Tuberculosis

Dr. Sameh Ahmad Muhamad abdelghany

Lecturer Of Clinical Pharmacology
Mansura Faculty of medicine
Contents
Introduction

Risk Factors

Types - Causes

Diagnosis(C/P – Investigation)

Treatment
INTRODUCTION
Definition

 Tuberculosis (TB) is a potentially fatal contagious

disease that can affect almost any part of the body
but is mainly an infection of the lungs.
 Neo-latin word :
o Tubercle = Round nodule/Swelling
o Osis = Condition
 Global Status of TB
 Tuberculosis (TB) kills 1.6 million people a year
o 0.2 million people infected with HIV
o 98% of these deaths occur in the developing world.

 Close to 9 million new cases develop every year and about one
third of the world’s population is infected with Mycobacterium
tuberculosis.

 TB is a major cause of death among people with HIV/AIDS

and infection is the most potent risk factor for the conversion
of latent TB infection to active TB.
 Global Status of TB
 Multidrug-resistant TB (MDR-TB) has emerged in
nearly every country of the world. Extensively drug-
resistant TB (XDR-TB) has been identified in 17
countries and in all geographical regions.
Causes of TB
Causative Organisms

 Mycobacterium tuberculosis Human

 Mycobacterium Bovis Animals
 Others:
o Mycobacterium africanum
o Mycobacterium microti
Mycobacterium tuberculosis-Characteristics
 Gram positive
 Obligate aerobe
 Slow generation time: 15-20 hours
 Lipid rich cell wall contains mycolic acid:
o Responsible for many of bacterium
characteristics.
o Acid fast.
o Causes resistance to antibacterials.
Types of TB
Classification
I. Pulmonary TB II. Extra pulmonary
 Lymph node TB
 Primary Disease  Pleural TB
 Secondary Disease  TB of upper airways
 Skeletal TB
 Genitourinary TB
 Miliary TB
 Pericardial TB
 Gastrointestinal TB
 Tuberculous Meningitis
TYPES

I. Pulmonary TB
 Primary Tuberculosis :-
 The infection of an individual who has not been
previously infected or immunised
 Lesions forming after infection is peripheral and
accompanied by hilar which may not be detectable
on chest radiography.
TYPES

 Secondary Tuberculosis :
 The infection that individual who has been
previously infected or sensitized is called
secondary or post primary or reinfection or
chronic tuberculosis.
TYPES
[Link]-pulmonary TB
i. Lymph node TB ( tuberculuous lymphadenitis)
 Seen frequently in HIV infected patients.
 Symptoms :- Painless swelling of lymph nodes most commonly at
cervical and Supraclavical (Scrofula)
 Systemic systems are limited to HIV infected patients.

ii. Pleural TB
 Involvement of pleura is common in Primary TB
 and results from penetration of tubercle bacilli into pleural space.
TYPES

iii. TB of Upper airways

 Involvement of larynx, pharynx and epiglottis.
 Symptoms :- Dysphagia, chronic productive cough

iv. Genitourinary TB
• 15% of all Extra pulmonary cases.
• Any part of the genitourinary tract get infected.
• Symptoms :- Urinary frequency, Dysuria, Hematuria.
TYPES
v. Skeletal TB
 Involvement of weight bearing parts like spine, hip, knee.
 Symptoms :- Pain in hip joints n knees, swelling of knees,
trauma.

vi. Gastrointestinal TB
 Involvement of any part of GI Tract.
 Symptoms :- Abdominal pain, diarrhea, weight loss
TYPES
vii. TB meningitis
 Results from Hematogenous spead of primary & secondary TB.

viii. TB Pericarditis
 1- 8% of All Extra pulmonary TB cases.
 Spreads mainly in mediastinal or hilar nodes or from lungs.
TYPES
ix. Miliary or disseminated TB
 Results from Hematogenous spread of Tubercle Bacilli.
 Spread is due to entry of infection into pulmonary vein producing
lesions in different extra pulmonary sites.

x. Less common Extra Pulmonary TB

 uveitis, panophthalmitis, painful Hypersensitivity related
phlyctenular conjuctivis.
Risk Factors
Risk factors
 Elderly
 Infants
 Low socioeconomic status
 Crowded living conditions
 Disease that weakens immune system like HIV
 Alcoholism
 Recent Tubercular infection (within last 2 years) and
ect.
Diagnosis
Medical History

 HIV status
 Symptoms of disease
 History of TB exposure, infection, or disease
 Past TB treatment
 Demographic risk factors for TB
 Other medical conditions that increase risk for TB
disease (e.g., diabetes)
Systemic Symptoms

 Fever
 Chills
 Night sweats
 Appetite loss
 Weight loss
 Fatigue
Symptoms of Pulmonary TB

 Productive, prolonged cough (duration of 2-3

weeks)
 Chest pain
 Hemoptysis (bloody sputum)
 Symptoms may vary based on HIV status
Investigation
LAB

 Bacteriological test
 Obtain 3 sputum specimens for
smear examination and culture
 3 respiratory specimens will
detect 90% of smear-positive
cases
 Look forAFB smear-microscopy
Acid fast smear showing TB bacilli
 PTB+ (Pulmonary TB smear-positive)
 One AFB-positive smear; i.e. any patient with at least one
positive smear result (irrespective of quantity of AFBs seen
on microscopy)
 PTB- (smear-negative)
i. Patients with three negative smear results and radiological
findings and doctor’s decision to treat for TB
ii. Patients with negative smear results and a positive culture
result for M. tuberculosis
iii. Patients who are unable to produce sputum and with
highly suspicious radiological and clinical findings and
doctor's decision to treat for TB
LAB

 Sputum culture test

Culture is indicated for
i. New and retreatment PTB cases
still smear- positive at end of
intensive phase
ii. Symptomatic contacts of known
MDR cases
Radiography

 Chest X-Ray(CXR)
 Cannot confirm diagnosis of TB
 May have unusual appearance in
HIV-positive persons
 CXR is helpful in HIV+, smear-
negative patients
Tuberculin skin test (PPD)
 Injection of fluid into the skin of the lower arm.
 48-72 hours later -checked for a reaction.
 Diagnosis is based on the size of the wheal:
o <6mm negative
o 6mm-15mm Hypersensitive to tuberculin
protein(Previous TB infection or BCG – atypical
mycobacteria)
o >15mm strongly Hypersensitive to
tuberculin protein(suggestive of TB infection)
Other biological examinations

 Cell count(lymphocytes)
 Protein(Pandy and Rivalta tests) – Ascites, pleural
effusion and meningitis.
Treatment
Aims of TB Treatment

 Cure the patient of TB

 Prevent death from active TB or its latent effects
 Prevent relapse of TB
 Decrease transmission of TB to others
 Prevent the development of acquired resistance
Preventive measures

 Mask
 BCG vaccine
 Regular medical follow up
 Isolation of Patient
 Ventilation
 Natural sunlight
BCG vaccine
 Only vaccine available today for protection against
tuberculosis.
 effective in protecting children from the disease.
 Given 0.1 ml intradermally.
 Duration of Protection 15 to 20 years
 Should be given to all healthy infants as soon as
possible after birth unless the child presented with
symptomatic HIV infection.
 Basic Principles of Treatment
 Determine the patient’s HIV status- this could save
their life!
 Provide safest, most effective therapy in shortest time
 Multiple drugs to which the organisms are
susceptible
 Never add single drug to failing regimen
 Ensure adherence to therapy (DOT)
 DOTS
 Directly observed treatment, short-course
 DOT means that a trained health care worker or other
designated individual provides the prescribed TB drugs
and watches the patient swallow every dose.
 DOT for all patients on all regimens (NO exceptions)
FIRST LINE ANTI-TUBERCULOUS
DRUGS
 Isoniazide
 Rifampicin (Rifampin)
 Ethambutol
 Pyrazinamide
 Streptomycin
SECOND LINE ANTI-TUBERCULOUS
DRUGS
 Para aminosalicylic acid
 Ethionamide
 Cycloserine
 Fluoroquinolones
 Capreomycin
REGIMEN OF TB THERAPY
Patients with active TB:
 Initial phase (first 2-4 months): 4 drugs are used (RIPE):
(Rifampin + INH + Pyrazinamide + Ethmabutol).
 Continuation phase (next 4-6 months): at least 2 drugs are
used (INH + rifampin).
REGIMEN OF TB THERAPY

Patients with latent TB:

 Latent TB (i.e. patients with +ve Tuberculin skin test and had
history of contact to a person proved to have TB)
 INH alone for 6 months or dual Rifampicin + INH for 3
months.
REGIMEN OF TB THERAPY

TB during pregnancy:
 The only anti-TB drug which is absolutely contraindicated
is streptomycin because of the high risk of congenital
deafness.
 other first line anti-TB drugs are safe for use in pregnancy.
REGIMEN OF TB THERAPY

TB with liver disease

 INH, rifampin, and pyrazinamide are hepatotoxic but
because of their effectiveness, they should be used depending
on monitoring of liver function tests.
 In severe liver damage, only one drug can be used.
Extrapulmonary TB

 In most cases, treat with same regimens used

for pulmonary TB
 Treatment extended > 6 months depending on
site of disease
 In TB meningitis Streptomycin replaces
Ethambutol
Multi-Drug Resistance TB
 TB caused by strains of Mycobacterium tuberculosis
that are resistant to at least isoniazid and rifampicin,
the most effective anti- TB drug.
 3.6% are estimated to have MDR-TB.
 Treatment must be individualized
 should seek expert consultation
 6 months intensive treatment (always including an
injectable drug) followed by at least an 18 month
continuation phase
Extensively drug resistance TB

 is a form of TB caused by bacteria that are

resistant to isoniazid and rifampicin (i.e. MDR-
TB) as well as any fluoroquinolone and any of the
second-line anti-TB injectable drugs (amikacin,
kanamycin or capreomycin).
Tuberculosis and HIV
 HIV positive people with pulmonary TB may have a
higher frequency of having sputum negative smears.
 The tuberculin test often fails to work, because the
immune system has been damaged by HIV; It may
not even show a response even though the person is
infected with TB.
 Chest Xray will show less cavitation.
 Cases of Extra pulmonary TB are more common.
 Management of HIV-related TB is complex
Thank you!
Any Questions?