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8/14/2019 DIAGNOSIS OF TUBERCULOSIS Dr T V Rao
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8/14/2019 DIAGNOSIS OF TUBERCULOSIS Dr T V Rao
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Dr.T.V.RaoDr.T.V.Rao
Robert Koch DiscoversRobert Koch Discovers
MycobacteriumMycobacterium
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Dr.T.V.Rao
A Global EmergencyA Global Emergency
The Tuberculosis in theThe Tuberculosis in the
beginning of the 21beginning of the 21stst
CenturyCenturydeclared as Global Emergencydeclared as Global Emergency
(WHO)(WHO)
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Dr.T.V.RaoDr.T.V.Rao
Why Tuberculosis is a ImportantWhy Tuberculosis is a Important
Disease.Disease. Tuberculosis continues to be aTuberculosis continues to be a
Important communicable disease.Important communicable disease. A leading cause of morbidity andA leading cause of morbidity and
mortality in Developing world.mortality in Developing world. Most Important communicableMost Important communicable
disease in Bangladesh, China,disease in Bangladesh, China,
Indonesia, Africa, and Pakistan.Indonesia, Africa, and Pakistan.
But it is Curable DiseaseBut it is Curable Disease
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Dr.T.V.RaoDr.T.V.Rao
Tuberculosis is a Global ProblemTuberculosis is a Global Problem
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Dr.T.V.RaoDr.T.V.Rao
Tuberculosis - ImportantTuberculosis - Important
communicable disease spread bycommunicable disease spread by
Respiratory routeRespiratory route
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Dr.T.V.RaoDr.T.V.Rao
Why Everybody Concerned.Why Everybody Concerned.
Tuberculosis kills young adults.Tuberculosis kills young adults.
Premature death of the infected aPremature death of the infected a
prominent future.prominent future. Today many are co infected with HIV.Today many are co infected with HIV.
The open cases of Tuberculosis infects aThe open cases of Tuberculosis infects a
few around his/her environment.few around his/her environment. A social burden to the family, society andA social burden to the family, society and
Nations.Nations.
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Dr.T.V.RaoDr.T.V.Rao
Tuberculosis in the era of Tuberculosis in the era of
HIV / AIDS.HIV / AIDS.
HIV / AIDS epidemic led to largeHIV / AIDS epidemic led to large
increase of Smear negativeincrease of Smear negative
pulmonary tuberculosis which in turnpulmonary tuberculosis which in turn
has led to poor treatment out comes,has led to poor treatment out comes,
and early mortalityand early mortality
Frequently involves Lower lobes of Frequently involves Lower lobes of
Lungs.Lungs.
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Dr.T.V.RaoDr.T.V.Rao
Why we fail to DiagnoseWhy we fail to Diagnose
Tuberculosis.Tuberculosis.
Lack of health infrastructure.Lack of health infrastructure.
Control is plagued with lack of Control is plagued with lack of
Accurate,Accurate,
Robust,Robust,
and Rapidand Rapid
Diagnostic methods,Diagnostic methods,
Technologies.Technologies.
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Dr.T.V.RaoDr.T.V.Rao
Why we failed ( Cont )Why we failed ( Cont )
Diagnostic services are poor, and soDiagnostic services are poor, and so
we failed at Individual andwe failed at Individual and
community levels.community levels.
Patients are diagnosed late.Patients are diagnosed late.
Many patients are never diagnosedMany patients are never diagnosedbefore death.before death.
Early deaths are burden toEarly deaths are burden to
Social Infrastructure andSocial Infrastructure andEconomic loss.
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Dr.T.V.RaoDr.T.V.Rao
Importance of Clinical servicesImportance of Clinical services
Early diagnosis rests with clinicians,Early diagnosis rests with clinicians,
whose contribution is immense inwhose contribution is immense in
prompt treatment.prompt treatment.
A clinicians knowledge, properA clinicians knowledge, properdocumentation are immense help indocumentation are immense help in
Developing countries.Developing countries.
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Dr.T.V.RaoDr.T.V.Rao
When to suspect TuberculosisWhen to suspect Tuberculosis
Cough longer than 3 weeks.Cough longer than 3 weeks.
Fever for 1 month, or both.Fever for 1 month, or both.
Blood stained sputum.Blood stained sputum. Night sweats, weight lossNight sweats, weight loss Age between 14 and 70 yearsAge between 14 and 70 years
(( Correlates National TuberculosisCorrelates National TuberculosisProgramme ).Programme ).
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Dr.T.V.Rao
DIAGNOSTIC METHODSDIAGNOSTIC METHODS
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Dr.T.V.RaoDr.T.V.Rao
Diagnosis.Diagnosis.
Tuberculosis is a diversified disease.Tuberculosis is a diversified disease.
Any organs can be involved.Any organs can be involved.
Any age group, gender no bar forAny age group, gender no bar for
Tuberculosis.Tuberculosis.
Involvement of Lungs contribute toInvolvement of Lungs contribute to
majority of tuberculosis.majority of tuberculosis. And involvement of Lungs is designated asAnd involvement of Lungs is designated as
Pulmonary tuberculosis.Pulmonary tuberculosis.
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Dr.T.V.RaoDr.T.V.Rao
Diagnosis of PulmonaryDiagnosis of Pulmonary
TuberculosisTuberculosis
Majority of Adults suffer with pulmonaryMajority of Adults suffer with pulmonarytuberculosis.tuberculosis.
Microbiological examination of SputumMicrobiological examination of Sputumcontinues to be a Gold standard in provingcontinues to be a Gold standard in provingthe Diagnosis.the Diagnosis.
Sputum examination in Children is notSputum examination in Children is not
sensitive in Diagnosis.sensitive in Diagnosis. Radiological examination of Lungs, mostRadiological examination of Lungs, most
commonly prescribed investigation.commonly prescribed investigation.
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Dr.T.V.RaoDr.T.V.Rao
X - ray examination of chest mostX - ray examination of chest most
easily available Investigation.easily available Investigation.
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Dr.T.V.Rao
MicrobiologicalMicrobiologicalInvestigations are essentialInvestigations are essential
for definitive Diagnosis of for definitive Diagnosis of Tuberculosis.Tuberculosis.
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Dr.T.V.RaoDr.T.V.Rao
Importance of Optimal SpecimensImportance of Optimal Specimens
Pulmonary Tuberculosis is thePulmonary Tuberculosis is the
commonest presentation of commonest presentation of
TuberculosisTuberculosis
Sputum is the Most importantSputum is the Most important
specimen for identification andspecimen for identification and
isolation of Acid fast bacilli.isolation of Acid fast bacilli.
The developing countries suffers theThe developing countries suffers the
most important step in getting anmost important step in getting an
ideal sample.ideal sample.
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Dr.T.V.Rao
Sputum specimensSputum specimens
Train the staff to obtain the appropriateTrain the staff to obtain the appropriatespecimenspecimen
A few minutes of education to patients onA few minutes of education to patients on
importance of ideal sample make a greatimportance of ideal sample make a greatdifference and improves the Diagnosis.difference and improves the Diagnosis.
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Dr.T.V.RaoDr.T.V.Rao
Observe to identify Sputum fromObserve to identify Sputum from
Saliva.Saliva.
SPUTUMSPUTUM
Specimens appear mucoidSpecimens appear mucoideven, blood stained.even, blood stained.
Contains manyContains many
Polymorphoneutrophils.Polymorphoneutrophils.
SALIVASALIVA
Appears clear, watery,Appears clear, watery,and frothy.and frothy.
Contains manyContains many
squamous epithelialsquamous epithelial
cellscellsAbsence of Absence of
Polymorphoneutrophils.Polymorphoneutrophils.
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Dr.T.V.RaoDr.T.V.Rao
Role of Microscopy in Tuberculosis.Role of Microscopy in Tuberculosis.
Microscopy for Diagnosis of Tuberculosis isMicroscopy for Diagnosis of Tuberculosis is
initiated in 1880initiated in 1880 The conceptions have not changed sinceThe conceptions have not changed since
then.then. Best efforts should be put to obtainBest efforts should be put to obtain
sputum,sputum, Processing of saliva loses all valuable cluesProcessing of saliva loses all valuable clues
to diagnose.to diagnose.
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Dr.T.V.RaoDr.T.V.Rao
Microscopy and TuberculosisMicroscopy and Tuberculosis
Microscopy withMicroscopy with
Ziehl – Neelsen’sZiehl – Neelsen’s
stainingstaining
A century oldA century old
procedureprocedure
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Dr.T.V.RaoDr.T.V.Rao
Why MicroscopyWhy Microscopy
Only we need Microscope, and fewOnly we need Microscope, and few
stains.stains.
Most rapid, economical,Most rapid, economical,
Can detect bacterial load.Can detect bacterial load.
A Diagnostic, and Prognostic tool.A Diagnostic, and Prognostic tool.
A little of sputum 0.2 µl is adequate.A little of sputum 0.2 µl is adequate. A prompt diagnosis after searchingA prompt diagnosis after searching
as few as 100 fields.as few as 100 fields.
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Dr.T.V.RaoDr.T.V.Rao
Limitation of Microscopy for Limitation of Microscopy for
Tuberculosis.Tuberculosis.
Repeated sample examinations. load onRepeated sample examinations. load ontechnical staff.technical staff.
Training and dedication of Microscopist.Training and dedication of Microscopist. The load of bacilli must be more thanThe load of bacilli must be more than
10,000 / 1 ml of sputum.10,000 / 1 ml of sputum. Low in sensitivity < 50 %Low in sensitivity < 50 % Repeated requests for samplesRepeated requests for samples High drop out by patients, for repeatedHigh drop out by patients, for repeated
samples.samples. Not dependable in pediatric age group.Not dependable in pediatric age group.
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Dr.T.V.RaoDr.T.V.Rao
Smear showing Acid Fast Bacilli.Smear showing Acid Fast Bacilli.
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Dr.T.V.RaoDr.T.V.Rao
What is Smear PositivityWhat is Smear Positivity
WHOWHO
All patients who have submittedAll patients who have submitted
twotwo
Specimens and found to beSpecimens and found to bepositivepositive
for identification of AFBfor identification of AFB
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Dr.T.V.RaoDr.T.V.Rao
Processing Direct smear negativeProcessing Direct smear negative
specimensspecimens Sputum Microscopy can be improved withSputum Microscopy can be improved with
Sputum liquefaction, concentration andSputum liquefaction, concentration andgravity sedimentation.gravity sedimentation.
Popular solventsPopular solventsSodium hypochlorite.Sodium hypochlorite.
Sodium hydroxide.Sodium hydroxide.
Ammonium sulphateAmmonium sulphate
N-acetyl-L-cysteine –sodiumN-acetyl-L-cysteine –sodiumhydroxide.hydroxide.
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Dr.T.V.RaoDr.T.V.Rao
Benefits of Liquefaction andBenefits of Liquefaction and
ConcentrationConcentration
Major studies showed processing of Major studies showed processing of sputum with chemicals and centrifugationsputum with chemicals and centrifugation
improved sensitivity up to 18 %.improved sensitivity up to 18 %. Incremental yield ( positive with bleachIncremental yield ( positive with bleachminus positives with Ziehl – Neelsen stain)minus positives with Ziehl – Neelsen stain)up to 9 %.up to 9 %.
Treating specimens with SodiumTreating specimens with Sodiumhypochlorite is Mycobactericidal and alsohypochlorite is Mycobactericidal and alsokills HIV and improves the safety andkills HIV and improves the safety andacceptability by technical staff.acceptability by technical staff.
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Dr.T.V.RaoDr.T.V.Rao
When Microscopy failsWhen Microscopy fails
Smear negative tuberculosis.Smear negative tuberculosis. In HIV infected patients, on manyIn HIV infected patients, on many
occasions prove negative. in spite of occasions prove negative. in spite of
presence of bacilli, ( as few bacilli arepresence of bacilli, ( as few bacilli areexpectorated).expectorated).
Needs concentration and liquefactionNeeds concentration and liquefaction
with chemicals.with chemicals. Time consuming, needs moreTime consuming, needs more
technical manpowertechnical manpower
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Dr.T.V.RaoDr.T.V.Rao
Growing role of Growing role of
Fluorescent MicroscopyFluorescent Microscopy
There is a growing need for screening forThere is a growing need for screening for
AFB by Florescent Microscopy.AFB by Florescent Microscopy. Several studies prove, FlorescentSeveral studies prove, Florescent
Microscopy in Diagnosis of Tuberculosis isMicroscopy in Diagnosis of Tuberculosis is
a priority,a priority, Developing world should opt and initiateDeveloping world should opt and initiate
florescent microscopy.florescent microscopy.
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Dr.T.V.RaoDr.T.V.Rao
Acid Fast Bacilli as seen under Acid Fast Bacilli as seen under
Fluorescent MicroscopeFluorescent Microscope
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Dr.T.V.RaoDr.T.V.Rao
Why we need FlorescentWhy we need Florescent
MicroscopyMicroscopy Useful when few bacilli are present.Useful when few bacilli are present. Increases the sensitivity in HIV patients withIncreases the sensitivity in HIV patients with
tuberculosis.tuberculosis. Reduces the time needed for testing.Reduces the time needed for testing. About 15 times as many fields of view can beAbout 15 times as many fields of view can be
scanned by fluorescent microscopy than by Ziehlscanned by fluorescent microscopy than by Ziehl– Neelsen’method in the same period.– Neelsen’method in the same period.
Increases the sensitivity by 10 %Increases the sensitivity by 10 %
Better conclusions with one or two specimens,Better conclusions with one or two specimens,unlike Ziehl Neelsen’s method needing 3 or > 3unlike Ziehl Neelsen’s method needing 3 or > 3specimens.specimens.
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Dr.T.V.RaoDr.T.V.Rao
Culturing MycobacteriumCulturing Mycobacterium
Culturing for isolation of Culturing for isolation of
Mycobacterium spp continues to be aMycobacterium spp continues to be a
Gold standard, particularly inGold standard, particularly in
Developing countries.Developing countries.
Need only 10 – 100 bacilli / 1 ml of Need only 10 – 100 bacilli / 1 ml of
sputum.sputum.
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Dr.T.V.RaoDr.T.V.Rao
CulturingCulturing
Most useful inMost useful in Surveillance,Surveillance, Drug sensitivity testing patterns.Drug sensitivity testing patterns. Identify treatment failures.Identify treatment failures.
Useful in Patients presenting withUseful in Patients presenting withrespiratory symptoms, X- ray’srespiratory symptoms, X- ray’ssuggestive, but smear negative. Can provesuggestive, but smear negative. Can proveculture positive.culture positive.
Cultures remain suggestive and helpful inCultures remain suggestive and helpful inearly treatment periods, failed drugearly treatment periods, failed drugregimes.regimes.
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Dr.T.V.RaoDr.T.V.Rao
Methods of Culturing.Methods of Culturing.
Culturing on Lowenstein Jenson’sCulturing on Lowenstein Jenson’s
culture medium remain theculture medium remain the
affordable ,economical method inaffordable ,economical method in
developing world.developing world.
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Dr.T.V.RaoDr.T.V.Rao
Limitation in CulturingLimitation in Culturing
Mycobacterium spp are slowMycobacterium spp are slow
growing.growing.
Need 6 – 8 weeks for growing.Need 6 – 8 weeks for growing.
Specimens can be contaminatedSpecimens can be contaminated
while growing, needs repeatedwhile growing, needs repeated
specimens, in turn patients loosespecimens, in turn patients loose
confidence in Laboratories.confidence in Laboratories.
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Dr.T.V.RaoDr.T.V.Rao
Recent facts on CulturingRecent facts on Culturing
Useful in HIV infected patients withUseful in HIV infected patients with
Tuberculosis.Tuberculosis.
As even few bacilli can be grown inAs even few bacilli can be grown in
spite of smear negativity.spite of smear negativity.
But the specimens to be incubatedBut the specimens to be incubated
for longer time as few bacilli arefor longer time as few bacilli are
present.present.
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Dr.T.V.RaoDr.T.V.Rao
Pitfalls in CulturingPitfalls in Culturing
Specificity is lost due toSpecificity is lost due tocontamination.contamination.
Can yield false positive results in 1 –Can yield false positive results in 1 –
4 % of the cases.4 % of the cases.
Cultures may be negative in spite of Cultures may be negative in spite of
x rays are suggestive of tuberculosis.x rays are suggestive of tuberculosis.
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Dr.T.V.RaoDr.T.V.Rao
Growth of Acid fast bacilli onGrowth of Acid fast bacilli on
L J Medium.L J Medium.
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Dr.T.V.Rao
ADVANCES INADVANCES IN
CULTURINGCULTURING
TECHNIQUES.TECHNIQUES.There are emerging Modern MediaThere are emerging Modern Media
with accurate detection, arewith accurate detection, are
replacing the Egg and Agar basedreplacing the Egg and Agar basedmedium.medium.
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Dr.T.V.RaoDr.T.V.Rao
Emerging methods in CulturingEmerging methods in Culturing
MGIT – Mycobacterium growthMGIT – Mycobacterium growth
incubator tube method.incubator tube method.
Growth occurs in shorter than eggGrowth occurs in shorter than egg
medium.medium.
Usefulness in HIV patientsUsefulness in HIV patients
established.established.
Contamination is lessContamination is less
But expensive to people inBut expensive to people in
Developing world.Developing world.
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Dr.T.V.RaoDr.T.V.Rao
Blood culturing for MycobacteriumBlood culturing for Mycobacterium
Useful in HIV patients, and children.Useful in HIV patients, and children.
Effective in isolation of AtypicalEffective in isolation of Atypicalmycobacterium.mycobacterium.
But not cost effective.But not cost effective.
May be important tool in future forMay be important tool in future fordiagnosing Tuberculosis in HIVdiagnosing Tuberculosis in HIV
infected.infected.
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Dr.T.V.Rao
Molecular Methods inMolecular Methods in
Diagnosis of TuberculosisDiagnosis of TuberculosisSeveral methods areSeveral methods are
available, mainly used asavailable, mainly used asResearch toolsResearch tools
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Dr.T.V.RaoDr.T.V.Rao
Real Time PCR replacing older Real Time PCR replacing older
MethodsMethods
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Dr.T.V.RaoDr.T.V.Rao
PCR How useful to our Patients?PCR How useful to our Patients?
PCR ( Polymerase chain reaction ) used byPCR ( Polymerase chain reaction ) used by
several investigators.several investigators.
However most cases can be diagnosedHowever most cases can be diagnosedwith simple methods if effectively used.with simple methods if effectively used.
The definite role of PCR continues to beThe definite role of PCR continues to be
controversialcontroversial
Above all not cost effective to DevelopingAbove all not cost effective to Developing
countries.countries.
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Dr.T.V.Rao
Rapid Diagnostic MethodsRapid Diagnostic Methods
in Tuberculosisin TuberculosisPast decade has seen severalPast decade has seen several
emerging technologiesemerging technologiesHow far practicable ?How far practicable ?
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Dr.T.V.RaoDr.T.V.Rao
Emerging Rapid Methods.Emerging Rapid Methods.
1. Fast Plaque TB uses phage amplification1. Fast Plaque TB uses phage amplification
technology.technology.
2. ELISA ( QuantiFERON – TB )2. ELISA ( QuantiFERON – TB )
3. Enzyme-Linked immunospot3. Enzyme-Linked immunospot
( ELISPOT )( ELISPOT )
ELISPOT proved highly useful to detect activeELISPOT proved highly useful to detect active
tuberculosis in Adults and children.tuberculosis in Adults and children.
E i T h l
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Dr.T.V.RaoDr.T.V.Rao
Emerging TechnologyEmerging Technology
MODSMODS Microscopic observation drug susceptibilityMicroscopic observation drug susceptibility
assay. ( MODS )assay. ( MODS ) A new method gained importance inA new method gained importance in
several reviews.several reviews. Use a tissue culture plate based assayUse a tissue culture plate based assay
with use of Middle Brook 7HG.with use of Middle Brook 7HG. Needs a inverted light microscope.Needs a inverted light microscope.
Even the drug resistance can be testedEven the drug resistance can be testedwith Rifampicin,and Isoniazid.with Rifampicin,and Isoniazid.
Safe to work with cultures.Safe to work with cultures.
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Dr.T.V.Rao
Non Specific TestsNon Specific Tests
Tuberculin testTuberculin test
( Mantoux Test )( Mantoux Test )
T b li TT b li T t
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Dr.T.V.RaoDr.T.V.Rao
Tuberculin TestTuberculin Test
( Mantoux Test )( Mantoux Test )
Test to be interpretedTest to be interpreted
in relation to clinicalin relation to clinical
evaluation.evaluation.
Even the induration of Even the induration of
5 mm to be5 mm to be
considered positiveconsidered positive
when tested on HIVwhen tested on HIV
patients.patients. Lacks specificity.Lacks specificity.
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Dr.T.V.RaoDr.T.V.Rao
Serology in Tuberculosis.Serology in Tuberculosis.
Several serological methods wereSeveral serological methods were
evaluated.evaluated.
But never gained the acceptance of But never gained the acceptance of
the majority of the clinicians.the majority of the clinicians.
Serological tests are low sensitivity.Serological tests are low sensitivity.
Many physicians depend on serologyMany physicians depend on serology
in extra pulmonary tuberculosis.in extra pulmonary tuberculosis.
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Dr.T.V.RaoDr.T.V.Rao
HIV/AIDSHIV/AIDS -- TuberculosisTuberculosis
Consider the HIV statusConsider the HIV status Identify the severity of Tuberculosis.Identify the severity of Tuberculosis. Early use of chest radiography.Early use of chest radiography.
Maximal number of sputum smearMaximal number of sputum smearexaminations.examinations.
Sputum concentration methods to beSputum concentration methods to beencouraged even by smaller laboratories.encouraged even by smaller laboratories.
Explore the use of Florescent Microscopy.Explore the use of Florescent Microscopy. All smear negative specimens should beAll smear negative specimens should be
cultured.cultured.
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Dr.T.V.RaoDr.T.V.Rao
Limitations of Rapid TestsLimitations of Rapid Tests
The testing needs advanced andThe testing needs advanced and
sophisticated infrastructure.sophisticated infrastructure.
These tests are known for theirThese tests are known for their
inability to diagnose between activeinability to diagnose between active
disease and latent infection.disease and latent infection.
Exclusively used in DevelopedExclusively used in Developed
nations.nations.
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Dr.T.V.Rao
Extra pulmonaryExtra pulmonary
TuberculosisTuberculosisPoses several challenges, YetPoses several challenges, Yet
no optimal, specific diagnosticno optimal, specific diagnostic
methodsmethods
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Dr.T.V.RaoDr.T.V.Rao
Extra pulmonary TuberculosisExtra pulmonary Tuberculosis
A real challenge to Clinicians andA real challenge to Clinicians and
Laboratories.Laboratories.
Optimal specimen collection a priority,Optimal specimen collection a priority, Molecular Methods are growing need.Molecular Methods are growing need.
Clinicians start drug regimes on empiricalClinicians start drug regimes on empirical
basis.basis. Several serological tests for antibodySeveral serological tests for antibody
determinations are evaluated.determinations are evaluated.
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Dr.T.V.Rao
Identification of AtypicalIdentification of Atypical
MycobacteriumMycobacteriumA growing concern on infections withA growing concern on infections with
less known, uncommon Mycobacteriumless known, uncommon Mycobacteriumin immunosupreesed, an emergingin immunosupreesed, an emerging
infectious disease probleminfectious disease problem
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Dr.T.V.RaoDr.T.V.Rao
Atypical MycobacteriumAtypical Mycobacterium
Needs the help of referenceNeeds the help of reference
laboratories.laboratories.
Needs different drug regimes, unlikeNeeds different drug regimes, unlike
typical Mycobacterium isolates.typical Mycobacterium isolates.
Now a gowning concern in the era of Now a gowning concern in the era of
AIDS.AIDS.
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Dr.T.V.RaoDr.T.V.Rao
Future perceptionsFuture perceptions
It is highly essential to explore and discoverIt is highly essential to explore and discoverrapid, simple, and accurate tuberculosisrapid, simple, and accurate tuberculosisdiagnostic tools.diagnostic tools.
A massive investment, greater scientific interest,A massive investment, greater scientific interest,
political commitment a top priority,political commitment a top priority, Man power development, Human resourceMan power development, Human resource
utilization a greater concern.utilization a greater concern. Microscopy and Florescent Microscopy utilizationMicroscopy and Florescent Microscopy utilization
should be immediate concern, and strengtheningshould be immediate concern, and strengthening
of treatment initiation protocols.of treatment initiation protocols. Effective methods in diagnosing smear negativeEffective methods in diagnosing smear negative
patients a growing priority.patients a growing priority.
Mi i T b l iMicroscopy in Tuberculosis
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Dr.T.V.RaoDr.T.V.Rao
Microscopy in TuberculosisMicroscopy in Tuberculosis
TODAYTODAY
In spite of severalIn spite of several
scientific, andscientific, and
molecularmolecularadvancesadvances
Microscopy inMicroscopy in
TuberculosisTuberculosis
continues to becontinues to beback bone inback bone in
Diagnosis.Diagnosis.
Specific detection of activeSpecific detection of active
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Dr.T.V.Rao
Specific detection of activeSpecific detection of active
Tuberculosis cases inTuberculosis cases in
patients with HIV infection or patients with HIV infection or AIDS is feasible andAIDS is feasible and
improves the rate of earlyimproves the rate of earlydiagnosis and successfuldiagnosis and successful
treatment of Tuberculosis.treatment of Tuberculosis.
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Created for Medical graduates andCreated for Medical graduates and
Health care workers in Developing worldHealth care workers in Developing world
Dr.T.V.Rao, MD.Dr.T.V.Rao, MD.
e mail;e mail; doctortvrao@gmail.comdoctortvrao@gmail.com
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