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1. By :- Ram Chandra Sharma Group No. ;- 418

2. 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 : - Round nodule/Swelling - Condition “Tubercle” “ O s i s ”

3. Epidemiology :

4. Classification Extra pulmonary Lymph node TB Pleural TB TB of upper airways Skeletal TB Genitourinary TB Miliary TB Pericardial TB Gastrointestinal TB Tuberculous Meningitis Less common forms Pulmonary TB Primary Disease Secondary Disease

5. T ypes : A. Pulmonary TB : Primary Tuberculosis :- The infection of an individual who has not been previously infected or immunised is called Primary tuberculosis or Ghon’s complex or childhood tuberculosis . Lesions forming after infection is peripheral and accompanied by hilar which may not be detectable on chest radiography. Secondary Tuberculosis : The infection that individual who has been previously infected or sensitized is called secondary or post primary or reinfection or chronic tuberculosis .

6. B . Extra Pulmonary TB : 20% of patients of TB Patient Affected sites in body are : 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. Pleural TB : Involvement of pleura is common in Primary TB and results from penetration of tubercle bacilli into pleural space.

7. 3 ) TB of Upper airways : Involvement of larynx, pharynx and epiglottis. Symptoms : Dysphagia, chronic productive cough Genitourinary TB :- 15% of all Extra pulmonary cases. Any part of the genitourinary tract get infected. Symptoms :- Urinary frequency, Dysuria, Hematuria. Skeletal TB : Involvement of weight bearing parts like spine, hip, knee. Symptoms :- Pain in hip joints n knees, swelling of knees, trauma. Gastrointestinal TB : Involvement of any part of GI Tract. Symptoms : Abdominal pain, diarrhea, weight loss

8. Mode of Transmission: Coughing without covering the mouth 2. Crowded places with poor ventilation. 3. Spitting everywhere. 4. Cannot be transmitted by sharing drinks, toys or personal items.

9. Early Signs and Symptoms: Cough Chest pain Loss of appetite Weight loss Tiredness Fever/chills/night sweats.

10. Severe Symptoms : Persistent cough Chest pain Coughing with bloody sputum Shortness of breath Urine discoloration Cloudy & reddish urine Fever with chills. Fatigue

11. Diagnosis : 1 . Bacteriological test : Zeihl-Neelsen stain Auramine stain(fluorescence microscopy) 2. Sputum culture test : Lowenstein –Jensen(LJ) solid medium: 4-18 weeks Liquid medium : 8-14 days Agar medium : 7 to 14 days

12. 3. Radiography : Chest X-Ray(CXR) 4. Nucleic acid amplification: Species identification ; several hours Low sensitivity, high cost Most useful for the rapid confirmation of tuberculosis in persons with AFB-positive sputa Utility AFB-negative pulmonary tuberculosis Extra pulmonary tuberculosis

13. 5 . 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. 1 dose = 0.1 ml contains 0.04µg Tuberculin PPD.

14. Tuberculin test interpretation

15. 6. Other biological examinations : Cell count(lymphocytes) Protein(Pandy and Rivalta tests) – Ascites, pleural effusion and meningitis.

16. Preventive measures : Mask BCG vaccine Regular medical follow up Isolation of Patient Ventilation Natural sunlight UV germicidal irradiation

17. It is important for the patient to remain at home on isolation.  As much as possible, he/she should stay away from other people in the house by staying in a separate room or wearing a surgical mask when leaving the room.  Separate bedrooms or beds are highly recommended, if possible.  The patient can not travel, go to work, go to school, go shopping or participate in any other activity where there is contact with other people. The patient needs to cover his/her mouth and nose with a tissue when coughing or sneezing.  These tissues should be flushed, burned or placed in a sealed leak proof bag before disposal. The patient can not leave home except to keep medical appointments.  He/she must wear a surgical mask to the clinic and doctor’s offices.

18. The patient should not allow anyone, other than those living with him/her or those individuals providing care to him/her, into the home and should stay away from young children. These isolation instructions remain in effect until the patient is told by the health department that he/she no longer has to stay in isolation. These isolation instructions may become effective again after the patient has been told that he/she is no longer infectious should the clinical situation change.

19. BCG vaccine Bacille Calmette Guerin (BCG). First used in 1921. Only vaccine available today for protection against tuberculosis. It is most effective in protecting children from the disease. Given 0.1 ml intradermally. Duration of Protection 15 to 20 years Efficacy to 80%. Should be given to all healthy infants as soon as possible after birth unless the child presented with symptomatic HIV infection.

20. Infectious Period: The infectious period is the time when a patient sick with active TB can pass the germs to other people. The infectious period begins 3 months prior to the onset of symptoms or clinical sign of TB. The infectious period continues until all of the following criteria is met: 1. 3 consecutive smear negative specimens   2. The patient is on appropriate medications 3. The patient is getting better. The infectious period is important to determine in order to focus the contact investigation

21. Management :

22. Dosage regimen Intensive phase + continuation phase HREZ (2 months) + HRE (4 months)

23. Treatment Regimen According to WHO ISONIAZID (H) RIFAMPICIN (R) PYRAZINAMIDE (Z) ETHAMBUTOL (E) STREPTOMYCIN (S)

24. D O T S 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.

25. Reference: https://www.saintlukeskc.org/health-library/discharge-instructions-tuberculosis-tb https://dph.georgia.gov/sites/dph.georgia.gov/files/TB-ClinicForm12_Points_PtEd.pdf