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TuberculosisTuberculosisThe greatest killer in the history of mankindThe greatest killer in the history of mankind
Brig Jawad AnsariBrig Jawad Ansari FCPS,FCCP,FRCPEFCPS,FCCP,FRCPE
Professor of Medicine & PulmonologistProfessor of Medicine & Pulmonologist
EPIDEMIOLOGYEPIDEMIOLOGY
1/31/3rdrd of world population is infected of world population is infected
TB contribute 25% of avoidable deathsTB contribute 25% of avoidable deaths
95% cases in developing world95% cases in developing world
98% of TB deaths in developing world98% of TB deaths in developing world
75% of TB cases in productive age group75% of TB cases in productive age group
Pakistan is 7Pakistan is 7thth in ranking with reported cases 0f 361000 in ranking with reported cases 0f 361000
per annum and prevalence of 1810/100,000per annum and prevalence of 1810/100,000
• Mycobacterium TB ComplexMycobacterium TB Complex
(Tubercle bacilli)(Tubercle bacilli)
(Acid Fast bacilli:AFB)(Acid Fast bacilli:AFB) M.tuberculosis (majority)M.tuberculosis (majority) M. bovisM. bovis M.africanumM.africanum
• Can remain dormant / persist for many yearsCan remain dormant / persist for many years• Atypical Mycobacterium/ OpportunisticAtypical Mycobacterium/ Opportunistic
Transmission of InfectionTransmission of Infection
Coughing patient of pulmonary TBCoughing patient of pulmonary TB Single cough: 3000 droplets nucleiSingle cough: 3000 droplets nuclei Also spread by talking, sneezing, spitting , singingAlso spread by talking, sneezing, spitting , singing Direct sunlight kill AFB in 5 minutesDirect sunlight kill AFB in 5 minutes Transmission is mostly indoorTransmission is mostly indoor Risks of exposure; concentration of droplet nuclei Risks of exposure; concentration of droplet nuclei
and the time spent in contaminated airand the time spent in contaminated air Bovine TB: cervical lymph node/ intestinal TBBovine TB: cervical lymph node/ intestinal TB
Is TB transmitted by following?Is TB transmitted by following?
FoodFood WaterWater Sexual intercourseSexual intercourse Blood transfusionBlood transfusion mosquitoesmosquitoes
Is TB transmitted by following?Is TB transmitted by following?
FoodFood WaterWater Sexual intercourseSexual intercourse Blood transfusionBlood transfusion mosquitoesmosquitoes
Infection to diseaseInfection to disease
90% of infected individuals do not develop disease90% of infected individuals do not develop disease Only evidence of infection is positive tuberculin testOnly evidence of infection is positive tuberculin test Chances of disease are higher soon after infectionChances of disease are higher soon after infection Higher in infants and childrenHigher in infants and children Emotional and physical stressEmotional and physical stress HIV infectionHIV infection
Natural History of TBNatural History of TB
If Untreated: then by 5 yearsIf Untreated: then by 5 years• 50%: will be dead50%: will be dead• 25%: cured by their immune system25%: cured by their immune system• 25%: become chronic25%: become chronic
TUBERCULOSIS
EXTRAPULMONARY TB
PULMONARY TB
WHO/CDS/TB/2003.313TREATMENT OF TUBERCULOSIS:GUIDELINESFOR NATIONAL PROGRAMMESTHIRD EDITION 2003
EXTRA-PULMONARY TBEXTRA-PULMONARY TB (WHO Categorization) (WHO Categorization)
MeningitisMeningitis MiliaryMiliary PericarditisPericarditis PeritonitisPeritonitis Bilateral/ Extensive Bilateral/ Extensive
pleural effusionpleural effusion SpinalSpinal IntestinalIntestinal GenitourinaryGenitourinary
SEVERE FORMS: Cat 1
EXTRA-PULMONARY TBEXTRA-PULMONARY TB (WHO Categorization) (WHO Categorization)
MeningitisMeningitis MiliaryMiliary PericarditisPericarditis PeritonitisPeritonitis Bilateral/ Extensive Bilateral/ Extensive
pleural effusionpleural effusion SpinalSpinal IntestinalIntestinal GenitourinaryGenitourinary
Lymph nodesLymph nodes Unilateral pleural Unilateral pleural
effusioneffusion Bones ( excluding Bones ( excluding
spinespine Peripheral jointsPeripheral joints Adrenal glandsAdrenal glands
SEVERE FORMS: Cat 1 LESS SEVERE FORMS: Cat 3
First year MBBS First year MBBS Teacher to student “Be good You will be fine”Teacher to student “Be good You will be fine”
Diagnosis: Clinical SuspicionDiagnosis: Clinical Suspicion
• Cough for more than 2-3 weeksCough for more than 2-3 weeks• Sputum productionSputum production• Weight lossWeight loss• Night sweatsNight sweats• Fatigue & tirednessFatigue & tiredness• No sign is specificNo sign is specific
Diagnosis: Lab TestsDiagnosis: Lab Tests
Detection of AFBs in sputum smearsDetection of AFBs in sputum smears Culturing of AFB & sensitivityCulturing of AFB & sensitivity Chest X-rayChest X-ray Tuberculin Skin Test ?Tuberculin Skin Test ? ESR ???ESR ??? PCRPCR
SPUTUM SAMPLINGSPUTUM SAMPLING
At least three isolated samplesAt least three isolated samples Sputum and not salivaSputum and not saliva Early morning samples preferableEarly morning samples preferable If no cough:If no cough:
• Assisted coughAssisted cough• Induced Sputum Induced Sputum
Alternate to sputumAlternate to sputum• Gastric washingsGastric washings• Bronchial washingsBronchial washings
Slide reportingSlide reportingUsing 1000x magnificationUsing 1000x magnification
Number of bacilliNumber of bacilli Result reportedResult reported
No AFB No AFB 00
1-9 AFB per 100 oil immersion 1-9 AFB per 100 oil immersion fieldsfields
ScantyScanty
10-99 AFB per 100 oil immersion 10-99 AFB per 100 oil immersion fieldsfields
++
1-10 AFB per oil immersion field1-10 AFB per oil immersion field ++++
11-100 AFB / oil immersion field11-100 AFB / oil immersion field ++++++
InterpretationInterpretation
Smear positiveSmear positive• At least 2 smears examined and both At least 2 smears examined and both
positive for AFBpositive for AFB Smear NegativeSmear Negative
• At least 02 smears reported as negativeAt least 02 smears reported as negative IndeterminateIndeterminate
• Only one smear examinedOnly one smear examined• 03 smears examined and only one 03 smears examined and only one
reported as positivereported as positive
MYCOBACTERIAL CULTURESMYCOBACTERIAL CULTURES
Growing AFB on culture confirms diagnosisGrowing AFB on culture confirms diagnosis AFB grown can be tested for their AFB grown can be tested for their
sensitivity against various drugssensitivity against various drugs MethodsMethods
• Lowenstein JensenLowenstein Jensen• Liquid mediaLiquid media• Bactec Bactec
Limitations: 6-8 weeks, skilled lab, Limitations: 6-8 weeks, skilled lab,
Tuberculin Skin TestTuberculin Skin Test
In population with high prevalence of In population with high prevalence of TB, skin test is of little diagnostic TB, skin test is of little diagnostic valuevalue
Does not distinguish disease from Does not distinguish disease from infectioninfection
Positive Tuberculin Test
1.1. Active TBActive TB
2.2. Previous TBPrevious TB
3.3. Previous BCG vaccinationPrevious BCG vaccination
4.4. Atypical mycobacteriaAtypical mycobacteria
5.5. Sarcoidosis ( in less than 30%)Sarcoidosis ( in less than 30%)
False Negative Tuberculin Test
1.1. HIV infectionHIV infection
2.2. MalnuitritionMalnuitrition
3.3. Immunosupressive drugs like steroidsImmunosupressive drugs like steroids
4.4. Severe bacterial infection Severe bacterial infection
5.5. Milliary TB/ Fulminant TBMilliary TB/ Fulminant TB
6.6. Viral infections like measles, chicken pox, glandular Viral infections like measles, chicken pox, glandular feverfever
7.7. CancerCancer
8.8. Incorrect injection of PPDIncorrect injection of PPD
ESR AND TBESR AND TB
It can not be relied upon for the It can not be relied upon for the diagnosis of Tuberculosis and should diagnosis of Tuberculosis and should not be advised in routine.not be advised in routine.
Not recommended by WHO and by Not recommended by WHO and by local guidelineslocal guidelines
Role of Raidiology Role of Raidiology
There is no radiological findings which There is no radiological findings which can be diagnostic of Pulmonary can be diagnostic of Pulmonary TuberculosisTuberculosis
ButBut
There are certain typical patterns, There are certain typical patterns, where TB can be strongly suspectedwhere TB can be strongly suspected
Tuberculosis
Pulmonary Extra-pulmonary
Smear positive Smear negative
Histopathology Cultures
WHO/CDS/TB/2003.313TREATMENT OF TUBERCULOSIS:GUIDELINESFOR NATIONAL PROGRAMMESTHIRD EDITION 2003
Smear positive ( PTB+ )
>02 sputum smear pos
01 sputum smear pos(plus) c/s + M. tuberculosis
01 sputum smear pos(plus) radiological evidence of active TB
WHO/CDS/TB/2003.313TREATMENT OF TUBERCULOSIS:GUIDELINESFOR NATIONAL PROGRAMMESTHIRD EDITION 2003
Smear Neg Pulmonary Tuberculosis (PTB-)
Three sputum smears negative for AFB
Strong clinical suspicion
No response to broad spectrum antibiotics
Radiographic findings suggestive of active TB
WHO/CDS/TB/2003.313TREATMENT OF TUBERCULOSIS:GUIDELINESFOR NATIONAL PROGRAMMESTHIRD EDITION 2003
DRUG SENSITIVE TBDRUG SENSITIVE TB
Tuberculosis where AFBs are Tuberculosis where AFBs are sensitive to first line anti-tuberculosis sensitive to first line anti-tuberculosis drugsdrugs
FIRST LINE DRUGSFIRST LINE DRUGS
RIFAMPICIN (R)RIFAMPICIN (R) ISONIAZID (H)ISONIAZID (H) ETHAMBUTOL (E)ETHAMBUTOL (E) PYRIZINAMIDE (Z)PYRIZINAMIDE (Z)
VERY POTENTVERY POTENT LESS SIDE EFFECTSLESS SIDE EFFECTS ECONOMICALECONOMICAL SHORT DURATIONSHORT DURATION
• (6-8 months)(6-8 months)
TB case
Re-treatment case
Previous ATT
NO YES
New case
relapse
Treatment after default
chronic
Treatment failure
never taken ATT or ATT < 1 month
Rarely sputum smear negative
Completed ATT
Incomplete ATT
Not responded to standard regimen
after re-treatment regimen
WHO/CDS/TB/2003.313 Treatment Of Tuberculosis:guidelinesfor National Programmesthird Edition 2003
New Cases New Cases (PTB +/- and Extra PTB)(PTB +/- and Extra PTB)
04 Drugs-02months
2 HRZE
02 Drugs-06months
6 HE02Drugs-05months
5 HE
Repeat initial phase-01month
1 HRZE
Initial phase
Continuation phase
Check sputum smear
Smear +
Smear -
Smear -
Guidelines for Diagnosis & Management of Tuberculosis. Pakistan Chest Society. March 2002.
4HR 4HRE
Re-treatment cases Re-treatment cases (Relapse, Failures, Default: Smear positive)(Relapse, Failures, Default: Smear positive)
2 HRZES / 1 HRZE
5 HRE 4 HRE
Check sputum smear
Chronic case
1HRZE
If smear+, send c/s
Still smear positive
Smear +Smear -
Initial phase
Continuation phase
Guidelines for Diagnosis & Management of Tuberculosis. Pakistan Chest Society. March 2002.
MDR-TB ?