Martin, Edgardo III G.

April 4, 2020
1MTO4- CPH_LAB
Summative Report about Tuberculosis (TB)
TB infection is caused by a bacterium called Mycobacterium tuberculosis, which is a
bacterium that is rod-shaped, acid-fast, slow-growing, obligate aerobe, non-motile and
facultative intracellular parasite. It can be transmitted from person to person through air such as
when an infected TB person cough, sneeze, spit or simply when speaking or singing then a
person inhales the infected airborne particle or droplet nuclei. According to World Health
Organization (WHO), an estimated 10 million people fell ill with TB globally in 2018 and 1.5
million people died from TB including those with HIV. Hence, it is said to be the world’s most
infectious killer. TB is called in victorian-era in England as ‘’white plague’’ wherein the infected
person suffered from weight loss, coughing of blood or hemoptysis, and ashen of skin. People
who are immunocompromised or have underlying issues are more likely to be infected like
people with diabetes, HIV, cancer or even the intravenous drug users (IVDU) and pregnant
women.
Mycobacterium tuberculosis usually attacks the individual’s lungs and resides
particularly in the alveoli so called tiny-air sacs in the lungs. If the person is healthy and strong
immune system it will destroy or inhibit the bacteria but when the person has a weak immune
system like person living with HIV (PLHIV) the immune cells particularly alveolar macrophages
cannot or failed to completely kill the bacteria through the process of phagocytosis since they are
inactivated. It is facultative intracellular parasite since, it multiplies inside the macrophage then it
will be released once the macrophage dies. Usually, the person is asymptomatic at first but when
unactivated macrophages containing the tubercle bacilli burst it can spread affecting not only the
lungs but other organ systems like the lymphatic, skeletal, nervous and genitourinary system
which is called military or disseminated tuberculosis. If the immune system failed fight off the
bacteria like when the tubercle bacilli multiply in the alveoli, the immune cells enclosed the
tubercle bacilli making calcified granuloma or tuberculoma which are harmless. When these
granulomas deteriorate there is a risk of the Mtb to emerge and cause infection. Moreover, when
the tubercle bacilli grow and forms colonies then infect nearby cells when the immune cells fail
to destroy it, the bacteria will release an enzyme that triggers tissue necrosis wherein if it is in the
lungs it is called caseous necrosis because the dead lung tissue is crumbly, dull white appearance
that resembles cheese. According to CDC there are two kind of test that detect if the person has
TB bacteria which are tuberculin skin testing (TST) and TB blood test wherein if the result is
positive it doesn’t determine whether person has latent TB infection (LTBI) or has progressive
TB disease. Latent TB refers when a person is infected with TB bacteria but doesn’t manifests
any signs and symptoms wherein the immune system contained the bacteria by formation of
granuloma whereas active TB the bacteria multiplies rapidly and are not contained thus it can
lead to progressive tuberculosis. In addition, person with LTBI has few alive TB bacteria but not
active and cannot spread the bacteria or not infectious unlike to a person with TB disease which
has a large amount of active TB bacteria and can infect others and counted as a TB case.
Montoux tuberculin skin test is the standard method of determining whether a person is infected
with Mycobacterium tuberculosis (CDC,2016). In the administration of montoux skin test it
requires a tuberculin syringe wherein 0.1mL of tuberculin purified protein derivatives is injected
intradermally in the inner surface of the forearm. It takes about 48-72 hours before reading the
test whether the skin is flat or there is an induration which is measured in millimetres. Typically,
a positive skin test is yield when the measurement of the induration is 5 mm or more wherein it
varies in different cases. Furthermore, tuberculin skin testing may give a false-positive result
such as when exposed to nontuberculous mycobacteria which other mycobacteria aside from
causative agent of tuberculosis(Mycobacterium tuberculosis) and leprosy (Mycobacterium
leprae) which are atypical and environmental mycobacteria and may give false-negative result
when the person has a recent or very old TB infection or have a recent live-virus injection. In
addition, Mycobacterium tuberculosis complex comprises M. tuberculosis, M. bovis, M.
bovis BCG, Mycobacterium africanum, among others (Wanger, et al.,2017). Furthermore,
tuberculosis (TB) blood test is also known as Interferon Gamma Release Assay or IGRA. Chest
x-ray is also used as a test for detection of tuberculosis disease. Other diagnostic methods used
are culture media such as Middlebrook's medium (agar based medium) and Lowenstein-Jensen
medium (egg based medium) and acid-fast staints like Ziehl-Neelsen (hot acid fast) stain,
Kinyoun (cold acid fast) stain and Truant flourochrome stain or Auramine–Rhodamine stain.
Fluorescent microscopy has the advantage of speed and ease of screening and reduces observer
fatigue. The modified fluorescent method was found to be more advantageous than routine
cytology and conventional ZN method, particularly in paucibacillary cases. The bacillary
positivity rates were higher in the modified fluorescent method than in the ZN method (Annam,
et al., 2009). The usual specimen for clinical testing of TB is the sputum of the patient, it will be
tested if there are any Acid fast bacilli to different TB stain if it is positive or negative it will still
proceed to the culture media wherein different culture medium will be used but it will take 2 to 6
weeks for interpretation and the advantage is that you can do sensitivity drug testing. Moreover,
another test that can be done is molecular testing like the use of polymerase chain reaction to
detect the presence of the TB bacteria and it gives result very fast instead of waiting for weeks
but the disadvantage is it is expensive and cannot do sensitivity drug testing. Meanwhile, if there
is no sputum especially in children, gastric aspirates is used instead or for other the doctor may
use bronchoscopy. Moving forward, the cell wall of the Mycobacterium tuberculosis is
composed of over 60 % lipid wherein it is composed of three components which are mycolic
acid, cord factor and wax-D and peptidoglycan. The large percent in the lipids in the cell wall
makes the bacteria to have an impermeability to stains and dye as well as resistance to certain
antibiotics, lethal oxidation to survive inside the macrophages, and to acids and alkaline
compounds. The use of TST, radiographic X-ray and culture media have disadvantages such as
longer time to culture the bacteria and TST and chest X-ray may give a false result.
DOTS or Directly Observed Therapy, shourt-course is a way to help TB infected patient
to recover through intensive monitoring of administration of the 4 TB drugs in 6 months or
longer. These are rifampicin (RIF), isoniazid (INH), pyrazinamide (PZA), ethambutol (EMB)
which are taken by the patient for the first 2 months and for the remaining 4 months INH and
rifampin or another alternative combination drugs are administered to the patient. With the aid of
DOTS it reminds the patient to take its medicines regularly and to have a healthy lifestyle. In the
Philippines there are health programs to prevent, treat and control TB which are National TB
control program and DOTS. Proper administration of TB drugs should be monitored since when
combined there are adverse effects and the healthcare worker should only observe the side
effects of the TB drugs such as optic neuritis by ethambutol. The antituberculosis drugs are
classified in two first- and second-line drugs. The first-line antituberculosis drugs are composed
of RIF, INH, PZA, EMB and streptomycin (SM) meanwhile secondary-line antituberculosis
drugs are divided into two the first group is fluoroquinolones(Oflaxacin, levoflaxacin,
moxifloxacin, ciprofloxacin) and the second are the injectable antituberculosis
drugs(Kanamycin, amikacin and capreomycin). When there is resistance to one of the first-line
durgs it is called monoresist-TB but if more than one other than both RIF AND INH it is called
polydrug-resistant-TB and if there is a resistance to atleast both RIF and INH it is could
multidrug-resistant-TB (MDR-TB). If there is a resistance to the INH and RIF plus second-line
antituberculosis drugs in any of the fluoroquinolones and to atleast one of the injectable drugs it
is called extensively drug-resistant-TB (XDR-TB). Rifampicin-resistant TB is when there is a
resistance to rifampicin in any of the above form or classification even with or without resistance
to other anti-TB drugs wherein it is is detect in either phenotypic or genotypic methods.
In the terms of geographical area of the trend of the disease, Philippines is the fourth
country in the eight countries that made up the two thirds of TB global cases with a percentage of
6% and the leading country is the India with 27% followed by China 9% then Indonesia 8% in
2018 based on the Global Tuberculosis Report 2019 of WHO. Therefore, early detection, faster
diagnosis and accessibility to DOTS facility will surely decreases the total number of deaths and
the spread of the disease. In addition, awareness and proper education about TB will help in the
prevention and control of the disease.
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