Tuberculosis

Definition - Causes- Risk factors - Clinical picture and investigation- treatment of Tuberculosis

1. Tuberculosis Dr. Sameh Ahmad Muhamad abdelghany Lecturer Of Clinical Pharmacology Mansura Faculty of medicine

2. Contents 2 Introduction Risk Factors Types - Causes Diagnosis(C/P – Investigation) Treatment

3. INTRODUCTION

4. 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 : Tubercle = Round nodule/Swelling Osis = Condition

5. Global Status of TB Tuberculosis (TB) kills 1.6 million people a year 0.2 million people infected with HIV 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.

6. 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.

7. Causes of TB

8. Causative Organisms Mycobacterium tuberculosis Human Mycobacterium Bovis Animals Others: Mycobacterium africanum Mycobacterium microti

9. Mycobacterium tuberculosis-Characteristics Gram positive Obligate aerobe Slow generation time: 15-20 hours Lipid rich cell wall contains mycolic acid: Responsible for many of bacterium characteristics. Acid fast. Causes resistance to antibacterials .

10. Types of TB

11. 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

12. TYPES 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.

13. 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 .

14. TYPES Extra-pulmonary TB 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 .

15. TYPES 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.

16. TYPES 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

17. TYPES TB meningitis Results from Hematogenous spead of primary & secondary TB. TB Pericarditis 1- 8% of All Extra pulmonary TB cases. Spreads mainly in mediastinal or hilar nodes or from lungs.

18. TYPES 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. Less common Extra Pulmonary TB uveitis, panophthalmitis , painful Hypersensitivity related phlyctenular conjuctivis .

19. Risk Factors

20. 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 .

21. Diagnosis

22. 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)

23. Systemic Symptoms Fever Chills Night sweats Appetite loss Weight loss Fatigue

24. Symptoms of Pulmonary TB Productive, prolonged cough ( duration of 2-3 weeks) Chest pain Hemoptysis (bloody sputum) Symptoms may vary based on HIV status

25. Investigation

26. 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

27. Acid fast smear showing TB bacilli

28. 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) Patients with three negative smear results and radiological findings and doctor’s decision to treat for TB Patients with negative smear results and a positive culture result for M. tuberculosis Patients who are unable to produce sputum and with highly suspicious radiological and clinical findings and doctor's decision to treat for TB

29. LAB Sputum culture test Culture is indicated for New and retreatment PTB cases still smear- positive at end of intensive phase Symptomatic contacts of known MDR cases

30. 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

31. 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: <6mm negative 6mm-15mm Hypersensitive to tuberculin protein(Previous TB infection or BCG – atypical mycobacteria) >15mm strongly Hypersensitive to tuberculin protein(suggestive of TB infection)

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

33. Treatment

34. 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

35. Preventive measures Mask BCG vaccine Regular medical follow up Isolation of Patient Ventilation Natural sunlight

36. 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.

37. 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)

38. 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)

39. FIRST LINE ANTI-TUBERCULOUS DRUGS 41 Isoniazide Rifampicin (Rifampin) Ethambutol Pyrazinamide Streptomycin

40. SECOND LINE ANTI-TUBERCULOUS DRUGS 42 Para aminosalicylic acid Ethionamide Cycloserine Fluoroquinolones Capreomycin

41. REGIMEN OF TB THERAPY 43 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).

42. REGIMEN OF TB THERAPY 44 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.

43. REGIMEN OF TB THERAPY 45 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.

44. REGIMEN OF TB THERAPY 46 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.

45. 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

46. 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

47. 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 ).

48. 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

49. Thank you! Any Questions?