Tuberculosis

Introduction
• Tuberculosis (TB) is one of the most prevalent infections of human
beings and contributes considerably to illness and death around the
world. It is spread by inhaling tiny droplets of saliva from the coughs
or sneezes of an infected person. It is a slowly spreading, chronic,
granulomatous bacterial infection, characterized by gradual weight
loss.

• TB is the world’s second most common cause of death from infectious

disease after HIV/AIDS.
DEFINITION
• Tuberculosis is the infectious disease primarily affecting lung
parenchyma is most often caused by Mycobacterium Tuberculosis. It
may spread to any part of the body including meninges, kidney, bones
and lymph-nodes.
TYPES
1. PULMONARY TUBERCULOSIS (M. TB)
2. AVIAN TUBERCULOSIS (Micobacterium avium; of birds)
3. BOVINE TUBERCULOSIS (Mycobacterium bovis; of cattle)
4. MILIARY TUBERCULOSIS /DISSEMINATED TUBERCULOSIS (Invade the
blood stream and spread to all body organs.
INCEDENTS
• With the increased incidence of AIDS, TB has become a great problem
in the U.S., and the world.
• India is the highest TB burden country in the world, home to 20
percent of cases occurring globally.
• Each year 1.8 million develop TB.
• In India 0.37 million people die because of TB every year.
RISK FACTORS
• Close contact with some one who have active TB.
• Immune compromised status (elderly, cancer)
• Drug abuse and alcoholism.
• People lacking adequate health care.
• Pre existing medical conditions (diabetes mellitus, chronic renal
failure).
• Immigrants from countries with higher incidence of TB.
• Institutionalization (long term care facilities)
• Living in substandard conditions.
• Occupation (health care workers)
TRANSMISSION
• TB spreads from person to person by airborne transmission
• An infected person releases droplet nuclei.
• ( usually particles 1 to 5 μm in diameter) through talking, coughing,
sneezing, laughing, or singing
PATHOPHYSIOLOGY
Mycobacteriam

Pulmonary alveoli

Immune system has lodged in (Alveolar Macrophages)

Detects presence of pathogen and engoulf the bacteria

Mycobacterium bacteria inhibits the Macrophages

(phagosome+ Lysosome) to forms phagolysosome

and remains protected inside the macrophages.

PATHOPHYSIOLOGY
Starts replication inside macrophages.

Primary infection occurs.

Cell mediated immunity gets activated, surrounds the cell

to forms granuloma (3weeks)

Leads to necrosis of tissues at infection site(TERMINUS

GHON’S FOCUS)

Involve nearby lymph nodes (GHON COMPLEX)

Calcification of ghon complex(LATENT T.B.)

Stages of Pulmonary Tuberculosis
Primary disease
• Immune system does not control primary infection
• Patient often have non specific signs and symptom's
• Non productive cough develops and diagnosis may be difficult
Primary progressive disease
• Cough becomes productive
• More signs and symptoms appears
• Diagnosis shows TB on chest x rays and sputum culture
Latent disease
• Mycobacterium persist in the body
• No sign and symptoms occur
• Patient are susceptible for reactivation of disease
• Granuloma lesion becomes calcify and fibrotic and appears on
• chest x rays.
• Reactivation stage.
CLINICAL MENIFESTATION
• CONSTITUTIONAL SYMPTOMS; Anorexia, Low grade fever, Night sweats,
Fatigue, Weight loss.

• PULMONARY SYMPTOMS; Dyspnea, Non resolving bronchopneumonia,

Chest tightness, cough (productive or Non productive cough),
Mucopurulent sputum with hemoptysis, Chest pain.

• EXTRA PULMONARY SYMPTOMS; mostly depend on the part affected.

Pain
Inflammation
ASSESSMENT AND DIAGNOSIS
• HISTORY COLLECTION
• PHYSICAL EXAMINATION
 Clubbing of the fingers or toes (in people with advanced disease)
 Swollen or tender lymph nodes in the neck or other areas
 Fluid around a lung (pleural effusion)
 Unusual breath sounds (crackles)
•  IF MILIARY TB;
 Physical exam may show:
Swollen liver, Swollen lymph nodes, Swollen spleen
Lab investigation and imaging
• Biopsy of the affected tissue (rare)
• Bronchoscopy
• Chest CT scan
• Chest x-ray
• Interferon-gamma release assey blood test such as the QFT- Gold
test to test for TB infection
• Sputum examination (Acid fast bacilli smear and culture)
• Thoracentesis
• Tuberculin skin test (also called a PPD test)
Pulmonary TB milliary TB with
HIV
• QUANTIFERON GOLD TEST
 QFT-Gold test measures interferon-gamma in the blood
after incubating the blood with specific antigens from M.
Tuberculosis proteins.
• TUBERCULIN SKIN TEST:-
 0.1 ml of PPD is injected forearm (s/c)
 After 48-72 hrs check for induration at the site
 If induration is equal to and more than 10mm:-Positive
COMPLICATIONs
• Bones: Spinal pain and joint destruction may result from TB that
infects your bones(TB spine or pott’s Disease)
• Brain(meningitis)
• Liver or kidneys
• Heart(cardiac tamponade)
• Pleural effusion
• Tb pneumonia
• Serious reactions to drug therapy(hepato-toxicity; hypersentivity)
MEDICAL MANAGEMENT
• PULMONARY TB is treated primarily with antituberculosis agents for 6
to 12 months.
Pharmacological management
First line antitubercular medications
 Streptomycin 15mg/kg/day.
 Isoniazid or INH (Nydrazid) 5 mg/kg (300 mg max/day)
 Rifampicin 10 mg/kg/day.
 Pyrazinamide 15 – 30 mg/kg/day.
 Ethambutol (Myambutol) 15 -25 mg/kg daily for 8 weeks and
continuing for up to 4 to 7 months
Second line medications
• Capreomycin 12 -15 mg/kg
• Ethionamide 15mg/kg
• Para-aminosalycilate sodium 200 - 300 mg/kg
• Cycloserine 15 mg/kg
• Vitamin b(pyridoxine) usually administered with INH
THIRD LINE DRUGS
• Other drugs that may be useful, but are not on the WHO list of SLDs:
• Rifabutin
• Macrolides:e.g.,clarithromycin (CLR)
• Linezolid(LZD)
• Thioacetazone(T)
• Thioridazine
• Arginine
DOTS
DOTS (directly observed treatment, short-course), is the name given to
the World Health Organization-recommended tuberculosis control
strategy that combines five components:
1. Government commitment (including both political will at all levels,
and establishing a centralized and prioritized system of TB
monitoring, recording and training)
2. Case detection by sputum smear microscopy
3. Standardized treatment regimen directly observed by a healthcare
worker or community health worker for at least the first two months
4. A regular drug supply
5. A standardized recording and reporting system that allows
assessment of treatment results
• DOT is especially critical for patients with drug resistant TB, HIV-
infected patients, and those on intermittent treatment regimens (i.e.,
2 or 3 times weekly).

Multiple-drug therapy
• Means taking several different antitubercular drugs at the same time.
• The standard treatment is to take isoniazid, rifampin, ethambutol, and
pyrazinamide for 2 months. Treatment is then continued for at least
4months with fewer medicines
South Sudan Guidelines for TB treatment
Prevention
• ISOLATION
• Ventilate the room
• Cover the mouth
• Wear mask
• Finish entire course of medication
• Vaccinations; BCG vaccine is given at birth to prevent it.