Tuberculosis
Tuberculosis
Tuberculosis
EPIDEMIOLOGY
WHAT IS TUBERCULOSIS?
Recent studies suggest, M. tuberculosis may have emerged about 70,000 years ago
in Africa
Subsequently disseminated along with modernization and started to spread globally
during the Neolithic period, when the human density started to increase.
Epidemiology: status around the world
IN WORLD:
It is estimated that nearly 2 billion people in the world (about one fourth of the
world’s population) are infected with M. tuberculosis.
Every year, about 10 million people develop TB disease and 1.6 million people die of
it. In fact, TB disease is the leading cause of death due to infectious disease in the
world.
IN USA: In 2017, the case rate was 2.8 cases per 100,000
persons.
In nepal
Mycobacterium tuberculosis
Mycobacterium bovis
Inhalation of droplets
Engulfed by macrophages
Caseous Necrosis
1. Pulmonary TB
TB affecting the lung
alveoli
2. Extra pulmonary TB
TB affecting sites other than lungs like lymph nodes, bones,
meninges, etc.
3. Miliary TB
It is a result of acute diffused dissemination of tubercle bacilli
via blood stream.
CLINICAL FEATURES OF PULMONARY TB
In general, clinical presentation of pulmonary tuberculosis includes:
Unresolved pneumonia
Weight loss
Spontaneous pneumothorax
1. PRIMARY PULMONARY TB
Occurs soon after the initial infection with tubercle bacilli.
Mostly asymptomatic
Regional lymphadenopathy
o Systemic symptoms:
-Fever
-Night sweats
-Malaise
-Loss of weight and appetite
-Fatigue
o Pulmonary symptoms:
-Cough : Initially non-productive and limited to morning and accompanied
by purulent sputum, sometimes blood streaking
-Hemoptysis
-Pleuritic chest pain sometimes develop with subpleural parenchymal
lesions or pleural disease
-Dyspnea and sometimes adult respiratory distress syndrome
CLINICAL FEATURES:
EXTRA-PULMONARY TB
Extrapulmonary TB accounts for 20%of cases in those who are HIV
negative but is more common in HIV positive patients.
Lymphadenitis
Pleural effusion may cause fever, chest pain, dyspnea and pleuritic chest
pain
Nocturia
Hematuria.
Dysuria.
Pelvic pain, menstrual abnormalities and infertility if fallopian tubes are affected
Tubo-ovarian abscess.
Prostatitis
Gastrointestinal
May involve of any part of the GI tract
Hematochezia
Abdominal lymphadenopathy
Mesenteric thickening
Ascites
Pericardial disease
Acute or subacute onset of fever.
Pericardial effusion
Raised JVP
Prominent ascites
Peripheral edema
CNS
Meningitis in young and HIV positive patients.
Coma
Hydrocephalus
Intracranial HTN
Bone and joint disease
Chronic back pain
Kyphosis, scoliosis
Cord compression
PULMONARY
Sputum
Bronchoscopy
Gastric washing (mainly used for children)
Specimens required
Extrapulmonary
Fluid examination
Cerebrospinal – for tuberculous meningitis
Ascitic
Pleural – for pleural disease
Pericardial
Join
Tissue biopsy
From affected site
Bone marrow/ liver may be diagnostic in disseminated(miliary)TB,
particularly in HIV-infected patients
Diagnostic Tests
1. AFB Microscopy
2. Mycobacterial culture
3. Radiographic procedures
a) Ziehl-Neelsen method
b) Rhodamine-auramine staining
a. Ziehl-Neelsen method
b. Rhodamine-auramine staining
This staining method causes tuberculous bacilli to fluoresce against a dark background
Easier to use when numerous specimens need to be examined.
2. Mycobacterial culture
It can be done is following media:
a) Solid media
1. Mycobacterium tuberculosis grows slowly (4-6 weeks) on solid
medium
2. E.g. Lowenstein-Jensen or Middlebrook
b) Liquid media
1. Faster growth (1-3 weeks)
2. E.g. BACTEC system(radioactive), Mycobacteria Growth Indicator
Tube (MGIT)
3. Radiographic procedures
Chest X-Ray
CT scan
4. Nucleic acid amplification tests
Helps in diagnosis of Tuberculosis and detect the presence of rifampicin
resistance.
WHO recommends its use worldwide as the first line diagnostic test in all
adults and children with signs or symptoms of active TB
It is also the first choice in individuals with HIV or those suspected to have
multidrug resistant tuberculosis.
5. Drug Susceptibility testing
This testing is important in following cases:
Previous history of TB
Treatment failure of TB
Chronic disease
HIV- positive
6. Diagnosis of Latent M. tuberculosis
infection (LTBI)
DOTS
Prothionamide
Para–aminosalicylic acid
Rifabutin
These have low antitubercular efficacy, higher toxicity and are reserve drugs.
During the intensive phase of treatment, every dose is administered under direct observation,
while during the continuation phase patients are asked to attend the treatment once a week,
when one dose is given under direct observation and the other two doses supplied to the patient
for self-administration.
In Revised National Tuberculosis Control Programme (RNTCP), each patient is allotted a box of
medicines that contains drugs for the full duration of the treatment.
Directly Observed Therapy Shortcourse
(DOTS)
Dots is a program to help cure TB.
A DOT lay worker meets with clients to help with TB medication, and provide
support and education.
After active TB in baby is ruled out, the baby should be given 6 months of
Isoniazid preventive therapy followed by BCG.
Health education
Specific protection
• Population strategy- BCG vaccine
• High risk strategy-
Isoniazid preventive therapy
Antiretroviral therapy for people with HIV
Secondary prevention
Intradermal infection
For all infants and children at particular risk of TB exposure in otherwise low-
endemic areas.
Contraindication
For persons with impaired immunity (symptomatic HIV infection, leukemia,
lymphoma or congenital immunodeficiency)
In pregnancy
2. High risk strategy
Recommended regimen-
The standard regimen for TB preventive therapy is-
Adults : Isoniazid(INH) 5mg/kg/day( maximum 300mg/day)
Children : Isoniazid (INH) 10 mg/kg/day ( maximum 300mg/day)
o Vitamin B6 25mg/day should be given concomitantly with isoniazid to prevent
the occurrence of peripheral neuropathy.
Patients with active liver disease or who are actively abusing alcohol because of
risk of hepatotoxicity
b. Anti Retroviral Therapy in people with HIV
ART can greatly reduce the risk of TB in a person living with HIV
Secondary prevention
Early detection- detection of latent TB
Commonly identified using the tuberculin skin test
https://www.who.int/tb/challenges/hiv/07_tb_prevention_diagnosis_and_tre
atment_eng.pdf
https://www.who.int/immunization/policy/schedule.pdf
https://www.who.int/hiv/pub/guidelines/south_africa_hiv_tb.pdf