PULMONARY TUBERCULOSIS

AISHA M SIDDIQUIAISHA M SIDDIQUI

PULMONARY TB FACTSFACTS HISTORYHISTORY DEFINITIONDEFINITION EPIDEMIOLOGYEPIDEMIOLOGY PATHOLOGYPATHOLOGY CLINICAL FEATURESCLINICAL FEATURES DIAGNOSISDIAGNOSIS COMPLICATIONSCOMPLICATIONS PREVENTIONPREVENTION CHEMOTHERAPYCHEMOTHERAPY REFERNCESREFERNCES

FACTS

““If you know TB, you know medicine” Sir If you know TB, you know medicine” Sir William Osler.William Osler.

1/3 world population is infected.1/3 world population is infected. 8,000 die/day, 2-3 million/year. >AIDS& 8,000 die/day, 2-3 million/year. >AIDS&

malaria.malaria. Accounts for 1/3 AIDS deathes.Accounts for 1/3 AIDS deathes. HIV patients 30 times more likely to get HIV patients 30 times more likely to get

sick with TB once infected.sick with TB once infected.

HISTORY

1882 Robert Koch identified the tubercle bacillus.1882 Robert Koch identified the tubercle bacillus. 1895 “Roentgen” x-rays.1895 “Roentgen” x-rays. 1921 BCG vaccine (France).1921 BCG vaccine (France). 1940 PPD (USA).1940 PPD (USA). 1944 Streptomycin.1944 Streptomycin. 1946 PAS.1946 PAS. 1952 INH.1952 INH. 1966 Rifampicin.1966 Rifampicin.

HISTORY (cont.)

Do Nothing Era.Do Nothing Era. Sanatorium Era.Sanatorium Era. Collapse therapy.Collapse therapy. Chemotherapy Era.Chemotherapy Era. Drug resistance.Drug resistance.

Definition

Acid fast, aerobic bacilli:Acid fast, aerobic bacilli:

MycobacteriumTuberculosis.MycobacteriumTuberculosis. Granuloma, central caseation, Langhan’s Granuloma, central caseation, Langhan’s

giant cells.giant cells.

EPIDEMIOLOGY(HIGH RISK)

Extremes of age.Extremes of age. Contacts with open TB.Contacts with open TB. Over crowded populations.Over crowded populations. Health workers.Health workers. Low immunity.Low immunity.

PATHOLOGY

PRIMARY INFECTION: Primary complex.PRIMARY INFECTION: Primary complex. P.M.N+ macrophages->>> T- cells->>> increase P.M.N+ macrophages->>> T- cells->>> increase

cell mediated immunity (3-8/52)->>> +PPD.cell mediated immunity (3-8/52)->>> +PPD. Caseating granuloma, Langhan’s giant cells, Caseating granuloma, Langhan’s giant cells,

lymphocytes & fibrosis------ healing lymphocytes & fibrosis------ healing &calcification.&calcification.

20% contain remaining bacilli, activate if low 20% contain remaining bacilli, activate if low immunity( decr host defences)immunity( decr host defences)

POST PRIMARY T.B.POST PRIMARY T.B.

CLINICAL FEATURES Prim TB: Symptomless usually.Prim TB: Symptomless usually. Miliary TB: Acute, diffuse, disseminated by blood. Old Miliary TB: Acute, diffuse, disseminated by blood. Old

people. Difficult diagnosis. Fatal if not treated.people. Difficult diagnosis. Fatal if not treated. Ill health, decrease wt., fever. (gradual)>>> meningitis, Ill health, decrease wt., fever. (gradual)>>> meningitis,

hepatosplenomegaly, choroidal tubercles.hepatosplenomegaly, choroidal tubercles. CXR miliary, may be normal.CXR miliary, may be normal. PPD+/-PPD+/- Transbronchial biopsy.Transbronchial biopsy. CT scan.CT scan. Liver & bone marrow biopsy& culture.Liver & bone marrow biopsy& culture.

CLINICAL FEATURES (cont’d)

Post primary TB:Post primary TB:

Vague ill health, fever, decr. Wt., sweating, Vague ill health, fever, decr. Wt., sweating, cough, haemoptysis.cough, haemoptysis.

Pneumonia/ pleural effusion.Pneumonia/ pleural effusion.

Abnormal CXR.Abnormal CXR.

CBC, sputum, biopsy.CBC, sputum, biopsy.

DIAGNOSIS CXR / CT.CXR / CT. PPD?PPD? Sputum: AFB( Z-N) Sputum: AFB( Z-N) FLUORESCENT 50% sensitivity.FLUORESCENT 50% sensitivity. NAA (DNA/ RNA), 6 hours, expensive, NAA (DNA/ RNA), 6 hours, expensive,

other specimens also.other specimens also..Culture: LJ.Culture: LJ BACTEC 7-10 daysBACTEC 7-10 days NIACIN test ++NIACIN test ++• BiopsyBiopsy• Bronchoscopy / LavageBronchoscopy / Lavage

INVESTIGATIONS (other)

CBCCBC U/EU/E ESRESR LFTLFT

COMPLICATIONS

ExtrapulmonaryExtrapulmonary AdrenalAdrenal SIADHSIADH

PREVENTION

BCG 70% immunityBCG 70% immunity Contact tracingContact tracing INHINH

CHEMOTHERAPY

Standard 6-9/12Standard 6-9/12 Inexpensive 12/12Inexpensive 12/12 ResistantResistant

Treatment

Ethambutol>>Ethambutol>> Pyrazinamide>> 2/12Pyrazinamide>> 2/12 INH>>>>>>INH>>>>>> Rifampicin >>>>>> 6/12Rifampicin >>>>>> 6/12 Pyridoxine>>>>>>Pyridoxine>>>>>>

STEROIDS?????STEROIDS?????

TREATMENT (cont’d)

Cheaper:* Streptomycin Cheaper:* Streptomycin

INHINH

2/12 daily then 2/wk……10/2/12 daily then 2/wk……10/

* INH 300* INH 300

Thiacetazone 150 Thiacetazone 150

12/12 daily.12/12 daily.

TREATMENT(cont’d)

Resistant: PAS 15 gms 12 hrly POResistant: PAS 15 gms 12 hrly PO

Ethionamide 0.75-1 gm POEthionamide 0.75-1 gm PO

Capreomycin 0.75- 1 gm IM Capreomycin 0.75- 1 gm IM

Cycloserine 0.75-1 gm POCycloserine 0.75-1 gm PO

CiprofluxacinCiprofluxacin

NEW

DOTSDOTS ICL enzyme.ICL enzyme.

REFERENCES

Scientific American Medicine Scientific American Medicine Davidson’s Principles and practice of Davidson’s Principles and practice of

MedicineMedicine WHO report on TBWHO report on TB