Development of the tuberculosis study history, epidemiology-1.pptx

About development of tb

1. Development of the tuberculosis study history, epidemiology of tuberculosis, tuberculosis etiology. Diagnosis and examination methods of tuberculosis patients Theme 1

2. Etiology and pathogenesis of tuberculosis Mycobacterium tuberculosis (MBT) belongs to the Class – Schizomycetes Order – Actinomycetes Family – Mycobacteriaceae Genus - Mycobacterium

3. M. tuberculosis complex: M. tuberculosis M. bovis and M.bovis BCG M. africanum M. microti M. pinnipedii M. caprae M. cannetti M. orygis M. mungi

4. Morphology MBT 1. Acid- and alcoholic resistant, thin straight or slightly curved sticks 1-10 μm , diameter 0.2-0.6 μm , homogeneous or grainy structure. 2. The MBT is immobile, the spores do not form aerobs . 3. According to the Gram they are slightly positively colored. 4. The bacterial cell consists of a multilayer shell, a cytoplasm with organelles, and a nuclear substance. It includes water, proteins, lipids, polysaccharides and mineral salts. 5. Reproduction occurs by direct division, in periods ranging from 13-14 to 18-24 hours. 6. Visible growth on a solid nutrient medium - 12-20 days.

5. Genome of MBT It was decoded in 1988 by the MBT gene. The MBT chromosome is a ring structure consisting of 4 411 529 nucleotide pairs, represented primarily by guanine and cytosine. It contains more than 4 thousand genes coding the composition and functions of mycobacterium. The M.tuberculosis complex genome is characterised by the presence of a larger number of repetitive DNA sequences, which determines their polymorphism. Unique genes have been identified for MBT, notably mtp40 and mpb70.

6. The main properties of mycobacteria Environmental resistance: acids, alcohols, alkalis, many antibiotics, chemicals, some disinfectants and physical factors. MBT is sensitive to high temperature, ultraviolet and chlorinated disinfectants. Polymorphism and variability: l-Form Formation

7. THE route of transmission 1) air-born; 2) alimentary (digestive); 3) contact; 4) intrauterine tuberculosis infection.

8. Air-born tuberculosis infection MBT are distributed in the air with cough droplets, sneezing and conversation by a patient with active TB. Inhalation of these infected droplets can penetrate into healthy lungs. This type of infection is known as air-droplet infection (Air-born infection). Depending on the force of cough impulses and of the droplets sizes MBT can be dispersed with air on different distances from the patient, upon coughing — up to 2 m, upon sneezing — up to 9 m. The basic movement of sputum throwing particles occurs on distance of 1 m directly in front of the patient. Tubercular sputum droplets, accumulated on floors, dry up and turn to dust particles. MBT being inside of the motes for some time remains viable. It has been established, that on the 18-th day of dried up sputum, and there are still about 1% of viable bacteria. Intensive air flow, floor sweeping, daily locomotion and any other type of movements will raise the MBT containing motes in the air, which can potentially penetrate into lungs and cause infection.

9. Infection through digestive (alimentary) tracts It is necessary to take into consideration that MBT penetration into the intestine can occur at swallowing by the lung tuberculous patients own sputum that proved by the presence of MBT in significant quantity in stomach flush waters.

10. Contact ways of MBT penetration into the host Cases of infection through a conjunctiva were observed among children and adults; acute conjunctivitis and inflammation of the lachrymal sac were sometime seen in these patient. The tuberculous infection through the skin is rare. The cases of tuberculosis infected milkmaids are described, at MBT penetration through the injured skin of hands from the cows infected by tuberculosis.

11. Intrauterine tuberculosis infection The possibility of tubercular infection of the fetus during intrauterine period of life was proved on section, of newborns died during the first days after birth. The infection occurs at tuberculosis lesion of placenta or at affection of injured placenta during delivery by the tuberculosis-infected mother. Such way of tubercular infection occurs very rare.

12. Physical examination of patient with tuberculosis Mandatory examination methods - mandatory diagnostic minimum : advanced history study physical examination (inspection, percussion, palpation, auscultation) blood test urinalysis X-rays in forward and side projection tuberculin sample Mantu with 2TE microscopic sputum smear for acid-resistant micobacteria

13. additional research methods - 1 Recuperation of sputum: cultural and molecular genetic methods CHEST CT quantumferone test and diaskent

14. additional research methods - 2 bronhologic examination with brushing, crimping, punctual biopsy trassbanhal lung biopsy transtoral biopsy of the lung or pleura diagnostic surgery

15. Optional methods External respiration function study ECG blood chemistry test immunology research

16. Symptoms If a patient has any of the following, consider him a ‘Tuberculosis Suspect’: 1. Cough for over 3weeks. 2. Haemoptysis . 3. Pain in the chest for over 3 weeks. 4. Fever for over 3 weeks.

17. Symptoms General Symptoms: Loss of weight. Fever and sweating. Loss of appetite. Breathlessness. Respiratory Symptoms: Cough. Sputum. Blood-spitting. Tiredness. Chest wall pain. Localized wheeze in lungs. Frequent colds.

18. Anamnesis When and how the disease was diagnosed: When a complaint was referred to a doctor or during a control examination. Related diseases: diabetes, silicosis, stomach and duodenal ulcer disease, alcoholism, drug addiction, HIV infection. It is important to know about the presence in regions with a high incidence of tuberculosis, about participation in hostilities, as well as about the stay in prison. Profession and nature of work, lifestyle, living conditions, alcohol consumption, smoking. Level of patient culture. Anti-tuberculosis vaccinations and results of tuberculin trials. Health status of family members, possible contact with tuberculosis patients and its duration. Also the probability of contact with sick animals and consumption of milk infected with MBT.

19. examination Habitus phtisicus : body deficit blush on a pale face bright eyes and wide pupils dystrophic skin changes long and narrow chest dilated intercostals acute supraspinous angle wing blade

20. physical development skin color and mucous membranes over- and subclavian pits symmetry of the right and left rib cages thoracic mobility narrowing or widening of intercostals on the fingers and toes, the end phalanges are deformed in the form of drumsticks and the nail shape changes in the form of convex watchglass shoulder examined scar after BCG vaccination

21. microbiological studies Are important for: Identification of the most serious cases of tuberculosis Verification of tuberculosis diagnosis Determination of MBT sensitivity to drugs Assessment of treatment efficacy and prognosis of tuberculosis surveillance

22. SPUTUM COLLECTION INSTRUCTIONS General Information Sputum is mucous or phlegm coughed from deep in the lungs. It is not saliva from the mouth or mucous from the back of the throat. Sputum specimens should be collected in the early morning if possible. Collect 2 sputum specimens on 2 consecutive days unless otherwise instructed. Specimens should be kept in the refrigerator until they are submitted to the laboratory. To reduce the likelihood of transmission, patients are encouraged to collect sputum specimens outdoors when possible and away from other people.

23. Procedure: 1. The container is clean. Do not open until ready to use. 2. The mouth should be free of foreign matter and may be rinsed with filtered or sterile water prior to collection. 3. Take deep breaths through your mouth and cough up the mucous from deep in your lungs. Breathing deeply over a pan of boiling water may help raise sputum. 4. Open the container and hold it close to your mouth. Cough the mucous into the container. 5. 1-2 teaspoons of specimen is adequate. The container should not be more than ½ full.

24. 6. Once collected, screw the lid on tightly. 7. Write patient name, date of birth and collection date on specimen bottle. 8. Write patient name, date of birth and collection date on laboratory slip. 9. Specimen should be double bagged in the plastic bags provided. 10. Store specimen in the refrigerator until transported. 11. Notify Department of Health staff to arrange for transport of specimen to the laboratory. Specimens should be transported the same day as collected unless otherwise instructed.

25. smear microscopy The simplest and most inexpensive method of examination to be used in all cases of suspected tuberculosis. The most common method for identifying acid-resistant mycobacterium is the Cil -Nilsen smear . The method is based on the penetration of carbolic fuxine into the microbial cell by the complementary heating. After discolouration with a solution of acid or hydrochloric alcohol, the smear is finished with a solution of methylene blue. As a result, acid-resistant mycobacteria are colored raspberry-red and other cell elements are colored blue.

26. Luminescent microscopy with fluorochromes is used to increase resolution. This method increases microscopy efficiency by 10-15%. In the treatment of pathological material, fluorochromes (auramine, rodoin ) bind to the waxes of the microbial cell. With ultraviolet irradiation, MBTs start to glow orange or golden light on a dark background.

27. culture method Is highly sensitive and has a number of advantages in comparison with microscopic smear. This method is based on the "golden" standard of microbiological research and allows the detection of MBT in the presence of several tens of 1 ml of biological material. The Levenstein -Jensen environment is recommended for primary MBT release and drug sensitivity determination.

28. It is a dense egg nutrient medium in which MBT growth is obtained for 20-25 days after planting bacterioscopically positive material. Positive sowing of bacterioscopically negative material can be obtained after 10-12 weeks.

29. Automated cultivation system: Bactec mgit-960 The automated modular system is designed for in vitro accelerated bacteriological diagnosis of tuberculosis for the study of various body fluids: sputums ; bronchial washing waters; pleural exudate; synovial and cerebral fluids. The instrument continuously automatically tests test tubes. The series of LEDs under the test tubes activates the fluorescent sensor, and the instrument’s photodetectors read the results (every 60 minutes). The recording of positive culture is immediately signalled by the instrument by means of a light indicator on the front panel of the section, the inclusion of an audio signal, and the station number is displayed on the liquid crystal display.

30. Samples are collected, processed and inoculated into special 7 ml BBL MGIT tubes. The device is simultaneously tested in 3 working sections for the presence in the mycobacteria environment, each section holds 320 vials, in which constant incubation is carried out. The growth of microorganisms is recorded optically. It is based on the fluorescence produced by oxygen consumption during the growth of mycobacteria. The oxygen-dependent fluorochrome dye is found on the bottom of the vial and is coated with a layer of silicone. The reproduction of mycobacterium leads to oxygen consumption in the vial and a decrease in its concentration, which causes fluorescence to increase. Fluorescence becomes visible when the test tube is exposed to ultraviolet light and is automatically detected by a photosensor integrated into the Bactec MGIT 960. The instrument continuously automatically tests test tubes. The series of LEDs under the test tubes activates the fluorescent sensor, and the instrument’s photodetectors read the results (every 60 minutes). The recording of positive culture is immediately signalled by the instrument by means of a light indicator on the front panel of the section, the inclusion of an audio signal, and the station number is displayed on the liquid crystal display.

31. Molecular - genetic methods - are based on the detection of mutations in the mycobacterium genome Gene- Xpert MTB/Rif It is based on an automated nucleic acid amplification system. The polymerase chain reaction results identify nucleic acid in the MBT genome. The data are obtained in real time. The study lasts about 2 hours and allows to identify the causative agent of tuberculosis, determine the drug sensitivity to Rifampicin. Hain-test (LPA-Line Probe Assay) It is based on hybridization with DNA probes. The presence of MTB in the sample, as well as the presence or absence of mutations in the researches of genes. The method allows to determine within 1 day the presence of MTB and determine their drug resistance to isoniazide and rifampicin. In case of massive bacterial division, this method allows to determine the type of MTB and drug sensation directly from sputum, without the release of pure culture.

32. Gene- Xpert MTB/Rif Hain-test (LPA-Line Probe Assay)

33. radiology Currently, clinical practice uses a fairly wide range of radiation diagnostic and radiological methods: X-rays , radionuclide scintigraphy; positron emission tomography.

34. Anatomy

35. Description of the x-ray It is convenient to use the following order of the description of x-ray shadows in lungs: 1. Localization of process. Specify: distribution on lobes and segments. 2. Number, quantity of shadows. Specify: individual or multiple. 3. Form. Specify: rounded, oval, polygonal, linear and irregular. 4. The size of a shadow. Specify: fine, average, and large. 5. The intensity. Specify: weak, average and high. 6. The structure of a shadow (homogeneous or non-homogenous). 7. The contours. Specify: precise and indistinct (dim). 8. Displaysness . Specify: a position deviation of lung structures from a normal arrangement, retraction of the neighbouring structures. 9. Condition of surrounding lung tissue. 

36. The main x-ray syndromes of the respiratory diseases Focus (focal shadow) – less than 12 mm of size Shadow (infiltration) – more than 12 mm of size (patchy or lobar shadow) Round shadow (shadow of rounded form with clear precise contour) Ring-like shadow (cavity) Lung dissemination (a lot of foci, which can’t calculate) Mediastinal lymphadenopathy (hilar lymph node enlargement) Hydrothorax

37. Normal x-ray

38. Focus (focal shadow)

39. Shadow (infiltration)

40. Round shadow

41. Ring-like shadow

42. Lung dissemination

43. Mediastinal lymphadenopathy

44. Hydrothorax