Diagnosis and treatment of TB:

TB is very important to study to its endemic affection in Egypt. a lot of Egyptians are affected some of
whom present with clinical symptoms and other do not present at all. TB is caused due to bacillus. it
could be cause by either mycobacterium tuberculosis or mycobacterium bovis ( which is transmitted
from contaminated bovine products ).

Now TB is not a very virulent bacteria per say but its virulence comes from its unique structure. the cell
wall structure it poses mycolic acids and glycolipids. it also has cord factor which is cytotoxic, and most
importantly mycobacterium sulfalipids which inhibit the phagolysosome fusion. the high lipid content of
TB is what makes it so unique it allows it to :

there are multiple stains that can allow us to visualize TB including Zeil nelson ( red in a blue black
background ), auramine-rhodamine ( fluorescent orange yellow in black background)

the problem with TB is its multi-resistance to anti-tuberculosis drugs.

there are several ways one can contract TB the most common routes of infections are 1. droplet
infection (lungs and tonsils), 2. ingestion of raw milk contain bovine bacili (affects the tonsils and
intestines ), 3. contact infection through ski.

-predisposing factors to contracting TB include the following: overcrowding, poor standards of living,
immunocompromised, handling infected material ( infected meat and infected wounds -for healthcare
worker), also the fact that one droplet can contain up to 3 bacilli. talking 5 minutes alone release up to
3000 droplets which is equal to 9000 bacilli, and only 10 -200 micro droplets are patent enough to cause
an infection.

Active tuberculosis may present in three different stages: 1. primary TB, secondary TB, and military TB.

primary TB occurs due to a first time infection and affects the lungs, tonsils, intestines, skin. it is marked
by a certain triad in pathology :
secondary TB occurs when a person is re-infected with TB or the TB has been re-activated.
complications of secondary TB include :infection of the pleura, infected sputum can cause intestinal TB,
blood vessel erosion (hemoptysis ), fibrosis leading to heart failure.

military TB is known as the dissemination of bacilli to produce numerous minute lesions in distant
organs. they lesions resemble millet seeds, hence the name.

the fate of TB is either 1) healing of the infection with treatment and immuno-patent patients. or 2)
spread of the infection either a) direct spread to the lung or pleura, or blood spread which depends on
the number of bacilli : few(destroyed), moderate number(settle in one organ), large number (disseminated
in many organs)
1. the final fate is encapsulation and reactivation of primary focus in lowered immunity.

patients may present with constitutional manifestations such as fever, night sweats, loss of weight, loss
of appetite. patients will usually present with non- specific symptoms.

in order to diagnose TB you must prove one of both the following scenarios or both of them together.
either prove that there is evidence of an infection or that there is evidence of an active disease.

in order to diagnose TB we must coincide the clinical presentation of the patient with as serious of test
including: clinical examination, radiology, lab tests, microbiology, and TB specific test ( the tuberculin
testing based on Type IV hypersensitivity).

lets start of with our radiological findings. to start of we need to know that TB may mimic any chest
disease according to the extent of damage that the organism causes. the most common presentation or
areas of affection by TB include the following: apical inflitrates, cavitation, mediastinal LN, pleural
effusion (either as part due to the hypersensitivity reaction that has occurred or the pleura itself maybe
affected), and the worst form of TB military shadows.

the following CHXR will show you multiple TB affections:

now moving on the bacteriological diagnosis:

we can either detect the organism or detect what is done by the organism.
we can either check the : sputum, laryngeal swab, gastric lavage, body fluids (pleural fluid, ascetic fluid,
csf), fiberoptic bronchoscopy specimen, tissue biopsy.

sputum :it is material expectorated from alveoli through the air passes then through the mouth. in case
of TB sputum sample must be taken on 3 consecutive mornings.

detection o fat intact bacilli can be done by direct smear microscopy, culture &sensitivity, animal
inoculation.

looking at the direct microscopy as we discussed earlier we have either the ziegler-neelson or
fluorescent.
you must also be able to identify the causes of false +ve smears and those of false -ve smears:

the agars we use can be based on several types of media including Egg based (lowentsein jensen,
petragnani, ATS egg yolk, potato flour media), agar based, and liquid base.

these cultures have benefits: there high sensitivity, species identification, and they can be able to detect
drug resistance. however these agars are expensive, require time (6-8), and require specialized personal.
now to over come these difficulties we use MGIT (mycobacterial growth indicator tube ) which takes
about 14 days.

we can also detect metabolic end product of the bacilli : such as mycobactins and radiometric
technology. :
we can also detect fragments of the bacillus:

the most famous antigens we can detect are lipids, polysaccharides, and proteins ( these are what we
derived the tuberculin test from which is now purified).
we can also carry out NAAT-PCR : but it has a lot of problems.
this test is very important in identifying drug resistance:

we can also monitor the immunological response, however it is highly non specific.
now for our lymphocyte activity markers ( ADA & gamma INF).
ADA is released from the lymphocytes as a weapon
in the case go Gamma INF : i draw a blood sample with sensitized lymphocytes. and then i add ESAT 6
and CFP 10 as our antigens, and then we process it within 12 hours. if INF has been released in a high
matter this means this patient has TB and needs treatment.

we also the tuberculin skin test:

people who ma not be vaccinated with BCG may include: are those who haven’t lived inn an endemic
region.