TUBERCULOSIS PRESENTED BY Dr Kusum Shah Senior Professor

TUBERCULOSIS PRESENTED BY; Dr. Kusum Shah Senior Professor

�Tuberculosis (TB) is one of the most prevalent infections of human being. �Spread of infection: By inhalation �Slowly spreading, chronic, granulomatous bacterial infection. Free template from www. brainybetty. com 12/29/2021 2

� Robert Koch discovered the tuberculous bacilli in 1881 March 23. � Incidence every year in India: 1. 8 million TB cases � Incidence of sputum positive pulmonary TB in INDIA : 0. 8 million � One sputum positive patient can infect 10– 15 persons in a year if left untreated � Inadequately treated patients can develop drug-resistant and potentially incurable forms of TB. Free template from www. brainybetty. com 12/29/2021 3

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� Causative Organism: Mycobacterium tuberculosis �Spread : Droplet nuclei (coughing, sneezing, laughing) �Exposure to TB Free template from www. brainybetty. com 12/29/2021 7

q CLOSE CONTACT WITH ACTIVE PULMONARY TB. q IMMUNO COMPROMISED STATUS q DRUG ABUSE AND ALCOHOLISM q CO- EXISTING CONDITIONS - DIABETES MELLITUS, CHRONIC RENAL FAILURE, MALIGENECY Free template from www. brainybetty. com 12/29/2021 8

q LIVING IN SUBSTANDARD CONDITIONS q OCCUPATION(HEALTH CARE WORKERS) q IMMIGRANTS FROM COUNTRIES WITH LOWER INCIDENCE OF TB. q LOW AIRBORNE INFECTION CONTROL STANDARD IN MEDICAL FACILITY. Free template from www. brainybetty. com 12/29/2021 9

� (INITIAL INFECTION OR PRIMARY INFECTION) � ENTRY OF MICRO ORGANISMS THROUGH DROPLET NUCLEI � BACTERIA ARE TRANSMITTED TO ALVEOLI THROUGH AIRWAYS � DEPOSITION AND MULTIPLICATION OF BACTERIA � BACILLI ARE ALSO TRANSPORTED TO OTHER PARTS OF THE BODY THROUGH BLOOD STREAM AND LYMPHATICS Free template from www. brainybetty. com 12/29/2021 10

� PHAGOCYTOSIS BY NEUTROPHILS AND MACROPHAGES � ACCUMULATION OF EXUDATE IN ALVEOLI BRONCHO PNEMONIA � TISSUE OF LIVE AND DEAD BACILLI ARE SURROUNDED BY MACROPHAGES WHICH FORM A PROTECTIVE MASS CALLED GRANULOMAS � GRANULOMAS THEN TRANSFORMS TO FIBROUS TISSUE MASS AND CENTRAL PORTION OF WHICH IS CALLED GHON TUBERCLE Free template from www. brainybetty. com 12/29/2021 11

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BACTERIA AND MACROPHAGES FORM NECROTIC CHEESY MATERIAL � MASS BECOMES CALCIFIED AND BECOMES COLAGENOUS SCAR � BACTERIA BECOME DORMANT AND NO FURTHER PROGRESSION OF ACTIVE DISEASE � (ACTIVE DISEASE OR REINFECTION) � � INADEQUATE IMMUNE RESPONSE ACTIVATION OF DORMANT BACTERIA Free template from www. brainybetty. com 12/29/2021 13

� � GHON TUBERCLE ULCERATES AND RELEASING CHEESY MATERIAL INTO BRONCHI BACTERIA THEN BECOME AIRBORNE RESULTING IN FURTHER SPREAD OF INFECTION ULCERATED TUBERCLE HEALS AND BECOMES SCAR TISSUE � � � INFECTED LUNG BECOME INFLAMMED FURTHER DEVOLOPMENT OF PNEUMONIA AND TUBERCLE FORMATION UNLESS THE PROCESS IS ARRESTED IT SPREADS DOWNWARDS TO THE HILUM OF LUNGS AND LATER EXTENDS TO ADJASCENT LOBES Free template from www. brainybetty. com 12/29/2021 14

� CONSTITUTIONAL SYMPTOMS � Low grade evening rise fever � Night sweats � Fatigue � Loss of weight � Loss of appetite Free template from www. brainybetty. com 12/29/2021 15

� SYMPTOMS � Cough OF PULM TB with or without expectoration - >= 2 Weeks � Hemoptysis � Chest pain � Breathlessness � SYMPTOMS � According OF EXTRA PULM TB to system / organ involved Free template from www. brainybetty. com 12/29/2021 16

� HISTORY TAKING: -Constitutional symtpoms of TB -Duration of Illness -Previous h/o TB -Family/ contacts h/o TB GENERAL EXAMINATION � Clubbing of the fingers or toes (in people with advanced disease) & cachexia � Enlarged & tender/ non tender lymphnodes in the neck or other areas Free template from www. brainybetty. com 12/29/2021 17

� RS Examination : - According to the lobes & pleura involved Free template from www. brainybetty. com 12/29/2021 18

Investigations � X-ray chest (PA view) � 2* sputum for AFB � Tuberculin skin test (also called a PPD/ Montoux test- if indicated) � FNAC/ Bx of suspected organ- USG/ CT guided � Plueral fluid tapping ( ADA, LDH, R/M) � USG/ CT SCAN of involved organ if required Free template from www. brainybetty. com 12/29/2021 19

� 0. 1 ML OF PPD IS INJECTED FOREARM(I. D) � AFTER � IF 48 -72 HRS CHECK FOR INDURATION AT THE SITE INDURATION IS EQUAL TO AND MORE THAN 10 MM � POSITIVE Free template from www. brainybetty. com 12/29/2021 20

� PULMONARY TB is treated primarily with antituberculosis agents for 6 to 12 months. � Pharmacological � First management line antitubercular medications � Streptomycin- 12 -15 mg/kg � Isoniazid or INH- 5 -10 mg/kg � Rifampin- 9 -12 mg/kg � Pyrazinamide- 25 -30 mg/kg � Ethambutol- 15 -20 mg/kg Free template from www. brainybetty. com 12/29/2021 21

�Second line medications �Capreomycin 12 -15 mg/kg �Ethionamide 15 mg/kg �Cycloserine 15 mg/kg �Levoflox – 15 mg/kg �Paraaminosalycilate sodium(PAS)150 -200 mg/kg Free template from www. brainybetty. com 12/29/2021 22

�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 Free template from www. brainybetty. com 12/29/2021 23

q Isolation q Ventilate the room q Cover the mouth/Wear mask q Disposal of sputum – 5% Phenol q Complete entire course of medication without default q Breast feeding can be done q Vaccination- BCG Free template from www. brainybetty. com 12/29/2021 25

Masood Level of Ziaee. , e evidence – Case Control t al Study Level C 920 patients suspected of having pulmonary tuberculosis were included in studies-2760 sputum sample was collected and stained by both Ziehl Neelsen and auraminphenol Methods. All positive smears by fluorescent microscopy were over-stained by ZN technique for confirmation. -102 out of 920 subjects had tb , of them 68 (66. 66%) patients were smear positive. The sensitivity, specificity, positive predictive value and negative predictive value were 51%, 100%, 94% and 57%, 100, 95% for the ZN and auramine phenol staining methods, respectively. Free template from www. brainybetty. com 12/29/2021 FM is more sensitive than ZN for diagnosis of TB. However, since FM is more sensitive and rapid, using this method in clinical laboratories with large specimen numbers is recommended. 26

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1. Humans become infected with Mycobacterium tuberculosis most frequently by A. inhalation B. ingestion C. contact D. inoculation Free template from www. brainybetty. com 12/29/2021 28

2. Symptoms of tuberculosis include all except A. High grade Fever B. Weight loss C. Loss of appetite D. fatigue Free template from www. brainybetty. com 12/29/2021 29

3 A positive Mantoux test indicates an area of induration of A. 4 -9 mm in diameter B. 1 -4 mm in diameter C. 10 mm or more in diameter D. None of these Free template from www. brainybetty. com 12/29/2021 30

4. The scientist who discovered M. tuberculosis was: A: Louis Pasteur B: Robert Koch C: Jean-Antoine Villemin D: Calmette and Guerin Free template from www. brainybetty. com 12/29/2021 31

5. Following are the first line antitubercular drugs except: A. isoniazid B. rifampin C. PAS D. streptomycin Free template from www. brainybetty. com 12/29/2021 32

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Authors: Marian Goble, Michael D. Iseman, Lorie A. Madsen, Dennis Waite, Lynn Ackerson, and C. Robert Horsburgh, Jr. N Engl J Med Type of study: Retrospecti ve cohort Method: The clinical courses of 171 patients with pulmonary disease due to M. tuberculosis resistant to rifampin and isoniazid who were referred to our hospital between 1973 and 1983. The patients' records were analyzed retrospectively. Their regimens were selected individually and preferably included three medications that they had not been given previously and to which the strain was fully susceptible. (evidence level III) Conclusion: For patients with pulmonary tuberculosis that is resistant to rifampin and isoniazid, even the best available treatment is often unsuccessful. Only about half of such patients eventually have negative sputum cultures despite carefully selected regimens administered for extended periods. Failure to control this resistant infection is associated with high mortality and ominous implications for the public health.