Tuberculosis III

7/27/2019 Tuberculosis III

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TUBERCUOSIS

byMeriah

Sembiring,Dr,Sp.ASubdivision Respirology of The

Pediatric the Ulin Hospital.


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INTRODUCTION

TB one of the oldest diseases of humanremains causes of the deadliest diseasesinthe wold

8 million of new case yearly3 million death yearly20- 40 % population is infectedreemergence global emergency

Indonesia : numb.1 causes death of theinfection diseases.


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DEFINITION

Tuberculosis is a disease due toMYCOBACTERIUM tuberculosis infectionwith systemic spread thus can affect almost

all organs ,and the most frequent site inthe lung,as the site of primary infection.


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M TUBERCULOSIS

CHARACTERISTICS;1. Live in weeks in dry condition2. no endotoxins, exotoxins.

3, hematogenic spread4. grows slowly (24 32 hr )5. no specific clinical manifestation

6. aerob,organ predilection lung7. wide spectrum of replication:dormant


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TRANSMISSION:

. Airborne human to human transmissionby DROPLET NUCLEI.

. adult pulmonary TB :

cough,sneeze,speak,or sing.. Droplet nuclei: cotain 2-3 bacili,smallsize(1-5U)keep in the air long period .

.inhalation, reach alveoli middle and lowerlobe.


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TRANSMISSION FACTORS

Doses/numbers.concentration in the air.virulence

.exposure duration

.host immun state


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Infection source

Know source of infection,has diagnostic

value

Shaw ( 1954 ),transmission rate :

- AFB ( + ) : 62,5

- AFB ( - ),M tb ( + ) : 26,8

- AFB ( - ),M tb ( - ) : 17,6


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PATHOGENESIS

Alveoli Ingestion by PAMS

Droplet nucle

inhalation

Intracellular replication ofbacili

Destruction of PAMS

Tuber formation Lymphogenic spread

Primay focus lymphangitis

Destruction of

bacili

Hilar lymph nodes

lymphadenitis

Hematogenic spread Primary complex

CMI

Acute hematogencispread

Occult hematogenicspread

Disseminated primary TBMultiple organs remote

foci Figure,pathogenesis of primary tuberculosis


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Incubation period

First implantation primary complex4 6 weeks ( 2 12 weeks ) incub.period

First weeks : logaritmic growth, : 10- 104 elicit cellular response

End of incubation period :

- primary complex formation

- cell mediated immunity

- tuberculin sensitivityPrimary TB infection haseastablished


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Hematogenous spread

During incubation peroid,before TB infectionestablishment :

- lymphogenic spread

- hematogenic spread

hematogenic spread ( HS ) :

- occult HS- acute generalized HS


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Occult Hs

Most common

Sporadic,small number

No immediate clinical manifestation

Remote foci in almost every organRich vascularization : brain,liver,bones &

joints,kidney

Including : lung apex region ( Simonfocus )

CMI ( + ) : silent foci dormant,potential forreactivation


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Acute HS

Less common

Large number

Immediate clinical manifestation :disseminated TB

Minilary TB,meningitis TB

Tubercle in same size,special appearance inCXR


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Primary complex

End of incubation period

TB infection establishment

Tuberculin sensitivity ( DTH )

Cell mediated immunity

End of hematogenic spread

End of TB bacili proliferetion

Small amount,live dormant in granuloma

New exogenous TB bacili : destroyed / localized


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TB Infection & TB disease

TB infection : CMI can control infection

Primary complex ( + )

Cell mediated immunity ( + )

Tuberculin sensitivity ( DTH ) ( + ) Limited amount of TB bacilli

no clinical or radiological manifestation

TB disease : CMI failed to control TBinfection TB infection + clinical and/orradiological manifestation


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TB Classification ( ATS/CDC modifled )

Class Contact Infetion Disease Treatment

0 - - - -

1 + - - proph I

2 + + - Proph II

3 + + + therapy


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Clinical manifestation

General

chronic fever,subfebrille anorexia

weight loss

malnutrition

malaise

chronic recurrent cough,think asthma ! chronic reccurrent diarrhea

other


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SpecifikRespiratory : cough,wheezing,dyspnea

Neurology : convulsion,neckstiffness,SOL manifestation

Orthopedic : gibbus,crippled

Lymph node : enlarge,scrofulodermaGastrointestinal : chronic diarrhea

others


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Tuberculin agent

Streng PPD SSeiber

PPD RT 23

First 1 TU 1 TU

Intermedite

(standard dose)

5 10 TU 2 5 TU

Second 250 TU 100 TU


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Tuberculin test

Mantoux 0,1 ml PPD intermediate strength Location : volar lower arm,intradermalReading time : 48 72 h post injection

Measurement :palpation,marked,measureReport : in milimeterInduration diameter :

05 mm : negative 59 mm : doubt

10 mm : positive


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Microbiology

Culture ( Lowenstein Jensen )

Confirm the diagnosis

Negative result do not rule out TBPositive result : 10 62 % ( old method )


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Radiographic picture

No radiographic picture is typical of TB

Many lung diseases have similarradiographic appearances mimicking PTB

Cannot distinguish active pulmonary TBinvactive PTB previously treated TB

May not detect early stages of TB disease

Under reading over reading

Intra individual inconsistency


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Do not always help,particularly in small

children at times can be confusing.

Some cases : extensive dosease fromradiography clinical exam little ornothing.

More confusing superadded bacterialpneumonia.

Commnoly found : enlargement of hilar /

paratracheal nodes sometimesdifficult to interpret requires thorax

CT with contrast.


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Diagnosis

1.Clinical manifestation

2.Tuberculin skin test

3.Chest X ray

4.Microbiologhy

5.Pathology

6.Hematology

7.Know infection soure

8.Others : serologic,lung function,bronchoscopy


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Proposed IDAI scoing system

Featur 0 1 2 3 Score

Contact Not clear Reported,AFB ( - )

- AFB (+)

TST - - - +BW (KMS) -


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Diagnosis by doctor

BW assessement at present

Fever & cough no respons to standard txCXR is NOT a main diagnostic tool in children

All accelerated BCG reaction should be evaluatedwith scoring system

TB diagnosis total score 5

Score 4 in under 5 child or strong suspicion,referto hospital

INH prophylaxix for AFB (+) contact with score


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Treatment

Objectives:Rapid reduction of the bacilli numbers,to cure the

patient

Sterillization, to prevent relapsesTo achieve two phases :

Initial phase ( 2 months)

intensive,baci.eradication

Maintenance(4 months /more)-sterillizing.

Prevention of acquired drug resistance


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Principles

Multi drug ,not single drug ( monotherapy )

Long term,continue,uninterruptedproblem

The drug is taken daily and regularly


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TB bacilli population

Location Cavity,extra cell Intramacrophage

Caseous mass

TB population A B C

TB amount Active/rapidly Slowly Sporadic/intermittent

Metabolism &replication

Active / rapidly Slowly Sproradic/intermittent

Acidity (pH) Neutral/base Acid Neutral

Most effectivedrug (conscly)

INH,RIF,ETB PZA,RIF,INH RIF,INH


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TB therapy regimen

2 mo 6 mo 9 mo 12 mo

INH --------------------------------------------------------

RIF --------------------------------------------------------

PZA ---------

ETB ---------

SM ---------PRED ---- -- --


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Dosage of antituberculosis drug

Drugs Dally dose(mg/kg/day)

2 time/week dose(mg/kg/dose))

Adeverse reactions

Isoniazid(INH)

5 -15 (300mg))

15 40 (900mg))

Hepatitis,perippheralneuritis,hypersensitivity

Rifampicin(RIF)

10 15 (600 mg)) 10 20 (500 mg) Gastrointestinal upset,skinreaction,hepatitis,thrombocytopania,hepatic enzymes,including

orange discolouraution ofsecretions

Pyrazinamide

(PZA)

15 40 (2 kg) 50 -70 (4 kg) Hepatotoxicity,hyperuricamia,ar

thralgia,gastrointestinal upset

Ethambutol(EMB)

15 25 (2,5 g) 50 (2,5 g) Optic neuritis,decreassed red-green colour

discrimination,hypersensitivity,gastrointestinal upset

Streptomycin(SM) 15 40 (1 g) 25 40 (1,5 g) Ototoxicity nephrotoxicity


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Corticosteroid

Anti inflammation

Prednison : oral,1 2 mg/kg BW/day,tid2- 4 weeks,tap off

Indications :

Miliary TB

Meningitis TB

Pleuritis TB with effusion


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THERAPY EVALUATION

Clinical evaluation Increased body weight

Increased appetite

Diminished /reducesymtoms ( fever,cought,etc)Supporting examination

Chest X ray :2/6 month

Blood : BSR TST : once positif,do not repeat !


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THERAPY FAILURE

Inadequate response, despite adequatetherapy :

Review the diagnosis, not a TB case ?

Review other aspects : nutrition, other disease

MDR rarely in children

Treatment discontinuation


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THANK YOU


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PATHOGENESIS

Alveoli Ingestion by PAMS

Droplet nucle

inhalation

Intracellular replication ofbacili

Destruction of PAMS

Tuber formation Lymphogenic spread

Primay focus lymphangitis

Destruction ofbacili

Hilar lymph nodes

lymphadenitis

Hematogenic spread Primary complex

CMI

Acute hematogencispread

Occult hematogenicspread

Disseminated primary TB

Multiple organs remote

foci Figure pathogenesis of primary tuberculosis

Documents

Tuberculosis III