Tuberculosis diagnosis and management in nepal

tb management

1. Tuberculosis Dr. Deepak Dhakal

2. Etiological agent M. tuberculosis Rod shaped Acid fast bacilli

3. Epidemiology Estimated tb burden  229(137-345)/100000 Estimated death  18000(9600-26000 )

4. Epidemiology

5. From exposure to infection Transmitted from person with infectious ptb by droplet nuclei containing bacilli (3000 infectious nuclei/cough) About 20 contacts infected by each AFB positive case before the index case is diagnosed.

6. From infection to disease Risk of developing disease depends on endogenous factors 10 % of infected person eventually develop active TB

7. Natural history

8. Figure 3 Mycobacterium tuberculosis infection Pai, M. et al. (2016) Tuberculosis Nat. Rev. Dis. Primers doi:10.1038/nrdp.2016.76

9. Figure 1 The spectrum of TB — from Mycobacterium tuberculosis infection to active (pulmonary) TB disease Pai, M. et al. (2016) Tuberculosis Nat. Rev. Dis. Primers doi:10.1038/nrdp.2016.76

10. CLINICAL MANIFESTATIONS Primary pulmonary tb Primary pulmonary TB occurs soon after the initial infection. It may be asymptomatic or may present with fever and occasionally pleuritic chest pain. In areas of high TB transmission, this form of disease is often seen in children Pleural effusion, which is found in up to two-thirds of cases

11. Post primary (Adult-Type) Disease localized to the apical and posterior segments of the upper lobes, fever and night sweats due to defervescence, weight loss, anorexia, general malaise, and weakness. In up to 90% of cases, cough eventually develops—often initially nonproductive and limited to the morning Hemoptysis develops in 20–30% of cases,

12. Lymph Node TB (Tuberculous Lymphadenitis) most common presentation of extrapulmonary TB painless swelling of the lymph nodes, most commonly at posterior cervical and supraclavicular sites Lymph nodes are usually discrete in early disease but develop into a matted nontender mass over time

13. Pleural TB Involvement of the pleura accounts for ~20% of extrapulmonary cases Isolated pleural effusion usually reflects recent primary infection, The fluid is straw-colored and at times hemorrhagic; it is an exudate with a protein concentration >50% of that in serum (usually ~4–6 g/dL), a normal to low glucose concentration

14. Hiv associated tb TB is one of the most common diseases among HIV-infected persons worldwide. A person with a positive TST who acquires HIV infection has a 3–13% annual risk of developing active TB When cell-mediated immunity is only partially compromised, pulmonary TB presents in a typical manner In late stages of HIV infection, when the CD4+ T-cell count is <200 primary TB–like pattern, with diffuse interstitial and subtle infiltrates, little or no cavitation, pleural effusion, and intrathoracic lymphadenopathy, is more common Overall, sputum smears are less frequently positive among TB patients with HIV infection

15. Diagnosis Nucleic Acid amplification Xpert MTB/RIF assay Xpert MTB/RIF Ultra assay (Ultra), Truenat MTB and MTC Plus TB-LAMP assay AFB microscopy Low sensitivity (40-60%) light microscopy of specimens stained with Ziehl- Neelsen basic fuchsin dyes auramine–rhodamine staining and fluorescence microscopy; this approach is more sensitive than the Ziehl- Neelsen method.

16. Mycobacterial culture Mycobacterial Growth Indicator Tube (MGIT) system (Becton Dickinson; Franklin Lakes, NJ) are recommended by the WHO Specimens may also be inoculated onto egg- or agar-based medium (e.g., Löwenstein-Jensen or Middlebrook 7H10 or 7H11) and incubated at 37°C (under 5% CO2 for Middlebrook medium).

17. Radiographic procedures Chest xray (sensitive but not specific) CT scan MRI Digitial xray Computer aided detection

18. Other diagnostic procedure lateral-flow urine lipoarabinomannan assay in HIV induced sputum specimens and specimens from early-morning gastric lavage may yield positive results in children biopsy and culture of bone marrow and liver tissue have a good diagnostic yield in disseminated (miliary) TB

19. DIAGNOSIS OF M. TUBERCULOSIS INFECTION Tuberculin Skin Testing IFN- γ Release Assays T-SPOT.TB test QuantiFERON-TB Gold test QuantiFERON-TB Gold Plus

20. Treatment The two main aims of TB treatment are to prevent morbidity and death by curing TB while preventing recurrences and emergence of drug resistance to interrupt transmission by rendering patients noninfectious to others. Chemotherapy for TB became possible with the discovery of streptomycin in 1943.

21. Prevention BCG VACCINATION Efficacy in the protection of infants and young children from serious disseminated forms of childhood TB, meningitis and miliary TB. TB PREVENTIVE TREATMENT (TPT)