Tuberculosis

overview of tb, tb n hiv overlap

1. Tuberculosis Dr. Nikhil Oza Intern BVDUMC A presentation on-

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” “ Osis ”

3. Causative Organisms Mycobacterium tuberculosis Mycobacterium Bovis Human Animals

4. Other causative organisms Mycobacterium africanum Mycobacterium microti Non-Mycobacterium Genus Mycobacterium l eprae Mycobacterium avium Mycobacterium asiaticum M. africanum M. Bovis M. Canetti M. microti   M. tuberculosis  complex

5. Discovered in 1882 by Robert Koch.

6. Classification Pulmonary TB - Primary Disease - Secondary Disease 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

7. Epidemiology

8. In 2011,there were an estimated 8.7million incidence cases of TB globally. Its equivalent to 125 cases in 1,00,000 population. Asian : 59% African : 26% Eastern Mediterranean Region: 7.7% The European Region : 4.3% Region of the America : 3%

9. Incidence of Tuberculosis

10. Spread of Tuberculosis

11. Severe Symptoms Persistent cough C hest pain Coughing with bloody sputum Shortness of breath Urine discoloration C loudy & reddish urine Fever with chills. Fatigue

12. Based on types of TB

13. Pathogenesis

14. Types A. Pulmonary TB :- 1. 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. 2. Secondary Tuberculosis : The infection that individual who has been previously infected or sensitized is called secondary or post primary or reinfection or chronic tuberculosis .

15. B} Extra Pulmonary TB :- 20% of patients of TB Patient Affected sites in body are :- 1) 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. 2 ) Pleural TB :- Involvement of pleura is common in Primary TB and results from penetration of tubercle bacilli into pleural space.

16. Involvement of larynx, pharynx and epiglottis. Symptoms :- D ysphagia, chronic productive cough 3) TB of Upper airways :- 4) Genitourinary TB :- 15% of all Extra pulmonary cases. Any part of the genitourinary tract get infected. Symptoms :- Urinary frequency, Dysuria, Hematuria. 5) Skeletal TB :- Involvement of weight bearing parts like spine, hip, knee. Symptoms :- Pain in hip joints n knees, swelling of knees, trauma. 6) Gastrointestinal TB :- Involvement of any part of GI Tract. Symptoms :- Abdominal pain, diarrhea, weight loss

17. 7) TB Meningitis & Tuberculoma :- 5% of All Extra pulmonary TB Results from Hematogenous spead of 1 & 2 TB . 8) TB Pericardiatis :- 1- 8% of All Extra pulmonary TB cases. Spreads mainly in mediastinal or hilar nodes or from lungs. 9) 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. 10) Less common Extra Pulmonary TB uveitis, panophthalmitis, painfull Hypersensitivity related phlyctenular conjuctivis.

18. 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

19. 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

20. 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.

21. Tuberculin test interpretation

22. Pathogenesis of tuberculin test

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

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

25. BCG vaccine Bacille Calmette Guerin (BCG ). F irst 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 0 to 80%. Should be given to all healthy infants as soon as possible after birth unless the child presented with symptomatic HIV infection.

26. Management

27. Drugs MOA Diagram Isoniazid Inhibits mycolic acid synthesis. RIFAMPICIN Blocks RNA synthesis by blocking DNA dependent RNA polymerase PYRAZINAMIDE Bactericidal-slowly metabolizing organism within acidic environment of Phagocyte or caseous granuloma.

28. Drugs MOA Diagram ETHAMBUTOL Bacteriostatic Inhibition of Arabinosyl Transferase STREPTOMYCIN Inhibition of Protein synthesis by disruption of ribosomal function

29. ADRs and its Management

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

31. Treatment regimen according to WHO ISONIAZID (H) RIFAMPICIN (R) PYRAZINAMIDE (Z) ETHAMBUTOL (E) STREPTOMYCIN (S)

32. DOTS 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.

33. 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. G lobally , 3.6 % are estimated to have MDR-TB. Almost 50% of MDR-TB cases worldwide are estimated to occur in China and India.

34. MDR-TB among new TB cases

35. MDR-TB in previously treated cases

36. Extensively drug resistance TB Extensively drug-resistant TB (XDR-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 ).

37. Tuberculosis and HIV Worldwide the number of people infected with both HIV and TB is rising. The HIV virus damages the body’s immune system and accelerates the speed at which TB progresses from a harmless infection to a life threatening condition. The estimated 10% activation of dormant TB infection over the life span of an infected person, is increased to 10% activation in one year, if HIV infection is superimposed. It is the opputunistic infection that most frequently kills HIV-positive people.

38. Epidemiological Impact Reactivation of latent infection- People who are infected with both HIV and TB are 25 to 30 times more likely to develop TB again than people only infected with TB. Primary Infection- New tubercular infection in people with HIV can progress to active disease very quickly. Recurring infection- in people who were cured of TB.

39. Diagnosis of TB in people with 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.

40. Thank you!