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Tuberculosis

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Intro to TB
epidemiology of TB
Structure of Mycobacterium TB
pathogenesis of TB
Immunosuppression by Mycobacterium TB
types of TB
Clinical manifestation
Diagnosis
Treatment

Intro to TB
epidemiology of TB
Structure of Mycobacterium TB
pathogenesis of TB
Immunosuppression by Mycobacterium TB
types of TB
Clinical manifestation
Diagnosis
Treatment

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Tuberculosis

  1. 1. Tuberculosis Dr. Sami
  2. 2. Definition:  Tuberculosis (TB) is a potentially fatal contagious disease that can affect almost any part of the body but is mainly an infection of the lungs.  Neo-latin word :  “Tubercle” Round nodule/Swelling  “Osis” Condition
  3. 3. Introduction:  Global Status of TB  Tuberculosis (TB) kills 1.6 million people a year o 0.2 million people infected with HIV o 98% of these deaths occur in the developing world. Close to 9 million new cases develop every year and about one third of the world’s population is infected with Mycobacterium tuberculosis. TB is a major cause of death among people with HIV/AIDS and infection is the most potent risk factor for the conversion of latent TB infection to active TB.
  4. 4. Causes of TB  Causative Organisms  Mycobacterium tuberculosis in Human  Mycobacterium Bovis in Animals  Others: o Mycobacterium africanum o Mycobacterium microti
  5. 5. Mycobacterium tuberculosis:
  6. 6.  Mycobacterium tuberculosis-Characteristics  Gram positive  Aerobic  Obligate aerobe  Mesophilic  Non motile Rod  Slow generation time: 15-20 hours  Lipid rich cell wall contains mycolic acid:  Responsible for many of bacterium characteristics.  Acid fast.  Causes resistance to antibacterials.
  7. 7. Pathogenesis & Immuno supression:
  8. 8. Types of Tuberculosis:  Latent TB.  You have the germs in your body, but your immune system keeps them from spreading. You don’t have any symptoms, and you’re not contagious. But the infection is still alive and can one day become active. If you’re at high risk for re-activation -- for instance, if you have HIV, you had an infection in the past 2 years, your chest X-ray is unusual, or your immune system is weakened -- your doctor will give you medications to prevent active TB.  Active TB.  The germs multiply and make you sick. You can spread the disease to others. Ninety percent of active cases in adults come from a latent TB infection.
  9. 9. Types:  Pulmonary TB.  Extra Pulmonary TB.
  10. 10. Pulmonary TB.  Primary Disease  Secondary Disease
  11. 11. Extra Pulmonary TB.  Lymph node TB  Pleural TB  TB of upper airways  Skeletal TB  Genitourinary TB  Miliary TB  Pericardial TB  Gastrointestinal TB  Tuberculous Meningitis
  12. 12. Pulmonary TB.  Primary Disease :  The infection of an individual who has not been previously infected or immunised is called Primary tuberculosis or Ghon’s complex or childhood tuberculosis.  Lesions forming after infection is peripheral and accompanied by hilar which may not be detectable on chest radiography.
  13. 13.  Secondary Tuberculosis :  The infection that individual who has been previously infected or sensitized is called secondary or post primary or reinfection or chronic tuberculosis.
  14. 14. Extra Pulmonary TB.  20% of patients of TB Patient  • Affected sites in body are :  - 1) Lymph node TB ( tuberculuous lymphadenitis):  Seen frequently in HIV infected patients  Symptoms :- Painless swelling of lymph nodes most commonly at cervical and Supraclavical (Scrofula)  Systemic systems are limited to HIV infected patients.  2) Pleural TB :  Involvement of pleura is common in Primary TB and results from penetration of tubercle bacilli into pleural space.
  15. 15.  3) TB of Upper airways :-  Involvement of larynx, pharynx and epiglottis.  Symptoms :- Dysphagia, chronic productive cough  4) Genitourinary TB :  15% of all Extra pulmonary cases.  Any part of the genitourinary tract get infected.  Symptoms :- Urinary frequency, Dysuria, Hematuria.  5) Skeletal TB :  Involvement of weight bearing parts like spine, hip, knee.  Symptoms :- Pain in hip joints n knees, swelling of knees, trauma.  6) Gastrointestinal TB :  Involvement of any part of GI Tract. •  Symptoms :- Abdominal pain, diarrhea, weight loss
  16. 16.  7) TB Meningitis & Tuberculoma :  5% of All Extra pulmonary TB  Results from Hematogenous spead of 10 & 20 TB.  8) TB Pericardiatis :-  1- 8% of All Extra pulmonary TB cases.  Spreads mainly in mediastinal or hilar nodes or from lungs.  9) Miliary or disseminated TB :  Results from Hematogenous spread of Tubercle Bacilli.  Spread is due to entry of infection into pulmonary vein producing lesions in different extra pulmonary sites.  10) Less common Extra Pulmonary TB  uveitis, panophthalmitis, painfull Hypersensitivity related phlyctenular conjuctivis. (nodular inflammation of the cornea)
  17. 17. Risk Factors:  Close contact with some one who have active TB.  Immuno 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)
  18. 18. Clinical Manifestation:  Anorexia  Low grade fever  Night sweats  Fatigue  Weight loss  Chills  Urine discoloration  Cloudy & reddish urine
  19. 19.  Pulmonary Symptoms:  Productive, prolonged cough (duration of 2-3 weeks)  Chest pain  Hemoptysis (bloody sputum)  Symptoms may vary based on HIV status  Dyspnea  Non resolving bronchopneumonia  Chest tightness
  20. 20. Diagnosis:  HISTORY  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)
  21. 21. Tests  Biopsy of the affected tissue (rare)  Bronchoscopy  Chest CT scan Chest x-ray  interferon-gamma release blood test such as the QFT- Gold test to test for TB infection  Sputum examination and cultures  Tuberculin skin test (also called a PPD test)
  22. 22. Tuberculin skin test (PPD)  Purified protein derivative (PPD) Injection of fluid into the skin of the lower arm  48-72 hours later -checked for a reaction.  Diagnosis is based on the size of the wheal:  <6mm negative  6mm-15mm Hypersensitive to tuberculin protein(Previous TB infection or BCG – atypical mycobacteria)  >15mm strongly Hypersensitive to tuberculin protein(suggestive of TB infection)  Cell count (Lymphocytes)
  23. 23. Treatment:
  24. 24. Aims of TB Treatment  Cure the patient of TB  Prevent death from active TB or its latent effects  Prevent relapse of TB  Decrease transmission of TB to others  Prevent the development of acquired resistance
  25. 25. Preventive measures  Mask  BCG vaccine  Regular medical follow up  Isolation of Patient  Ventilation  Natural sunlight
  26. 26. BCG vaccine  Only vaccine available today for protection against tuberculosis.  effective in protecting children from the disease.  Given 0.1 ml intradermal.  Duration of Protection 15 to 20 years  Should be given to all healthy infants as soon as possible after birth unless the child presented with symptomatic HIV infection.
  27. 27. Basic Principles of Treatment  Determine the patient’s HIV status- this could save their life!  Provide safest, most effective therapy in shortest time  Multiple drugs to which the organisms are susceptible  Never add single drug to failing regimen  Ensure adherence to therapy (DOT)
  28. 28. DOTS  Directly observed treatment, short-course  DOT means that a trained health care worker or other designated individual provides the prescribed TB drugs and watches the patient swallow every dose.  DOT for all patients on all regimens (NO exceptions)
  29. 29. MEDICAL MANAGEMENT PULMONARY TB  MEDICAL MANAGEMENT PULMONARY TB is treated primarily with antituberculosis agents for 6 to 12 months.  Pharmacological management
  30. 30. Pharmacological management
  31. 31. FIRST LINE ANTI-TUBERCULOUS DRUGS  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
  32. 32. SECOND LINE ANTI-TUBERCULOUS DRUGS  Capreomycin 12 -15 mg/kg  Ethionamide 15mg/kg  Para-aminosalycilate sodium 200 - 300 mg/kg  Cycloserine 15 mg/kg  Vitamin b(pyridoxine) usually adminstered with INH
  33. 33. REGIMEN OF TB THERAPY TB
  34. 34. REGIMEN OF TB THERAPY Patients with active TB:  Initial phase (first 2-4 months): 4 drugs are used (RIPE): (Rifampin + INH + Pyrazinamide + Ethmabutol).  Continuation phase (next 4-6 months): at least 2 drugs are used (INH + rifampin).
  35. 35. REGIMEN OF TB THERAPY Patients with latent TB  Latent TB (i.e. patients with +ve Tuberculin skin test and had history of contact to a person proved to have TB)  INH alone for 6 months or dual Rifampicin + INH for 3 months.
  36. 36. REGIMEN OF TB THERAPY TB during pregnancy:  The only anti-TB drug which is absolutely contraindicated is streptomycin because of the high risk of congenital deafness.  other first line anti-TB drugs are safe for use in pregnancy.
  37. 37. REGIMEN OF TB THERAPY TB with liver disease  INH, rifampin, and pyrazinamide are hepatotoxic but because of their effectiveness, they should be used depending on monitoring of liver function tests.  In severe liver damage, only one drug can be used.
  38. 38. Extra pulmonary TB  In most cases, treat with same regimens used for pulmonary TB  Treatment extended > 6 months depending on site of disease  In TB meningitis Streptomycin replaces Ethambutol
  39. 39. Multi-Drug Resistance TB  TB caused by strains of Mycobacterium tuberculosis that are resistant to at least isoniazid and rifampicin, the most effective anti- TB drug.  3.6% are estimated to have MDR-TB.  Treatment must be individualized  should seek expert consultation  6 months intensive treatment (always including an injectable drug) followed by at least an 18 month continuation phase
  40. 40. Extensively drug resistance TB  is a form of TB caused by bacteria that are resistant to isoniazid and rifampicin (i.e. MDR- TB) as well as any fluoroquinolone and any of the second-line anti-TB injectable drugs (amikacin, kanamycin or capreomycin).
  41. 41. Tuberculosis and HIV  HIV positive people with pulmonary TB may have a higher frequency of having sputum negative smears.  The tuberculin test often fails to work, because the immune system has been damaged by HIV; It may not even show a response even though the person is infected with TB.  Chest Xray will show less cavitation. Cases of Extra pulmonary TB are more common. Management of HIV-related TB is complex

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