INTRODUCTION , ETIOLOGY , NEED TO KNOW, CLINICAL MANISFESTATIONS ,

DIAGNOSIS , TREATMENT , PREVENTION OF

TUBERCULOSIS

INTERNAL
MEDICINE
CLERKSHIP
MODULE

CREATED BY: PED C. SILVESTRE RN

1 ……………………………………………...Introduction

2 …………………………………………………Etiology

3 ………………………………………......Need to know

4 …………………………………Clinical Manifestations

5 ……………………………………………….Diagnosis

6 ………………………………………………Treatment

7 ……………………………………………….Prevention
INTRODUCTION
Tuberculosis is a disease that is caused by a bacteria which is the Mycobacterium
tuberculosis. It was known that this disease is one of the oldest that have emerged 70,000
years ago in Africa and now disseminated with anatomically modern humans that expands
globally during the Neolithic Age as humans started to populate the world.

The bacteria usually attack the lungs, but can attack any part of the body such lymph nodes,
bones and joints, the brain, and other organs.
• If TB is treated properly, most people can be cured of TB
• If TB is NOT treated properly, people can die from TB or develop drug-resistant
forms of TB

Although TB is preventable and treatable, it is not just a disease of the past. Right now it is
still one of our world’s deadliest disease.

ETIOLOGY

Mycobacteria is from the family Mycobacteriaceae and the order Actinomycetales.
Mycobacteria tuberculosis complex is a pathogenic specie which comprises eight distinct
subgroups and the most common that affects human lives by far is M. tuberculosis.

Other bacteria that belongs to the complex includes some zoonotic members, such as
• M.bovis is a bovine tubercle bacillus and it is resistant to pyrazinamide, once an
important cause of TB transmitted by unpasteurized milk.
• M. caprae is related to M. bovis.
• M. pinnipedii is a bacillus infecting seals and sea lions in the Southern Hemisphere
and recently isolated from humans.
• M. mungi is isolated from banded mongooses in southern Africa.
• M. orygis is described in oryxes and other Bovidae in Africa and Asia and a potential
cause of infection in humans.
• M. microti is a “vole” bacillus, a less virulent organism
• M. canetti is a rare isolate from East African cases

M. tuberculosis is a rod-shaped, non-spore-forming, thin aerobic bacterium measuring 0.5
μm by 3 μm.



NEED TO KNOW
How TB is transmitted?
TB is spread through the air from person to person. Tiny water particles containing M.
tuberculosis may be expelled into the air when a person with infectious TB of the lungs,
airway, or larynx:

• Coughs
• Sneezes
• Speaks
• Sings

The particles that expelled into the air is called a droplet nuclei that can remain in the air
for several hours depending on the environment.

If another person inhales air that contains droplet nuclei, they may become infected.
However, not every person that is exposed to TB becomes infected with M. tuberculosis.

There are two TB-related conditions:
• Latent TB infection
• TB disease

It is important to know that not everyone infected with M. tuberculosis becomes sick.
People who are infected but not sick have latent TB infection. Some people with latent TB
infection go on to develop TB disease.

Risk of developing TB Disease
The risk of developing TB disease is much higher for persons with weakened immune
systems than for persons with normal immune systems. HIV infection is the strongest risk
factor in developing TB disease. Other people that have weak immune systems that put
them at high risk for developing TB disease includes:
• Children younger than 5 years of age
• Persons who are receiving immunosuppressive therapy
• Persons with silicosis, diabetes, chronic renal failure, leukemia, lymphoma, or
cancer of the head, neck, or lung
• Persons who have had a gastrectomy or jejunoileal bypass
• Persons who weigh less than 90% of their ideal body weight
• Persons who abuse drugs and alcohol






How TB develops?

Inhaled droplet Bacilli enter the
nuclei that Bacilli begin to multiply in the small air sacs bloodstream
contain tubercle of the lungs then spreads in
bacilli the body


Usually within 2 to 8 weeks, the immune system intervenes, preventing further spread. At
this point, the person is considered to have Latent TB infection. Since the immune system
is keeping the tubercle bacilli under control, people with latent TB infection do not feel sick
and they cannot spread TB to others.

If the immune system cannot keep the tubercle bacilli under control, the bacilli multiply
and destroy tissue. The bacteria usually attack the lungs, but can attack any part of the
body such as lymph nodes, bones and joints, the brain, and other organs.
At this point, the person has TB disease. People with TB disease may feel sick and may
spread TB to others.

CLINICAL MANIFESTATIONS
Persons with TB disease usually have one or more symptoms. Because different parts of
the body can be affected by TB, symptoms can vary


GENERAL SYMPTOMS PULMONARY TB DISEASE EXTRAPULMONARY TB
DISEASE
(DEPENDS ON THE AFFECTED PART )

• Fever • Cough lasting 3 or • TB disease in spine
• Chills more weeks may cause back pain
• Night sweats • Chest pain
• Weight loss • Coughing up blood or • TB disease in kidneys
• Appetite loss sputum (phlegm) may cause blood in
• Fatigue urine
• Malaise

• TB disease in lymph
nodes may cause
swelling in the neck





DIAGNOSIS
When you suspect a patient who has symptoms of TB always think that the person has TB.
The CDC said that the key to diagnosing the disease is to “ THINK TB”.

Anyone with symptoms of TB disease or anyone who has a positive tuberculin skin test
(TST) or interferon-gamma release assay (IGRA) result should be medically evaluated for
TB disease. Medical evaluation includes five parts:

1. Medical history - A medical history includes a patient’s social, family, medical, and
occupational information.

2. Physical examination - This is an essential part, it can provide valuable
information about the patient’s overall health and help to identify any factors that
may affect how TB disease is treated if it is diagnosed.


3. Test for TB infection (TST or IGRA)- Patients with symptoms of TB disease may
be given a TST or an IGRA to help confirm infection with M. tuberculosis. However,
these tests cannot confirm if a person has TB disease.

4. Chest x-ray- The chest x-ray will usually appear abnormal when a patient has TB
disease in the lungs. It may show infiltrates or cavities. However, chest x-ray results
cannot confirm that a person has TB disease.


5. Bacteriological examination- done in a laboratory that identifies M. tuberculosis
and other mycobacteria. Five components of bacteriological examination include
these 5 steps:

1. Specimen collection
2. Acid-fast bacilli smear examination
3. Direct identification of specimen (Nucleic Acid Amplification)
4. Specimen culturing and identification – A positive culture confirms the diagnosis of
TB
5. Drug susceptibility testing





TREATMENT

Latent TB Infection
These are the three option treatment of latent TB infection:

1. Isoniazid (INH) daily for 9 months.
2. Isoniazid (INH) and rifapentine (RPT) given in 12 once weekly doses under Direct
Observed Therapy.

This regimen is not recommended for:
§ younger than 2 years old
§ people with HIV/AIDS who are taking antiretroviral (ARV) treatment
§ people who are presumed to have been infected with isoniazid (INH) or
rifampin (RIF)-resistant M. tuberculosis
§ Pregnant women, or women expecting to be pregnant within the 12-week
regimen
3. Rifampin (RIF) daily for 4 months

TB Disease
Unlike treatment for latent TB infection which only requires one drug, treatment for TB
disease must contain several drugs to which the tubercle bacilli are susceptible. It is more
effective at killing all of the tubercle bacilli and helps to prevent drug resistance.

The drugs most commonly used to treat TB disease are
§ Isoniazid (INH)
§ Rifampin (RIF)
§ Pyrazinamide (PZA)
§ Ethambutol (EMB)

TB disease must be treated for at least 6 to 9 months. Regimens for treating TB have an
initial phase of 2 months, followed by a continuation phase of either 4 or 7 months. This is
because even though most tubercle bacilli are killed within the first 8 weeks of treatment
(initial phase), there are still active bacilli in the body. Treatment with at least 2 drugs must
continue for several more months to kill remaining bacilli.

PREVENTION
The only way to prevent TB is to diagnose and isolate infectious cases rapidly and to
administer appropriate treatment until patients are already noninfectious and the disease
is cured. BCG vaccination and treatment of persons with LTBI who are at high risk of
developing active disease is also important.
REFERENCE
Ø Harrison’s Principles of Internal Medicine 20th ed
Ø CDC – Centers For Disease Control and Prevention