PBL #3

Pulmonary Tuberculosis

Group (A)
 Pulmonary
Tuberculosis
By: Ali Hussain Al-Harshan
 Table of contents
01 02
Microbial agent
Definition
Overview on Mycobacterium
Tuberculosis

03 04
Types Epidemiology
01
Definition
 * What is TB?

Tuberculosis (TB) is ??

Affected site in the body?

TB caused by?

Mode of Transmission??
* Mycobacterium Tuberculosis
 02
Epidemiology
 * Epidemiology

It is estimated that one-third of the

world’s population is infected with In 2014 there were 9.6 million
tuberculosis with majority of cases new cases of TB
around 65% seen in Africa and Asia.

TB was responsible for 1.6 million deaths worldwide in 2017

and 20% of these were in HIV co infected individuals
 03
Types of TB
 * Types of TB:

1- Active TB 2- Latent
* Cilinically: Bacilli go dormant in lungs (Carrier state -
I. Primary without symptoms) i.e., TB test ??
II. Secondary Can Latent TB turn into active or just
continuous as dormant ?

3- Extrapulmonary
During ? bacilli disseminated to ?
(most common) ?
(2nd most common) ?
Mycobacterium Tuberculosis

Mohammed Ali
MORPHOLOGY and Characteristics
Slightly curved rods with rounded ends.
They are non-motile, non-sporing, non-capsulated, and acid-fast bacilli.
Aerobic

Grow on typical media?

Acid- fast bacilli can be stained by gram stain?

SENSITIVITY TO PHYSICAL AND CHEMICAL AGENTS

Resistant to drying
They can survive exposure to many disinfectant, why? .

CELL WALL
Mycolic acid which are responsible for?
morphology of mycobacteria

13
ANTIGENIC STRUCTURE
• Two types of antigens , cell wall (insoluble) , and cytoplasmic
(soluble) antigens.

• Virulence factors
• Does it have exotoxins?

MODE OF INFECTION
Human become infected with M. tuberculosis by inhalation of
infective droplets coughed or sneezed in to air by a patient with
tuberculosis.
What is the finding?

15
The activity of TB

16
TB favor the apex of lung,
why?

17
Pathogenesis of TB
Abdulaziz Asiri
Transmission
Virulence factors
Fate of T.B.
•Thank you
 RECURRENT TB
Presented by: Yasir Awaji
 Recurrent tuberculosis: the
diagnosis of a subsequent episode of
TB following cure treatment.

Types:
I. TB Relapse
II. TB Reinfection
A. Relapse: Relapse disease is defined as a subsequent
episode of TB disease due to the reactivation of the original
infecting strain of MTB, determined by genotypic
homogeneity assessment of primary and recurrent MTB
strains.

B. Reinfection: Reinfection is defined as a subsequent

episode of TB disease due to the exogenous infection with
an MTB strain that is distinct from the organism that caused
the original infection.
 Risk factors?
I. HIV infection
II. Inadequate treatment
III. Endemic high prevalence
IV. Reduced local defence: Cigarette smoking, Air pollution, chronic
lung disease.
 Clinical
Features
By: Ali Hamzah Al-makrami
Investigation
of
Tuberculosis
Ali Hussein AL- shareef
 TABLE OF CONTENTS

LABORATORY BIOCHEMICAL
METHODS 01 TESTING 02

X-rays 03 Other tests 04

 LABORATORY METHODS
- SPECIMENS:
Suspected site of lession, consist of sputum, laryngeal swabs, bronchial
washings, CSF, urine, pleural fluid, joint fluid, blood etc.

1- Staining method - Zeihl Neelsen stain.

2- Cultural isolation –From deposit after concentration

decontamination culture on agar media Lowestein Jensen (L J)
medium,Incubation aerobic at 37 C for 2-8 weeks.
Zeihl Neelsen stain
 BIOCHEMICAL TESTING
- Niacin test- 10%
cyanogen bromide
& 40% aniline in
ethanol. Add a
suspention of
bacterial culture.
- a yellow color shows
positive reaction.

- Catalase : negative.
 CHEST X-RAY

● In active pulmonary TB, infiltrates or consolidations and/or cavities are

often seen in the upper lungs with or without lymphadenopathy or
pleural effusions .

Cavity Consolidation
Ghon focus
 TUBERCULIN TEST
● A skin test to detect development of Cell mediated immunity 
and delayed hypersensitivity to Tuberculosis.
● Also called Mantoux test.
● Preparations :
● Purified Protein Derivative (PPD).
● look for red wheal to form in 48-72 hours.
Uses of tuberculin test:
- Diagnose active infection in infants and young children.
- To select susceptibles for BCG vaccines & indication of
successful BCG vaccination.
NUCLEIC ACID AMPLIFICATION TESTING (NAAT)
- A nucleic acid amplification test, or NAAT, for tuberculosis (TB) is
a molecular test used to detect the DNA of Mycobacterium
tuberculosis complex (MTBC) in a sputum or other respiratory
sample.
- Because the amount of DNA in a sample is very small, NAA testing
includes a step that amplifies (or copies) the genetic material.
- Polymerase Chain Reaction (PCR) is a common form of NAAT
used in laboratory diagnosis.
ADVANTAGES OF A NAAT FOR TB?

✓ A NAAT can detect MTBC genetic material even when very small amounts
are present in the sample tested.
✓ NAAT results are typically available in 24 to 48 hours.
Thanks
Any questions?
DDx
 Pulmonary tuberculosis

• Pulmonary tuberculosis should be distinguished from other

diseases that cause cough, hemoptysis, fever, night sweat
,and weight loss such as :

• Bacterial pneumonia

• Brucellosis

• Bronchogenic carcinoma
01 Bacterial pneumonia
Sudden onset of symptoms, such as high
fever, cough, purulent sputum, chest pain,
leukocytosis, chest X-ray shows
consolidation.

02 Bronchogenic carcinoma
may be asymptomatic, usually at
older ages (> 50 years
old)  cough, hemoptysis, weight
loss

03 Brucellosis
Fever, anorexia, night sweats,malaise,
back pain , headache, and depression.
History of exposure to infected
animal
 Extra-pulmonary tuberculosis

• Tuberculous Lymphadenitis : Lymphoma, squamous cell carcinoma, papillary

thyroid cancer, pyogenic infection
• Skeletal Tuberculosis : Multiple myeloma bone metastasis spinal cord
abscess osteoporosis
• Tuberculous Arthritis : Bacterial septic arthritis, pseudogout

• Central Nervous System Tuberculosis : Bacterial meningitis  viral

meningitis, encephalitis
• Tuberculosis Peritonitis : Bacterial peritonitis chronic peritoneal dialysis
Thank you
Do you have any questions ?
 Treatment of TB
By: Yousef Alwadie , Omar Alshahrani
TB Treatment

❑ Combinations of drugs are required, to prevent the resistance

during the course of therapy (mycobacteria can develop the
resistance to any single drug)

❑ Treatment must be administered for months to years (depending on

kinds of drugs), because the response of mycobacterial infections to
chemotherapy is slow.
TB Treatment

❖ First-line” drugs:
Isoniazid (INH), Rifampin (RIF), Pyrazinamide (PZA), Ethambutol (EMB),
Streptomycin (SM)

❖ Second-line” drugs:
Ethionamid, Capreomycin, Cycloserine, Amino salicylic Acid (PAS), Ciprofloxacin,
Ofloxacin, Rifabutin, Clofazimine
TB Treatment

Anti tuberculous drugs can be divided into:

❑ Bacteriostatic:
• Ethambutol (EMB)
❑ Bactericidal:
• Pyrazinamide (PZA)
• Streptomycin (SM)
• Isoniazid (INH) (against rapidly growing mycobacteria)
• Rifampin (against slowly growing organisms)
 Adverse reactions of antituberculosis drugs:

1- Isoniazid (INH) :
• a. Allergy reactions – fever and skin rashes, lupus
erythematosus

• b. Toxic effect – injury to the liver:

❑ - Often asymptomatic, rare with loss of appetite, nausea,

vomiting, jaundice
❑ -Toxicity depends on age, is greater in alcoholic, during

pregnancy and post-partum period,

 Adverse reactions of antituberculosis drugs:

C. Peripheral neuropathy
• Due to INH-induced pyridoxine deficiency .
• More frequent in alcoholic, poor nourished persons, elderly .
• Daily dose of 25 to 50 mg of pyridoxine can prevent this complications

D. Anemia

E. Agranulocytosis
Q1:

• Following are the first line antitubercular drugs except:

• A. isoniazid
• B. rifampin
• C. PAS
• D. streptomycin
 Adverse reactions of antituberculosis drugs:

2- Rifampin:
• Hepatitis ( transient increase of transaminase and bilirubin)
• Thrombocytopenia
• Renal failure
• Fever
• Allergic reactions
 Adverse reactions of antituberculosis drugs:

3-Pyrazinamide :
• Hepatotoxicity (1-5% patients) especially, when high doses are used.
• Hyperuricemia .
• Gastrointestinal symptoms.
4-Streptomycin :
• Nephrotoxicity – renal tubular damage
• Ototoxicity
• Vestibular damage
 Adverse reactions of antituberculosis drugs:

5-Ethambutol (EMB) :
• Can affect ocular nerve (first symptom is inability to distinguish blue from
green) .
• Hyperuricemia.
Therapeutic protocols of T.B.:

❑ 1- In uncomplicated T.B., short course therapy for 6 months can be satisfactory

provided that both isoniazid and rifampin are administered.
• One such regimen isoniazid + rifampin + pyrazinamide can be given for 2 months
followed by 4 additional months of isoniazid + rifampin.

❑ 2- In extensive pulmonary T.B., those with extrapulmonary disease, miliary T.B.,

meningitis or drug resistance another drug is added to the above regimen which
is usually ethambutol or streptomycin. (for 6 months)
Q2:

• Whichone of the following anti-tubercular drugs acts best in

acidic pH:

• A. INH
• B. Pyrazinamide
• C. Streptomycin
• D. Rifampicin
Complications
Khalid Shaker Althagafi
Complications

Most patients have a relatively benign course.

Complications are more frequently seen in patients with the risk
factors mentioned above.
Some of the complications associated with tuberculosis are:
Extensive lung destruction

Damage to cervical sympathetic ganglia leading to Horner's

syndrome.

Acute respiratory distress syndrome

Milliary spread (disseminated tuberculosis)including TB meningitis.

Empyema

Pneumothorax

Systemic amyloidosis