Transcript Tuberculosis

TUBERCULOSIS
Prof. E. Sevda Özdoğan
TUBERCULOSIS
Infectious disease (airborne infection)
Lungs and all the tissues can be
involved
Mycobacterium tuberculosis (AFB)
Source of infection is the ill (Pulmonary
TB) patient:
Speaking: 0-210 bacillei
Coughing: 0-3500 bacillei
Sneezing: 4500-1 million bacillei
Droplet nuclei
(Flugge droplets)
Natural course of Tuberculosis
Eksogen reinfection
Active disease
No
infection
%65-70
Primary
Adult type
(reactivation)
%5
%5
Basillie
inhalation
%31-36
Infection
Latent
infection
%90
Latent
infection,
no disease
Pathogenesis-1 (initial encounter)
Capillary
Alveolar
makrophage
Peripheral
blood
monocytes
Hilar lymph
nodes
Hematogen
spread
Primary
complex
Evolution of Cellular immunity and
Delayed type HS
Option 1
(Primary infection)
Bacterial proliferation is
halted and bacillary
population falls
substantially
The primary lesion and
the metastatic foci
involute, leaving minimal
residues
The tuberculin skin test
becomes reactive (2-12
wk)
Option 2
(Primary disease)
An insufficient immune
response occurs and the
patient experience
progressive lung or
extrapulmonary disease
Liquefaction and accelerated bacillary
proliferation (Postprimary disease)
Pulmonary focus reactivates and undergoes
liquefaction with cavity formation
Extracellular bacilli multiply exponentially
during this accelerated bacillary proliferation
Patient expectorates bacillei, another person
inhales them, cycle is completed
Immunologic reactions
Cell mediated immunity
Delayed type hypersensitivity (Type IV
immune response)
2-12 weeks
Tuberculin skin test (+)
Tb Infection:
Infection with M. tuberculosis
manifested by significant tuberculin skin test reaction
without any sign of clinically and/or radiologically
active disease
Tb disease:Clinically, bacteriologically,
histologically and/or radiologically active disease
Differences between tb infection and tb disease
Condition
Tb infection
Tb disease
Tb bacilli in body
yes
Yes
Number of
organisms
103-104
107-108
Tb skin test
Usually positive
Usually positive
Chest radiography
Usually normal
Usually abnormal
Sputum
smear/culture
Negative for AFB
Usually positive in
respiratory cases
symptoms
No
Usually yes
Infectious
No
Often before
treatment
Risk Factors for Infection
Infectious person
Number of the bacilli in sputum (Cavitary, larhynx)
Cough frequency, sneeze
Live bacilli
Virulence of the bacilli
Environmental
Close contact (family)
Ventilation
Ultraviolet
Crowded and bad living conditions
Host factors
Nonspecific immunity (Ch 1 BCGr-BCGs region)
Concomitant diseases (that increase the risk of
infection)
Duration of exposure to the source of infection
EPİDEMİOLOGİCAL VIEW:
Number of infectious patients in the community
Delay in diagnosis
Delay in treatment
Risk Factors for disease progression
Recent infection (first 2 years)
Smoking
Long term corticosteroid use
(15mg/day>4weeks)
Sequel infiltration (simon foci)
To be <5-10 % of the ideal body
weight
To be in 0-5 or old age group
HIV
Diabetus mellitus
Silikosis
Kr. Malabsorbtion
Organ Transplant.
Chronic renal failure
Gastrectomy
Jejunoileal by-pass
Iv drug abuse
Leukemia,
lymphoma
Head and neck
cancers
Immunosuppressive
treatment
World tb
1/3 of the world population is infected
with tb
8 million new tb cases are detected
each year
1,5 million people die from tb
Starwing, poverty, war, immigration,
HIV infection cause the difficulties in
disease control
Tuberculosis in Turkey (n/100 000)
YILLARA GÖRE YENİ OLGULARIN ve TÜM OLGULARIN OLGU HIZLARI, 1998-2008
35
28,5
25,6
25,3
20
23,5
25,5
24,6
27,9
26
25,4
25,2
2007
28,3
25
28,1
2006
32,0
2005
30
25,8
23,4
15
10
5
YILLAR
Yeni Olgular
Tüm Olgular
2008
2004
2003
2002
2001
2000
1999
0
1998
OLGU HIZI (100.000 nüfusta)
40
Diagnosis
History
Physical examination
Chest x ray
Microbiology or pathology (Gold Standart)
Tuberculin test (PPD)
diagnostic)
(Not definitive
Symptoms
Pulmonary
Cough > 3 weeks
Sputum and
Hemopthysis
Chest pain, side pain
Breathlessnes
Hoarseness
General
Fatique
Loss of appetide
and weight
Fever
Night sweats
Clinical Presentation
Primary Tuberculosis
Usually
asymptomatic
Contact history +
PPD
Typical radiology
Complications
Postprimary
Tuberculosis
Typical symptoms
Typical radiology
Primary pulmonary tuberculosis
Postprimary pulmonary tuberculosis
Complications and other forms
Miliary tb
Radiologic 2-4 mm miliary
nodules (late presentation)
PPD (-) 50%
Choroidal tubercules on eye
examination
Liver, bone marrow (+)
Pleural tb
Mainly seen in young adults
PPD (-) 30%
AFB in pleural fluid (+) 2-10%
Exudative effusion, lymphocyte
predominance, low glucose, low
mesothelial cells, high ADA
Tb lymphadenitis
Frequently cervical
LAP
Fistulization may
occur
No tenderness
Bone tb
Vertebral tb (pott)
Absscess among the
muscless (Psoas)
Monoartritis
Physical examination
Signs in respiratory system:
No signs specific to tuberculosis
Occasionaly localised/ posttusive crackles
General signs:
Erythema nodosum
Fluctenular conjunctivitis
Lymphadenitis
Radiology
Upper zone nodular, alveolar
infiltration + kavity
Tipical for tb? NOO!!
Tb diagnosis cannot rely on
radiology only.
Radiology may be normal in
Endobronchial TB and in HIV
(+) patients.
Bacteriology
Microscopy: Minimum 3 sputum smear
should be performed.
Culture:Gold standard in diagnosis.
Drug sensitivity tests: Performed in
Referans laboratory.
Reporting
Reporting of tb cases is mandatory!!.
Definitions
Localization of tb disease
Bacteriologic condition
Previous treatment history
Localization of TB disease
Lung paranchyma Pulmonary TB
All tb forms without lung
involvement Extrapulmonary TB
Pulmonary and extrapulmonary
together  Pulmonary and
extrapulmonary TB
Bacteriology
Smear positive case
Smear negative case
Smear positive case
A patient whose sputum smear is positive
for AFB in at least 2 specimens
One AFB positivity in sputum smear with a
clinicians judgement that the patient’s
clinical and/or radiological signs and/or
symptoms are compatible with tb
One AFB positivity in sputum smear with
positive culture
Smear negative case
Smear negative in specimens
examined twice in 2 weeks time but
radiological signs compatible with
active tb and no clinical or radiological
response to 1 week nonspecific
antibiotic treatment
This decision should be made hospital
based with all the differential
diagnostic examination!
Treatment History
New Case
Relaps
Treatment Failure
Treatment after interruption
Chronic case
New Case
A patient who has never had drug
treatment for tb or who has taken
antitb drugs for<4 weeks
Relapse
A patient who has been declared cured
of any form of tb in the past and has
developed sputum smear or culture
positive disease
Treatment
First line antitb
drugs
INH
RIF
PZA
EMB
SM
Second line antitb
drugs
Thiacetasone
PAS
Cycloserine
Ethionamide
Canamycin
Capreomycin
Principles of Treatment
Combination Therapy (6 months)
4 or 5 drugs in the initial phase;
2 or 3 drugs in the continuation phase
Adequate dose and duration of
treatment to avoid relaps
Regular drug intake
Start the tx immediately after the
diagnosis
Prognosis in tb
Result
Death (%)
Cure (%)
Chronic
infectivity
(%)
No
treatment
Good
treatment
Bad
treatment
50
2-3
10
25
95
60
25
1-2
30
Prevention
Efective Treatment of infectious cases
Kemoprophylaxis (INH 6-9 months)
BCG
Infection control measures (institutions)
Tuberculin skin test (PPD)
BCG (+)
0-5 mm Negative
6-14 mm due to
BCG
15 mm < Positive
(infection)
BCG (-)
0-5 mm Negative
If 6-9 mm repeat
test 1 week later,
again 6-9 mm
Negative, 10mm <
Positive
10mm< Positive
Kemoprophlaxis without known contact
PPD (+), <15 years age
New infection
PPD convertion
Being + in the last 2 years
time or 6mm increased
enduration
Sequel fibrotic lesion on
chest x ray
<35 years age, no history
of treatment
Immunodeficient PPD (+)
person
PPD (+) that will receive
immunosuppressive
treatment
PPD: positive if >=5mm
Contact with TB patients
People <35
years age
Kemoprophylaxis for 6
months, in children <6 years
age if PPD (-) in the end of
treatment BCG vaccination
Kemoprophylaxis: INH 300mg/day 6-9 months
Thank you