Tuberculosis presentation with introduction of its bacteria

This slides give information about mycobacterium tuberculosis with its pathogenesis and the diseases related to it such as latent and active tb.

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2. INTRODUCTION Tuberculosis is an infectious bacterial disease caused by Mycobacterium tuberculosis. The lungs are the most common site of primary infection by tuberculosis and are a major source of spread of the disease and of individual morbidity and mortality. Neo- latin word : - Tubercle” - Round nodule/Swelling “ Osis ” - Condition 2

3. Pulmonary tuberculosis Is a contagious bacterial infection caused by Mycobacterium tuberculosis that involves the lungs. It may spread to other organs. Causes Mycobacterium Tuberculosis : Human Mycobacterium Bovis : Animals Mycobacterium Africanism Mycobacterium micros 3

4. Mycobacterium Tuberculosis 4

5. Tuberculosis is either latent or active Latent TB   Person carries the TB bacteria within their body, but the bacteria are present in very small numbers and are kept under control by the body’s immune system. People with latent TB don't have any symptoms of TB and can't spread the disease to others. 5

6. Contn … Active TB   Occurs when the TB bacteria have started to multiply and they become numerous enough to overcome the body’s immune system. It causes a person to feel ill and able to spread the disease to others. Incubation period: Varies between 4-12 weeks. 6

7. Risk factors Close contacts of patients with smear-positive pulmonary tuberculosis Overcrowding Poor environment and malnutrition Primary infection < 1 year previously IV drugs abusers, alcoholic, smokers, homeless people and health workers Immigrants from high-prevalence countries 7

8. Transmission 8

9. Tuberculosis 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 9

10. Extra pulmonary Pulmonary 10

11. Pathophysiology Primary infection occurs in the lungs, resulting in granuloma formation 11 Inhalation of infected droplets Inflammatory response occurs, bacteria are engulfed by macrophages The lesion develop in lungs is called Ghon’s Focus (primary lesion) Transfer of bacilli to the hilar lymph node via lymphatic, involving the lymph node( Ghon’s complex)

12. Contn … The macrophage phagocytes the bacilli then ingested bacilli aggregate and enlarge the lesion 12 At 2-4 weeks two distinct T-cell mediated immune response start A delayed type hypersensitivity reaction that destroy non activated macrophages containing bacilli but also results in necrosis an caseation Granuloma formation which is a soft tubercle with central caseation necrosis surrounded by epitheloid cells.

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15. Clinical Features Constitutional Symptoms Anorexia Low grade fever Night sweats Fatigue Weight loss 15

16. Pulmonary Symptoms Dyspnea Non resolving bronchopneumonia Chest tightness Non productive cough Mucopurulent sputum with hemoptpysis Chest pain 16

17. EXTRA PULMONARY SYMPTOMS Pain Inflammation 17

18. Diagnosis History taking Physical examination Clubbing of the fingers or toes Swollen or tender lymph nodes in the neck or other areas Fluid around a lung Unusual breath sounds 18

19. Diagnostic tests Laboratory Diagnosis Tuberculin test Sputum smears and culture Gene Xpert Quanti FERON -TB ( QFT ) HIV test 19

20. Diagnostic tests… Imaging tests Chest X-ray Chest CT Scan Bronchoscopy Others Thoracocentesis Biopsy of the affected tissue (done rarely) 20

21. Tuberculin test Tuberculin skin test (also called a PPD test) 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

22. Interpretation of Mantoux test Size of induration <5 mm : Negative; no active disease 5-10 mm : Borderline; consider positive in immunocompromised host; contact with adult patient with sputum AFB positive tuberculosis. ≥10 mm :Positive; suggests disease in presence of clinical features. 22

23. Drug resistent tuberculosis Multidrug-resistant tuberculosis (MDR-TB): Tuberculosis caused by organisms that are resistant to isoniazid and rifampicin, two first-line anti -TB drugs is defined as MDR TB. Extensively drug-resistant TB (XDR-TB): Defined as MDR-TB that is resistant as well to any one of the fluoroquinolones and to at least one of three injectable second-line drugs ( amikacin , capreomycin or kanamycin), 23

24. Complications Pleural effusion TB pneumonia Serious reactions to drug therapy: hepatitis, skin rashes, GI upset, deafness or neuritis Multidrug resistance TB Spread of TB infection( miliary TB) 24

25. Treatment First line drugs Isoniazid (H) Rifampicin (R) Pyrazinamide (Z) Ethambutol (E) Streptomycin (S) 25 Second line drugs Kanamycin Capreomycin Amikacin Ethionamide Para Aminosalicylic acid (PAS) Cycloserine Ciprofloxacin

26. Relative activity of first line drugs INH: potent bactericidal (Synergistic effect ) Rifampicin (R): potent bactericidal (Synergistic effect) Pyrazinamide (Z) : weak bactericidal Ethambutol (E): bacteriostatic Streptomycin (S) : bactericidal 26

27. Medicines are available in fixed dose combination (FDC) HRZE Isoniazide [75 mg] Rifampicin [150 mg] Pyrazinamide [400mg} Ethambutol [275mg] HR Isoniazide ( 150mg ) Rifampicin ( 150mg ) HRE Isoniazide [75 mg] Rifampicin [150 mg] 27

28. CATEGORY I New sputum smear-positive, sputum smear-negative and extra-pulmonary TB cases. 28

29. CATEGORY II Retreatment TB cases including failures, relapse and return after default. 29

30. WHO updates of tuberculosis regimen Only 2 regimen Drug susceptibility regimen Drug resistant regimen 1. All forms of new TB cases 2HRZE+4HR 2. Severe case ( CNS TB, Pericarditis TB, Musculoskeletal TB, Miliary TB) 2HRZE+7-10 HRE 30

31. WHO updates of tuberculosis regimen 3. Retreatment all type of TB cases 2HRZE+ 4HR 4. Isoniazide Resistant + Rifampicin Sensitive 6RZE + Levofloxacin 5. Isoniazide not known + Rifampicin sensitive 6HRZE 6. Rifampicin sensitive ISH resistant and fluroquinolones resistant 6RZE 31

32. Main adverse reaction of drugs Name of drug Adverse reaction Isoniazid Peripheral neuropathy Hepatitis Rash Rifampicin Febrile reactions Hepatitis Rash Gastrointestinal disturbance Red discoloration of all body fluids 32

33. Contn … Pyrazinamide Hepatitis Gastrointestinal disturbance Hyperuricaemia Streptomycin 8th nerve damage Rash Ethambutol Optic neuritis Arthralgia   33

34. Second Line Drugs Drugs used in MDR For intensive phase, 8months duration Injection Kanamycin Tab Cycloserine Tab Levofloxacin Tab Ethionamide Tab Pyrizinamide For continuation phase, 12 months duration: Except inj Kanamycin , all oral drugs are used. 34

35. Drugs used in XDR For intensive phase, 12months duration Injection Capreomycin Tab PAS (4 gm sachet) Tab Moxifloxacin Tab Clofazimine Tab Cycloserine Tab Pyrizinamide Tab Clavuam ( Amoxicillin 500mg + Clavulanate 125mg ) For continuation phase, 12-18 months duration: Except inj capreomycin , all oral drugs are used. 35

36. Supportive management Vitamin supplementation (esp. Vit B6 ) Rest and sleep Nutrition – High protein diet Oxygen therapy (if required) Prognosis Symptoms often improve in 2 to 3 weeks after starting treatment. A chest x-ray will not show this improvement until weeks or months later 36