Diagnosis of Tuberculosis an Update
Transcript of Diagnosis of Tuberculosis an Update
Diagnosis of Tuberculosis
an update DrTVRao MD
DrTVRao MD 1
Testing for TB Infectionbull Tuberculosis (TB) is a disease that is
spread through the air from one person to another There are two kinds of tests that are used to determine if a person has been infected with TB bacteria the tuberculin skin test and other direct and indirect Tests
DrTVRao MD 2
Diagnosis of TB Diseasebull People suspected of having TB disease should
be referred for a medical evaluation which will include
Medical history Physical examination Test for TB infection (TB skin test or TB blood test)bull Chest radiograph (X-ray) andbull Appropriate laboratory tests
DrTVRao MD 3
Who Should Get Tested for TBbull TB tests are generally not needed for people
with a low risk of infection with TB bacteriabull Certain people should be tested for TB
bacteria because they are more likely to get TB disease including
bull People who have spent time with someone who has TB disease People with HIV infection or another medical problem that weakens the immune system
bull People who have symptoms of TB disease (fever night sweats cough and weight loss)
DrTVRao MD 4
Who Should Get Tested for TB
bull People who have spent time with someone who has TB disease
bull People with HIV infection or another medical problem that weakens the immune system
bull People who have symptoms of TB disease (fever night sweats cough and weight loss)
DrTVRao MD 5
Who Should Get Tested for TBbull People from a country where TB disease is
common (most countries in Latin America the Caribbean Africa Asia Eastern Europe and Russia)
bull People who live or work somewhere in the United States where TB disease is more common (homeless shelters prison or jails or some nursing homes)
bull People who use illegal drugsDrTVRao MD 6
X ray of Chest a Commonly used Diagnostic tool
bull Acute pulmonary TB can be easily seen on an X-ray However the picture it presents is not specific and a normal chest X-ray cannot exclude extrapulmonary TB Also in countries where resources are more limited there is often a lack of X-ray facilitiesDrTVRao MD 7
Other testsbull Other tests such
as a chest x-ray and a sample of sputum are needed to see whether the person has TB disease
DrTVRao MD 8
Types of specimens-Sputum- BAL-Pleural effusions- Urine- Stool-CSF-Aspiration ( gastric ndash cold abscess)- Blood in case of haematogenous TB
DrTVRao MD 9
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFB
Sputum Collectionbull Sputum specimens
are essential to confirm TBndash Specimens should be
from lung secretions not saliva
bull Collect 3 specimens on 3 different days
bull Spontaneous morning sputum more desirable than induced specimens
bull Collect sputum before treatment is initiated
11
Interpretation of sputum stained by Z N Stain (WHO )
More than 10 bacilli field ------- +++From 1 ndash 10 bacilli field ------- ++From 10 ndash 99 bacilli 100 fields ----- +From 1 -9 bacilli100 fields ------ write the noNo bacilli seen ---------- negative
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by auramine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
Acid Fast Bacilli under Fluorescent Microscope
DrTVRao MD 14
Culturebull Used to confirm
diagnosis of TBbull Culture all
specimens even if smear is negative
bull Initial drug isolate should be used to determine drug susceptibility
15
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFBDrTVRao MD 16
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by aura mine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
DrTVRao MD 17
LowensteinndashJensen mediumbull When grown on LJ
medium M tuberculosis appears as brown granular colonies (sometimes called buff rough and tough) The media must be incubated for a significant length of time usually four weeks due to the slow doubling time of M tuberculosis DrTVRao MD 18
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Testing for TB Infectionbull Tuberculosis (TB) is a disease that is
spread through the air from one person to another There are two kinds of tests that are used to determine if a person has been infected with TB bacteria the tuberculin skin test and other direct and indirect Tests
DrTVRao MD 2
Diagnosis of TB Diseasebull People suspected of having TB disease should
be referred for a medical evaluation which will include
Medical history Physical examination Test for TB infection (TB skin test or TB blood test)bull Chest radiograph (X-ray) andbull Appropriate laboratory tests
DrTVRao MD 3
Who Should Get Tested for TBbull TB tests are generally not needed for people
with a low risk of infection with TB bacteriabull Certain people should be tested for TB
bacteria because they are more likely to get TB disease including
bull People who have spent time with someone who has TB disease People with HIV infection or another medical problem that weakens the immune system
bull People who have symptoms of TB disease (fever night sweats cough and weight loss)
DrTVRao MD 4
Who Should Get Tested for TB
bull People who have spent time with someone who has TB disease
bull People with HIV infection or another medical problem that weakens the immune system
bull People who have symptoms of TB disease (fever night sweats cough and weight loss)
DrTVRao MD 5
Who Should Get Tested for TBbull People from a country where TB disease is
common (most countries in Latin America the Caribbean Africa Asia Eastern Europe and Russia)
bull People who live or work somewhere in the United States where TB disease is more common (homeless shelters prison or jails or some nursing homes)
bull People who use illegal drugsDrTVRao MD 6
X ray of Chest a Commonly used Diagnostic tool
bull Acute pulmonary TB can be easily seen on an X-ray However the picture it presents is not specific and a normal chest X-ray cannot exclude extrapulmonary TB Also in countries where resources are more limited there is often a lack of X-ray facilitiesDrTVRao MD 7
Other testsbull Other tests such
as a chest x-ray and a sample of sputum are needed to see whether the person has TB disease
DrTVRao MD 8
Types of specimens-Sputum- BAL-Pleural effusions- Urine- Stool-CSF-Aspiration ( gastric ndash cold abscess)- Blood in case of haematogenous TB
DrTVRao MD 9
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFB
Sputum Collectionbull Sputum specimens
are essential to confirm TBndash Specimens should be
from lung secretions not saliva
bull Collect 3 specimens on 3 different days
bull Spontaneous morning sputum more desirable than induced specimens
bull Collect sputum before treatment is initiated
11
Interpretation of sputum stained by Z N Stain (WHO )
More than 10 bacilli field ------- +++From 1 ndash 10 bacilli field ------- ++From 10 ndash 99 bacilli 100 fields ----- +From 1 -9 bacilli100 fields ------ write the noNo bacilli seen ---------- negative
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by auramine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
Acid Fast Bacilli under Fluorescent Microscope
DrTVRao MD 14
Culturebull Used to confirm
diagnosis of TBbull Culture all
specimens even if smear is negative
bull Initial drug isolate should be used to determine drug susceptibility
15
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFBDrTVRao MD 16
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by aura mine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
DrTVRao MD 17
LowensteinndashJensen mediumbull When grown on LJ
medium M tuberculosis appears as brown granular colonies (sometimes called buff rough and tough) The media must be incubated for a significant length of time usually four weeks due to the slow doubling time of M tuberculosis DrTVRao MD 18
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Diagnosis of TB Diseasebull People suspected of having TB disease should
be referred for a medical evaluation which will include
Medical history Physical examination Test for TB infection (TB skin test or TB blood test)bull Chest radiograph (X-ray) andbull Appropriate laboratory tests
DrTVRao MD 3
Who Should Get Tested for TBbull TB tests are generally not needed for people
with a low risk of infection with TB bacteriabull Certain people should be tested for TB
bacteria because they are more likely to get TB disease including
bull People who have spent time with someone who has TB disease People with HIV infection or another medical problem that weakens the immune system
bull People who have symptoms of TB disease (fever night sweats cough and weight loss)
DrTVRao MD 4
Who Should Get Tested for TB
bull People who have spent time with someone who has TB disease
bull People with HIV infection or another medical problem that weakens the immune system
bull People who have symptoms of TB disease (fever night sweats cough and weight loss)
DrTVRao MD 5
Who Should Get Tested for TBbull People from a country where TB disease is
common (most countries in Latin America the Caribbean Africa Asia Eastern Europe and Russia)
bull People who live or work somewhere in the United States where TB disease is more common (homeless shelters prison or jails or some nursing homes)
bull People who use illegal drugsDrTVRao MD 6
X ray of Chest a Commonly used Diagnostic tool
bull Acute pulmonary TB can be easily seen on an X-ray However the picture it presents is not specific and a normal chest X-ray cannot exclude extrapulmonary TB Also in countries where resources are more limited there is often a lack of X-ray facilitiesDrTVRao MD 7
Other testsbull Other tests such
as a chest x-ray and a sample of sputum are needed to see whether the person has TB disease
DrTVRao MD 8
Types of specimens-Sputum- BAL-Pleural effusions- Urine- Stool-CSF-Aspiration ( gastric ndash cold abscess)- Blood in case of haematogenous TB
DrTVRao MD 9
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFB
Sputum Collectionbull Sputum specimens
are essential to confirm TBndash Specimens should be
from lung secretions not saliva
bull Collect 3 specimens on 3 different days
bull Spontaneous morning sputum more desirable than induced specimens
bull Collect sputum before treatment is initiated
11
Interpretation of sputum stained by Z N Stain (WHO )
More than 10 bacilli field ------- +++From 1 ndash 10 bacilli field ------- ++From 10 ndash 99 bacilli 100 fields ----- +From 1 -9 bacilli100 fields ------ write the noNo bacilli seen ---------- negative
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by auramine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
Acid Fast Bacilli under Fluorescent Microscope
DrTVRao MD 14
Culturebull Used to confirm
diagnosis of TBbull Culture all
specimens even if smear is negative
bull Initial drug isolate should be used to determine drug susceptibility
15
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFBDrTVRao MD 16
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by aura mine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
DrTVRao MD 17
LowensteinndashJensen mediumbull When grown on LJ
medium M tuberculosis appears as brown granular colonies (sometimes called buff rough and tough) The media must be incubated for a significant length of time usually four weeks due to the slow doubling time of M tuberculosis DrTVRao MD 18
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Who Should Get Tested for TBbull TB tests are generally not needed for people
with a low risk of infection with TB bacteriabull Certain people should be tested for TB
bacteria because they are more likely to get TB disease including
bull People who have spent time with someone who has TB disease People with HIV infection or another medical problem that weakens the immune system
bull People who have symptoms of TB disease (fever night sweats cough and weight loss)
DrTVRao MD 4
Who Should Get Tested for TB
bull People who have spent time with someone who has TB disease
bull People with HIV infection or another medical problem that weakens the immune system
bull People who have symptoms of TB disease (fever night sweats cough and weight loss)
DrTVRao MD 5
Who Should Get Tested for TBbull People from a country where TB disease is
common (most countries in Latin America the Caribbean Africa Asia Eastern Europe and Russia)
bull People who live or work somewhere in the United States where TB disease is more common (homeless shelters prison or jails or some nursing homes)
bull People who use illegal drugsDrTVRao MD 6
X ray of Chest a Commonly used Diagnostic tool
bull Acute pulmonary TB can be easily seen on an X-ray However the picture it presents is not specific and a normal chest X-ray cannot exclude extrapulmonary TB Also in countries where resources are more limited there is often a lack of X-ray facilitiesDrTVRao MD 7
Other testsbull Other tests such
as a chest x-ray and a sample of sputum are needed to see whether the person has TB disease
DrTVRao MD 8
Types of specimens-Sputum- BAL-Pleural effusions- Urine- Stool-CSF-Aspiration ( gastric ndash cold abscess)- Blood in case of haematogenous TB
DrTVRao MD 9
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFB
Sputum Collectionbull Sputum specimens
are essential to confirm TBndash Specimens should be
from lung secretions not saliva
bull Collect 3 specimens on 3 different days
bull Spontaneous morning sputum more desirable than induced specimens
bull Collect sputum before treatment is initiated
11
Interpretation of sputum stained by Z N Stain (WHO )
More than 10 bacilli field ------- +++From 1 ndash 10 bacilli field ------- ++From 10 ndash 99 bacilli 100 fields ----- +From 1 -9 bacilli100 fields ------ write the noNo bacilli seen ---------- negative
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by auramine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
Acid Fast Bacilli under Fluorescent Microscope
DrTVRao MD 14
Culturebull Used to confirm
diagnosis of TBbull Culture all
specimens even if smear is negative
bull Initial drug isolate should be used to determine drug susceptibility
15
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFBDrTVRao MD 16
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by aura mine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
DrTVRao MD 17
LowensteinndashJensen mediumbull When grown on LJ
medium M tuberculosis appears as brown granular colonies (sometimes called buff rough and tough) The media must be incubated for a significant length of time usually four weeks due to the slow doubling time of M tuberculosis DrTVRao MD 18
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Who Should Get Tested for TB
bull People who have spent time with someone who has TB disease
bull People with HIV infection or another medical problem that weakens the immune system
bull People who have symptoms of TB disease (fever night sweats cough and weight loss)
DrTVRao MD 5
Who Should Get Tested for TBbull People from a country where TB disease is
common (most countries in Latin America the Caribbean Africa Asia Eastern Europe and Russia)
bull People who live or work somewhere in the United States where TB disease is more common (homeless shelters prison or jails or some nursing homes)
bull People who use illegal drugsDrTVRao MD 6
X ray of Chest a Commonly used Diagnostic tool
bull Acute pulmonary TB can be easily seen on an X-ray However the picture it presents is not specific and a normal chest X-ray cannot exclude extrapulmonary TB Also in countries where resources are more limited there is often a lack of X-ray facilitiesDrTVRao MD 7
Other testsbull Other tests such
as a chest x-ray and a sample of sputum are needed to see whether the person has TB disease
DrTVRao MD 8
Types of specimens-Sputum- BAL-Pleural effusions- Urine- Stool-CSF-Aspiration ( gastric ndash cold abscess)- Blood in case of haematogenous TB
DrTVRao MD 9
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFB
Sputum Collectionbull Sputum specimens
are essential to confirm TBndash Specimens should be
from lung secretions not saliva
bull Collect 3 specimens on 3 different days
bull Spontaneous morning sputum more desirable than induced specimens
bull Collect sputum before treatment is initiated
11
Interpretation of sputum stained by Z N Stain (WHO )
More than 10 bacilli field ------- +++From 1 ndash 10 bacilli field ------- ++From 10 ndash 99 bacilli 100 fields ----- +From 1 -9 bacilli100 fields ------ write the noNo bacilli seen ---------- negative
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by auramine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
Acid Fast Bacilli under Fluorescent Microscope
DrTVRao MD 14
Culturebull Used to confirm
diagnosis of TBbull Culture all
specimens even if smear is negative
bull Initial drug isolate should be used to determine drug susceptibility
15
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFBDrTVRao MD 16
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by aura mine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
DrTVRao MD 17
LowensteinndashJensen mediumbull When grown on LJ
medium M tuberculosis appears as brown granular colonies (sometimes called buff rough and tough) The media must be incubated for a significant length of time usually four weeks due to the slow doubling time of M tuberculosis DrTVRao MD 18
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Who Should Get Tested for TBbull People from a country where TB disease is
common (most countries in Latin America the Caribbean Africa Asia Eastern Europe and Russia)
bull People who live or work somewhere in the United States where TB disease is more common (homeless shelters prison or jails or some nursing homes)
bull People who use illegal drugsDrTVRao MD 6
X ray of Chest a Commonly used Diagnostic tool
bull Acute pulmonary TB can be easily seen on an X-ray However the picture it presents is not specific and a normal chest X-ray cannot exclude extrapulmonary TB Also in countries where resources are more limited there is often a lack of X-ray facilitiesDrTVRao MD 7
Other testsbull Other tests such
as a chest x-ray and a sample of sputum are needed to see whether the person has TB disease
DrTVRao MD 8
Types of specimens-Sputum- BAL-Pleural effusions- Urine- Stool-CSF-Aspiration ( gastric ndash cold abscess)- Blood in case of haematogenous TB
DrTVRao MD 9
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFB
Sputum Collectionbull Sputum specimens
are essential to confirm TBndash Specimens should be
from lung secretions not saliva
bull Collect 3 specimens on 3 different days
bull Spontaneous morning sputum more desirable than induced specimens
bull Collect sputum before treatment is initiated
11
Interpretation of sputum stained by Z N Stain (WHO )
More than 10 bacilli field ------- +++From 1 ndash 10 bacilli field ------- ++From 10 ndash 99 bacilli 100 fields ----- +From 1 -9 bacilli100 fields ------ write the noNo bacilli seen ---------- negative
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by auramine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
Acid Fast Bacilli under Fluorescent Microscope
DrTVRao MD 14
Culturebull Used to confirm
diagnosis of TBbull Culture all
specimens even if smear is negative
bull Initial drug isolate should be used to determine drug susceptibility
15
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFBDrTVRao MD 16
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by aura mine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
DrTVRao MD 17
LowensteinndashJensen mediumbull When grown on LJ
medium M tuberculosis appears as brown granular colonies (sometimes called buff rough and tough) The media must be incubated for a significant length of time usually four weeks due to the slow doubling time of M tuberculosis DrTVRao MD 18
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
X ray of Chest a Commonly used Diagnostic tool
bull Acute pulmonary TB can be easily seen on an X-ray However the picture it presents is not specific and a normal chest X-ray cannot exclude extrapulmonary TB Also in countries where resources are more limited there is often a lack of X-ray facilitiesDrTVRao MD 7
Other testsbull Other tests such
as a chest x-ray and a sample of sputum are needed to see whether the person has TB disease
DrTVRao MD 8
Types of specimens-Sputum- BAL-Pleural effusions- Urine- Stool-CSF-Aspiration ( gastric ndash cold abscess)- Blood in case of haematogenous TB
DrTVRao MD 9
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFB
Sputum Collectionbull Sputum specimens
are essential to confirm TBndash Specimens should be
from lung secretions not saliva
bull Collect 3 specimens on 3 different days
bull Spontaneous morning sputum more desirable than induced specimens
bull Collect sputum before treatment is initiated
11
Interpretation of sputum stained by Z N Stain (WHO )
More than 10 bacilli field ------- +++From 1 ndash 10 bacilli field ------- ++From 10 ndash 99 bacilli 100 fields ----- +From 1 -9 bacilli100 fields ------ write the noNo bacilli seen ---------- negative
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by auramine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
Acid Fast Bacilli under Fluorescent Microscope
DrTVRao MD 14
Culturebull Used to confirm
diagnosis of TBbull Culture all
specimens even if smear is negative
bull Initial drug isolate should be used to determine drug susceptibility
15
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFBDrTVRao MD 16
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by aura mine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
DrTVRao MD 17
LowensteinndashJensen mediumbull When grown on LJ
medium M tuberculosis appears as brown granular colonies (sometimes called buff rough and tough) The media must be incubated for a significant length of time usually four weeks due to the slow doubling time of M tuberculosis DrTVRao MD 18
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Other testsbull Other tests such
as a chest x-ray and a sample of sputum are needed to see whether the person has TB disease
DrTVRao MD 8
Types of specimens-Sputum- BAL-Pleural effusions- Urine- Stool-CSF-Aspiration ( gastric ndash cold abscess)- Blood in case of haematogenous TB
DrTVRao MD 9
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFB
Sputum Collectionbull Sputum specimens
are essential to confirm TBndash Specimens should be
from lung secretions not saliva
bull Collect 3 specimens on 3 different days
bull Spontaneous morning sputum more desirable than induced specimens
bull Collect sputum before treatment is initiated
11
Interpretation of sputum stained by Z N Stain (WHO )
More than 10 bacilli field ------- +++From 1 ndash 10 bacilli field ------- ++From 10 ndash 99 bacilli 100 fields ----- +From 1 -9 bacilli100 fields ------ write the noNo bacilli seen ---------- negative
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by auramine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
Acid Fast Bacilli under Fluorescent Microscope
DrTVRao MD 14
Culturebull Used to confirm
diagnosis of TBbull Culture all
specimens even if smear is negative
bull Initial drug isolate should be used to determine drug susceptibility
15
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFBDrTVRao MD 16
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by aura mine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
DrTVRao MD 17
LowensteinndashJensen mediumbull When grown on LJ
medium M tuberculosis appears as brown granular colonies (sometimes called buff rough and tough) The media must be incubated for a significant length of time usually four weeks due to the slow doubling time of M tuberculosis DrTVRao MD 18
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Types of specimens-Sputum- BAL-Pleural effusions- Urine- Stool-CSF-Aspiration ( gastric ndash cold abscess)- Blood in case of haematogenous TB
DrTVRao MD 9
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFB
Sputum Collectionbull Sputum specimens
are essential to confirm TBndash Specimens should be
from lung secretions not saliva
bull Collect 3 specimens on 3 different days
bull Spontaneous morning sputum more desirable than induced specimens
bull Collect sputum before treatment is initiated
11
Interpretation of sputum stained by Z N Stain (WHO )
More than 10 bacilli field ------- +++From 1 ndash 10 bacilli field ------- ++From 10 ndash 99 bacilli 100 fields ----- +From 1 -9 bacilli100 fields ------ write the noNo bacilli seen ---------- negative
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by auramine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
Acid Fast Bacilli under Fluorescent Microscope
DrTVRao MD 14
Culturebull Used to confirm
diagnosis of TBbull Culture all
specimens even if smear is negative
bull Initial drug isolate should be used to determine drug susceptibility
15
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFBDrTVRao MD 16
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by aura mine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
DrTVRao MD 17
LowensteinndashJensen mediumbull When grown on LJ
medium M tuberculosis appears as brown granular colonies (sometimes called buff rough and tough) The media must be incubated for a significant length of time usually four weeks due to the slow doubling time of M tuberculosis DrTVRao MD 18
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFB
Sputum Collectionbull Sputum specimens
are essential to confirm TBndash Specimens should be
from lung secretions not saliva
bull Collect 3 specimens on 3 different days
bull Spontaneous morning sputum more desirable than induced specimens
bull Collect sputum before treatment is initiated
11
Interpretation of sputum stained by Z N Stain (WHO )
More than 10 bacilli field ------- +++From 1 ndash 10 bacilli field ------- ++From 10 ndash 99 bacilli 100 fields ----- +From 1 -9 bacilli100 fields ------ write the noNo bacilli seen ---------- negative
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by auramine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
Acid Fast Bacilli under Fluorescent Microscope
DrTVRao MD 14
Culturebull Used to confirm
diagnosis of TBbull Culture all
specimens even if smear is negative
bull Initial drug isolate should be used to determine drug susceptibility
15
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFBDrTVRao MD 16
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by aura mine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
DrTVRao MD 17
LowensteinndashJensen mediumbull When grown on LJ
medium M tuberculosis appears as brown granular colonies (sometimes called buff rough and tough) The media must be incubated for a significant length of time usually four weeks due to the slow doubling time of M tuberculosis DrTVRao MD 18
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Sputum Collectionbull Sputum specimens
are essential to confirm TBndash Specimens should be
from lung secretions not saliva
bull Collect 3 specimens on 3 different days
bull Spontaneous morning sputum more desirable than induced specimens
bull Collect sputum before treatment is initiated
11
Interpretation of sputum stained by Z N Stain (WHO )
More than 10 bacilli field ------- +++From 1 ndash 10 bacilli field ------- ++From 10 ndash 99 bacilli 100 fields ----- +From 1 -9 bacilli100 fields ------ write the noNo bacilli seen ---------- negative
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by auramine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
Acid Fast Bacilli under Fluorescent Microscope
DrTVRao MD 14
Culturebull Used to confirm
diagnosis of TBbull Culture all
specimens even if smear is negative
bull Initial drug isolate should be used to determine drug susceptibility
15
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFBDrTVRao MD 16
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by aura mine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
DrTVRao MD 17
LowensteinndashJensen mediumbull When grown on LJ
medium M tuberculosis appears as brown granular colonies (sometimes called buff rough and tough) The media must be incubated for a significant length of time usually four weeks due to the slow doubling time of M tuberculosis DrTVRao MD 18
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Interpretation of sputum stained by Z N Stain (WHO )
More than 10 bacilli field ------- +++From 1 ndash 10 bacilli field ------- ++From 10 ndash 99 bacilli 100 fields ----- +From 1 -9 bacilli100 fields ------ write the noNo bacilli seen ---------- negative
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by auramine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
Acid Fast Bacilli under Fluorescent Microscope
DrTVRao MD 14
Culturebull Used to confirm
diagnosis of TBbull Culture all
specimens even if smear is negative
bull Initial drug isolate should be used to determine drug susceptibility
15
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFBDrTVRao MD 16
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by aura mine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
DrTVRao MD 17
LowensteinndashJensen mediumbull When grown on LJ
medium M tuberculosis appears as brown granular colonies (sometimes called buff rough and tough) The media must be incubated for a significant length of time usually four weeks due to the slow doubling time of M tuberculosis DrTVRao MD 18
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by auramine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
Acid Fast Bacilli under Fluorescent Microscope
DrTVRao MD 14
Culturebull Used to confirm
diagnosis of TBbull Culture all
specimens even if smear is negative
bull Initial drug isolate should be used to determine drug susceptibility
15
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFBDrTVRao MD 16
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by aura mine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
DrTVRao MD 17
LowensteinndashJensen mediumbull When grown on LJ
medium M tuberculosis appears as brown granular colonies (sometimes called buff rough and tough) The media must be incubated for a significant length of time usually four weeks due to the slow doubling time of M tuberculosis DrTVRao MD 18
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Acid Fast Bacilli under Fluorescent Microscope
DrTVRao MD 14
Culturebull Used to confirm
diagnosis of TBbull Culture all
specimens even if smear is negative
bull Initial drug isolate should be used to determine drug susceptibility
15
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFBDrTVRao MD 16
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by aura mine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
DrTVRao MD 17
LowensteinndashJensen mediumbull When grown on LJ
medium M tuberculosis appears as brown granular colonies (sometimes called buff rough and tough) The media must be incubated for a significant length of time usually four weeks due to the slow doubling time of M tuberculosis DrTVRao MD 18
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Culturebull Used to confirm
diagnosis of TBbull Culture all
specimens even if smear is negative
bull Initial drug isolate should be used to determine drug susceptibility
15
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFBDrTVRao MD 16
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by aura mine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
DrTVRao MD 17
LowensteinndashJensen mediumbull When grown on LJ
medium M tuberculosis appears as brown granular colonies (sometimes called buff rough and tough) The media must be incubated for a significant length of time usually four weeks due to the slow doubling time of M tuberculosis DrTVRao MD 18
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Laboratory Diagnosis1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB
Advantage - cheap ndash rapid - Easy to perform - High predictive value gt 90 - Specificity of 98Disadvantages - sputum ( need to contain 5000-10000 AFB ml) - Young children elderly amp HIV infected persons
may not produce cavities amp sputum containing AFBDrTVRao MD 16
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by aura mine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
DrTVRao MD 17
LowensteinndashJensen mediumbull When grown on LJ
medium M tuberculosis appears as brown granular colonies (sometimes called buff rough and tough) The media must be incubated for a significant length of time usually four weeks due to the slow doubling time of M tuberculosis DrTVRao MD 18
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
2- Detecting AFB by fluorochrome stain using fluorescence microscopy
The smear may be stained by aura mine-O dye In this method the TB bacilli are stained yellow against dark background amp easily visualized using florescent microscope
Advantages - More sensitive - RapidDisadvantages - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain
DrTVRao MD 17
LowensteinndashJensen mediumbull When grown on LJ
medium M tuberculosis appears as brown granular colonies (sometimes called buff rough and tough) The media must be incubated for a significant length of time usually four weeks due to the slow doubling time of M tuberculosis DrTVRao MD 18
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
LowensteinndashJensen mediumbull When grown on LJ
medium M tuberculosis appears as brown granular colonies (sometimes called buff rough and tough) The media must be incubated for a significant length of time usually four weeks due to the slow doubling time of M tuberculosis DrTVRao MD 18
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
3- Cultures on L J media Lowenstein ndashJensen medium is an egg based media
with addition of salts 5 glycerol Malachite green
Advantages - Specificity about 99 - More sensitive (need lower no of bacilli 10-100
ml) - Can differentiate between TB complex amp
NTM using biochemical reactions - Sensitivity tests for antituberculous drugs ( St INH Rif E) Disadvantages Slowly growing ( up to 8 weeks ) DrTVRao MD 19
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Recent Methods for DiagnosisI ndashBACTEC 460 ( rapid radiometric
culture system ) specimens are cultured in a liquid medium
(Middle brook7H9 broth base )containing C14 ndash labelled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Mycobacteria Growth Indicator Tube (MGIT)
Tube contains modified Middlebrook 7H9 broth base with OADC enrichment amp PANTA antibiotic mixture
All types of clinical specimens pulmonary as well as extra-pulmonary ( except blood) could be cultured on this type of media
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
The MGIT 960 System The MGIT 960 system is a non-radiometeric
automated system that uses the MGIT media amp sensors to detect the fluorescence
Advantages -The system holds 960 plastic tubes which are
continuously monitored- Early detection as the machine monitoring amp
reading the tubes every hour
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Detection and identification of mycobacteria directly
from clinical samplesbull Genotypic Methods bull 1048708 PCRbull 1048708 LAMPbull 1048708 TMA NAAbull 1048708 Ligase chain reactionbull 1048708 Phenotypic Methods bull 1048708 FAST Plaque TB
DrTVRao MD 23
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
bull Essentially PCR is a way to make millions of identical copies of a specific DNA sequence which may be a gene or a part of a gene or simply a stretch of nucleotides with a known DNA sequence the function of which may be unknown
Polymerase Chain Reaction (PCR)
DrTVRao MD 24
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
bull Interferon-γ assays measure cell-mediated immunity by quantifying IFN-γ released from sensitized T cells in whole bloodPBMCs incubated with TB antigens
Quantiferon-GOLD
DrTVRao MD 26
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
What Positive Skin Test ( Tuberculin Test means) bull A positive TB skin test
or TB blood test only tells that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease
DrTVRao MD 27
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Tuberculin TestInterpretation A positive test indicates previous exposure and carriage
of TB A negative tuberculin test excludes infection in
suspected persons Tuberculin positive persons may develop reactivation
type of TB Tuberculin negative persons are at risk of gaining new
infection False positive reactions are mainly due to - Infection with nontuberculous mycobacteria
DrTVRao MD 28
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
False negative reactions may be due to -bull False negative reactions may be due to
- Sever tuberculosis infection (Miliary TB) - Hodgkinrsquos disease bull Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no
exposure historybull Positive test must be regarded suspicious
DrTVRao MD 29
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Tuberculin Test( Mantoux Test )
bull Test to be interpreted in relation to clinical evaluation
bull Even the induration of 5 mm to be considered positive when tested on HIV patients
bull Lacks specificity
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Positive Test Means bull This means the personrsquos
body was infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 31
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Negative Test Means bull This means the
personrsquos body did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 32
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Tuberculin Testing - Limitations
bull False positive reactions are mainly due tobull - Infection with nontuberculous mycobacteriabull False negative reactions may be due tobull - Sever tuberculosis infection (Miliary TB) -
Hodgkinrsquos disease bull - Corticosteroid therapy - Malnutrition -
AIDSbull Children below 5 years of age with no exposure
historybull - Positive test must be regarded suspicious
DrTVRao MD 33
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Recent Methods for DiagnosisI ndash BACTEC 460 ( rapid radiometric culture system )
Specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C14 ndash labeled palmitic acid amp PANTA antibiotic mixture
Growing mycobacteria utilize the acid releasing radioactive CO2 which is measured as growth index (GI) in the BACTEC instrument
The daily increase in GI output is directly proportional to the rate amp amount of growth in the medium
DrTVRao MD 34
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
TB blood testsbull TB blood tests (also called interferon-gamma
release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB An IGRA measures how strong a personrsquos immune system reacts to TB bacteria by testing the personrsquos blood in a laboratory
bull Two IGRAs are approved by the US Food and Drug Administration (FDA) and are available in the United States
DrTVRao MD 35
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Positive IGRAbull This means that the
person has been infected with TB bacteria Additional tests are needed to determine if the person has latent TB infection or TB disease A health care worker will then provide treatment as needed
DrTVRao MD 36
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Negative IGRAbull This means that
the personrsquos blood did not react to the test and that latent TB infection or TB disease is not likely
DrTVRao MD 37
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
IGRAs are the preferred method of TB infection testing for the following
People who have received bacilli ChalmettendashGueacuterin (BCG) BCG is a vaccine for TB disease People who have a difficult time returning for a second appointment to look for a reaction to the TSTThere is no problem with repeated IGRAs
DrTVRao MD 38
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
III Polymerase Chain Reaction (PCR) amp Gene probe
Nucleic acid probes amp nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from mycobacterial cells
Advantages - Rapid procedure - High sensitivity (1-10 ( 3 ndash 4 hours) bacilli ml sputum)
DrTVRao MD 39
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Molecular DR testing is particularly useful for
bull Patients suspected or at high risk of having drug-resistant TBvery ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 40
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Detection of MDR Tuberculosis
bull Very ill patients for whom drug-susceptibility information might alter case management decisions such as patients who do not get better while taking standard first-line therapy
DrTVRao MD 41
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Detection of MDR Tuberculosis
bull outbreak or contact investigations when drug resistance is suspected in the source case or in some severely immunocompromised persons such as HIV-infected persons or those receiving dialysis in which knowledge of drug-susceptibility would be a significant benefit and affect preventive therapy decisions
DrTVRao MD 42
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Tuberculosis and HIV infection
bull HIV association has become a threat to the developed countries too
bull HIV association will lead to rapid spread of tuberculosis
DrTVRao MD 43
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
HIV Considerationsbull HIV is the strongest risk factor for
progression to active diseasebull HIV kills CD4+ T Helper cells which
normally inhibit M tuberculosisbull HIV interferes with PPD skin testbull Protease inhibitors interfere with
rifampin
DrTVRao MD 44
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Epidemiologybull An ancient disease called as white plaguebull 13 of the world population is infected bull 2 billion infectedbull Each year 9 lakhs to 1 million are infectedbull Poor nations phase the burnt of the diseasebull In developing world gt 4o of the population is
effectedbull 15 million suffer the diseasebull 3 million are highly infective
DrTVRao MD 45
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
MDR tuberculosisbull Multidrug resistant tuberculosis has become a
global threatbull In 1993 WHO declared Tuberculosis a Global
emergencybull Animals shed the bacilli in Milk humanrsquos get
infected after drinking the unsterilized Milkbull Pasteurization has reduced the incidence of
Bovine tuberculosis
DrTVRao MD 46
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
Why Tuberculosis continues to be Important
bull Someone in the world is newly infected with TB bacilli every second
bull Overall one-third of the worlds population is currently infected with the TB bacillus
bull 5-10 of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life People with HIV and TB infection are much more likely to develop TB
DrTVRao MD 47
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-
bull Programme Created by DrTVRao MD for Medical and Paramedical
Students in Developing world bull Email
bull doctortvraogmailcom
DrTVRao MD 48
- Diagnosis of Tuberculosis an update
- Testing for TB Infection
- Diagnosis of TB Disease
- Who Should Get Tested for TB
- Who Should Get Tested for TB (2)
- Who Should Get Tested for TB (3)
- X ray of Chest a Commonly used Diagnostic tool
- Other tests
- Slide 9
- Laboratory Diagnosis
- Sputum Collection
- Interpretation of sputum stained by Z N Stain (WHO )
- Slide 13
- Acid Fast Bacilli under Fluorescent Microscope
- Culture
- Laboratory Diagnosis (2)
- Slide 17
- LowensteinndashJensen medium
- 3- Cultures on L J media Lowenstein ndash
- Recent Methods for Diagnosis
- Mycobacteria Growth Indicator Tube (MGIT)
- The MGIT 960 System
- Detection and identification of mycobacteria directly from clin
- Polymerase Chain Reaction (PCR)
- Polymerase Chain Reaction (PCR) amp Gene probe
- Quantiferon-GOLD
- What Positive Skin Test
- Tuberculin Test
- False negative reactions may be due to -
- Tuberculin Test ( Mantoux Test )
- Positive Test Means
- Negative Test Means
- Tuberculin Testing - Limitations
- Recent Methods for Diagnosis (2)
- TB blood tests
- Positive IGRA
- Negative IGRA
- IGRAs are the preferred method of TB infection testing for the
- III Polymerase Chain Reaction (PCR) amp Gene probe
- Molecular DR testing is particularly useful for
- Detection of MDR Tuberculosis
- Detection of MDR Tuberculosis (2)
- Tuberculosis and HIV infection
- HIV Considerations
- Epidemiology
- MDR tuberculosis
- Why Tuberculosis continues to be Important
- Slide 48
-