB
patients not diagnosed by X-ray
• 40% of patients diagnosed as
having TB on the basis of x-ray
alone do not have active TB
Specimen Collection

• Obtain 3 sputum specimens for

smear examination and culture
• Persons unable to cough up sputum
• induce sputum
• bronchoscopy
• gastric aspiration
• Follow infection control precautions
during specimen collection
Number of sputum samples
required
• overall diagnostic yield for sputum
examination related to
• the quantity of sputum (at least 5 mL)
• the quality of sputum
• multiple samples obtained at different
times to the laboratory for processing
• 3 samples obtained at least eight hours apart
with at least one sample obtained in the early
morning
Smear Examination

• Strongly consider TB in patients

with smears containing acid-
fast bacilli (AFB)
• Results should be available
within 24 hours of specimen
collection
• Presumptive diagnosis of TB
• Not specific for M. tuberculosis
AFB smear

Mycobacterium tuberculosis (stained red) in sputum

Cultures
Signs and Symptoms
Signs and Symptoms
• Hemoptysis
• Also known as coughing
up blood, it is a symptom
of bleeding somewhere in
the respiratory tract.
Frothy and bright red
blood may come from the
nose, mouth, or throat
(upper respiratory tract),
the lower respiratory
tract, or the lungs. The
seriousness of the
disorder depends on the
cause of the bleeding.
Signs and Symptoms

• Anorexia
• The sysmptom
of poor appetite
whatever the
cause
Treatment
Tuberculosis treatment

• The standard "short" course treatment for

tuberculosis (TB), is isoniazid, rifampicin,
pyrazinamide, and ethambutol for two months, then
isoniazid and rifampicin alone for a further four
months. The patient is considered cured at six
months (although there is still a relapse rate of 2 to
3%). For latent tuberculosis, the standard
treatment is six to nine months of isoniazid alone.
• If the organism is known to be fully sensitive, then
treatment is with isoniazid, rifampicin, and
pyrazinamide for two months, followed by isoniazid
and rifampicin for four months. Ethambutol need
not be used.
Drugs
• All first-line anti-tuberculous drug
names have a standard three-letter
and a single-letter abbreviation:
1. ethambutol is EMB or E,
2. isoniazid is INH or H,
3. pyrazinamide is PZA or Z,
4. rifampicin is RMP or R,
5. Streptomycin is STM or S.
Drugs
• There are six classes of second-line drugs (SLDs)
used for the treatment of TB. A drug may be classed
as second-line instead of first-line for one of two
possible reasons: it may be less effective than the
first-line drugs.
1. aminoglycosides: e.g., amikacin (AMK), kanamycin
(KM);
2. polypeptides: e.g., capreomycin, viomycin,
enviomycin;
3. fluoroquinolones: e.g., ciprofloxacin (CIP),
levofloxacin, moxifloxacin (MXF);
4. thioamides: e.g. ethionamide, prothionamide
5. cycloserine (the only antibiotic in its class);
6. p-aminosalicylic acid (PAS or P).
Drugs
• considered "third-line drugs"
• not very effective or because their efficacy has not
been proven .
• Rifabutin is effective, but is not included on the WHO
list because for most developing countries, it is
impractically expensive.

1. rifabutin
2. macrolides: e.g., clarithromycin (CLR);
3. linezolid (LZD);
4. thioacetazone (T);
5. thioridazinea;
6. arginine;
7. vitamin D;
8. R207910.
Drugs

• Daily Dose of TB
Drugs
Drugs

• Multi-drug resistant TB (MDR-TB) is

defined as resistance to the two
most effective first-line TB drugs:
rifampicin and isoniazid.
• Extensively drug-resistant TB (XDR-
TB) is also resistant to three or more
of the six classes of second-line
drugs.
Monitoring and DOTS
• DOTS stands for "Directly Observed Therapy, Short-
course" and is a major plan in the WHO global TB
eradication programme.
• The DOTS strategy focuses on five main points of
action.
1. These include government commitment to control
TB,
2. diagnosis based on sputum-smear microscopy tests
done on patients who actively report TB symptoms,
3. direct observation short-course chemotherapy
treatments,
4. a definite supply of drugs, and
5. standardized reporting and recording of cases and
treatment outcomes.
Prevention

• TB prevention and control takes two

parallel approaches.
• In the first, people with TB and their
contacts are identified and then
treated.
• Identification of infections often
involves testing high-risk groups for
TB.
• In the second approach, children are
vaccinated to protect them from TB.
Vaccines

• Many countries use Bacillus Calmette-Guérin (BCG)

vaccine as part of their TB control programs,
especially for infants. According to the W.H.O., this
is the most often used vaccine worldwide, with
85% of infants in 172 countries immunized in 1993.
• BCG provides some protection against severe forms
of pediatric TB
• unreliable against adult pulmonary TB,
• Currently, there are more cases of TB on the planet
than at any other time in history
• urgent need for a newer, more effective vaccine
that would prevent all forms of TB—including drug
resistant strains—in all age groups and among
people with HIV.
Current Surgical Intervention
• Patients with hemoptysis first received
Bronchial Artery Embolization because of
the recurrent hemoptysis.
• Current indication of Lung Resection for
pulmonary tuberculosis includes MDR-TB
with a poor response to medical therapy,
hemoptysis due to bronchiectasis or
Aspergillus superinfection, and destroyed
lung as previously reported, which are
consistent with our indications.   
• Surgery remains a crucial adjunct to
medical therapy for the treatment of MDR-
TB and medical failure lesions.
Thank You