Module staff: Dr.

Ahmed Ibrahim
• Dr. Nehaya Mnahi Dr. Ahmed Jaafer
[module leader] Dr.Karam Basil
• Dr. Ahmed Badr Dr. Amir Qasim
• Dr. Nawal Mustafa DR.Ahmed Qasim
• Dr. Firas Mohamed Dr.Mohammed Adil
• Dr.Zuhair Abdulkareem
• is caused by infection with Mycobacterium
tuberculosis (MTB), which is part of a complex of
organisms that also includes M. bovis (reservoir
cattle) and M. africanum (reservoir human).
• Also there is atypical mycobactrium e.g M.kansasi,
…e.c.t
Mode of transmission
• Airborne (most common)
• Vertical (rare)
• Direct skin (rare in wounds
• Ingestion of milk of infected cow
The formation of a mass of
granulomas surrounding an area of
caseation leads to the appearance
of the primary lesion in the lung,
referred to as the ‘Ghon focus’.
• The combination of a primary
lesion and regional lymph node
involvement is termed the ‘Ghon
complex’.
• If the bacilli spread (either by lymph or blood)
before immunity is established, secondary foci may
be established in other organs, including lymph
nodes, serous membranes, meninges, bones, liver,
kidneys and lungs

• These foci resolve once an immune response is

mounted and the organisms gradually lose viability
• However, ‘latent bacilli' may persist for many years
• The estimated lifetime risk of developing disease
after primary infection is 10%, with roughly half of
cases occurring in the first 2 years after infection
 Classification of TB
1. According to the site
• Pulmonary : (infectious)
– Smear positive (S+)
– Smear Negative (S- )
• Extra-pulmonary : (NOT infectious) any organ
 Pulmonary TB
• Occurs insidiously over several weeks Systemic
symptoms include cough often with haemoptysis,
fever, night sweats, malaise, and loss of appetite
and weight

• TB Suspect: any patient with cough more than two

weeks without response to broad spectrum
antibiotics
 Extra Pulmonary Disease

• Cervical or mediastinal lymphadenitis is the most

common extra pulmonary presentation
• Meningeal disease represents the most important
form of CNS TB, as it is rapidly fatal if unrecognised
and untreated
Extra Pulmonary TB
 Military TB

• Blood-borne dissemination, which may present

acutely but is often characterised by 2–3 weeks
of fever, night sweats, anorexia, weight loss and
dry cough
• Headache may indicate coexistent tuberculous
meningitis
• Hepatosplenomegaly may be present
• Auscultation is frequently normal, although with
more advanced disease widespread crackles occur
• Fundoscopy may show choroidal tubercles
• CXR demonstrates fine 1–2-mm lesions (‘millet
seed') distributed throughout the lungs.
• Anaemia and leucopenia may be present
2- According to Drug Resistance
• Drug Sensitive TB (DS TB )
• Drug Resistant TB (DR TB)
 Drug Sensitive TB
• Cat. I : NEW cases
• Cat. II : ( Past history with TB )
 Relapse : A patient who has been declared cured
of any form of TB in the past by a physician after
one full course of chemotherapy, and has
become sputum smear-positive

 Failure : A patient who is on treatment, remained

or became again smear-positive, five months or
later after commencing treatment

 Loss to follow up: A patient who interrupts

treatment for two months or more, and returns to
the health service with smear-positive sputum
 Investigations
• Sputum
• Direct AFB
• PCR (Genx Pert )
• Culture and Sensitivity
• Radiology
• CXR
• CT Scan

• Bronchoscopy
• Bronchial wash
• Biopsy

• Tuberculin skin test

• IGRA (Interferon Gamma Release Assay ).
• Extra pulmonary investigation
• Biopsies
• Fluids aspiration
• Radiology
 •
Genxpert (PCR) •
*Highly sensitive and specific for TB •
*It detect the typical mycobactrium only. •
* It can determin wether the mycobactrium is •
resistant to refampicin or not .
Treatment of Drug Sensitive TB
(First Line Anti TB)
Category I and Category II
• Initial phase: 2 month of 4 drugs which are (INH ,
Rifampicin, Ethambutol, Pyrazinamide) so refer to it
as (2HREZ)
• Continuation phase: 4 month of 2 drugs which are
(INH ,Rifampicin )so refer to it as ( 4HR)
2HREZ / 4HR

* In Extra pulmonary the continuation phase will be

longer
 Treatment Follow Up
The Initial phase
2 HREZ

Check sputum smear at the end

Of 2nd , 5th, 6th months

If smear -ve If smear +ve

At end of 2nd or At 5th month
3rd month (failure)

Continuation Retreatment
Phase 4HR Cat II
 •
DOTs strategy •

Directly observed short course therapy •

it is now applicable in Iraq in order to prevent •
loss to follow up in TB.
 Drug Resistant TB
• Multidrug Resistant (MDR) :Resistant to both INH,
Rifampicin together
• Extensive Drug Resistant (XDR): MDR + one of
fluoroquinolone + one of injectable
• Mono Drug Resistant :One of anti TB BUT not
Rifampicin
• Poly Drug Resistant : Two and more anti TB BUT not
both INH+ Rifampicin (MDR)
• Rifampicin Resistant (RR) : Regards as MDR
 Prevention of TB
• Detection of all cases of pulmonary TB and treatment
of them
• Detection of latent TB ( asymptomatic) and give them
chemoprophylaxis ( 6 month Isoniazid)
• Good measures of infection control especially in
health institutions and prison
• BCG (the Calmette–Guérin bacillus)
– This is a live attenuated vaccine used to stimulate protective
immunity. It prevents disseminated disease in children but
efficacy in adults is inconsistent
• Community education about TB and its control
• Raise the economic state of people
Chemoprophylaxis is also recommended for:

1. All Contacts to pulmonary TB smear positive

2. Children under 5 yr. in close contact to all type of
TB
3. Those with recent confirmed tuberculin
conversion
4. Babies of mothers with pulmonary TB
5. HIV-infected close contacts of a patient with
smear-positive disease and there tuberculin or
IGRA IS POSITVE
• Tuberculin skin testing may be falsely positive in
BCG-vaccinated patients and those exposed to non-
tuberculous mycobacteria
• False- Negative skin tests occur with
immunosuppression or overwhelming infection
• These limitations may be overcome by employing
interferon-gamma release assays (IGRAs) that are
specific to MTB
 Only if Medications
are Taken,
Patients Can Get
Cured
Poor treatment adherence or
weak TB programs ...

RESISTANCE
The first chance to cure a patient is always the
best chance
Need for Universal Health Care and patient
centered approach