Running head: AN INVESTIGATION AND MANAGEMENT OF TUBERCULOSIS

An Investigation and Management of Tuberculosis Christina (Ngu) Phoo Molloy College

AN INVESTIGATION AND MANAGEMENT OF TUBERCULOSIS An Investigation and Management of Tuberculosis

Tuberculosis (TB) is an active infectious disease, which is accountable for 2 million deaths per year; indeed, 9 million people worldwide have become infected with mycobacteria, according to the centers for disease control and prevention (CDC) (Knechel, 2009). It has a higher mortality rates in low socioeconomic countries due to the general lack of awareness of the disease process, insufficient resources, needed diagnosis and treatment, and the general knowledge to correctly identify and manage TB. There is a high prevalence risk of TB in patients who are immunosuppressant, who are also infected with human immunodeficiency virus (HIV). Moreover, the vulnerability of spreading TB is high among health care workers, residence in prisons and jails, people born in foreign counties with high spread of TB, an increased in bacterial resistance to medication, travelling to high risk areas that are also widespread with TB, homelessness, and multi drug abusers (Knechel, 2009). TB is a growing concern to the public, patients, and healthcare workers; additionally, it is amongst the eighth leading causes of death in the world (Sia & Wieland, 2011). Finally, it is essential to understand the pathophysiology, clinical assessments and findings, the current treatment plans, and proper care and management strategies to prevent the spread of TB. Tuberculosis (TB) is an infectious disease which affects the lungs; and overtime, may also spread to other areas of body, especially to blood streams and the vital organs, if it is untreated (Knechel, 2009). It is caused by Mycobacteria, which is a rod-shaped, non-sporeforming, aerobic bacterium with a unique cell wall that has a significant amount of fatty acid and mycolic acid (Knechel, 2009, p. 35). These acids are covalently attached to the underlying peptidoglycan-bound polysaccharide arabinogalactan; hence, this binding process provides the

AN INVESTIGATION AND MANAGEMENT OF TUBERCULOSIS

bacteria with stronger lipid barrier of the cell membrane that is a necessary for its virulence and growth rate (Knechel, 2009, p. 35). Another important factor for its survival is the composition and quantity of the bacterias cell wall. The cell wall is made of lipoarabinomannan, a carbohydrate structural antigen on the outside of the organism that is immunogenic and facilitates the survival of mycobacteria within macrophages (Knechel, 2009, p. 35). Nevertheless, the properties that created a strong barrier of cell membrane and the components of cell wall have provided much greater strength for mycobacteria for its survival and growth rate; hence, in becoming resistance to antibiotics and host defense mechanisms (Knechel, 2009). Mycobacterium tuberculosis, its transmission is from small air droplets that are introduced from a persons cough or sneeze; and even from singing, and or talking to a person who has, or already had infected with pulmonary or laryngeal tuberculosis (Knechel, 2009). The main site for its transmission is by the respiratory tract, inhalation; therefore, leading Mycobacterium tuberculosis into the lungs, which caused the start of respiratory tract infection (Knechel, 2009). The droplets after a person expectorate, remained as airborne for minutes to hours. In addition, the number of bacilli in the droplets, the virulence of the bacilli, exposure of the bacilli to UV light, degree of ventilation, and occasions for aerosolization all influence transmission (Knechel, 2009, p. 35). Once a person inhaled the infectious droplets, the majority of the bacilli are landed in the upper parts of the airways where the mucus secreting goblet cells are present to catch any foreign substances. In addition, the cilia on the surface are responsible for bringing up the entrapped particles for removal; as well as, initiating the bodys physical defense to prevent further infection and body expose to tuberculosis (Knechel, 2009). Furthermore, these droplets in the

AN INVESTIGATION AND MANAGEMENT OF TUBERCULOSIS

mucociliary reach to the alveoli, where alveolar macrophages are also there to engulf and invade any pathogenic cells (Knechel, 2009). This phagocytosis by macrophages is the initial cascade that results in either successful control of the infection, followed by latent tuberculosis, or progression to active disease, called primary progressive tuberculosis (Knechel, 2009, p. 35). Finally, the outcome is determined by the quality of the host defenses and the balance that occurs between host defenses and the invading mycobacteria (Knechel, 2009, p. 35). The bacterial cell division continues to multiply slowly after the initial ingestion; indeed, it occurs every twenty-five to thirty-two hours, despite of, infection being in controlled, and or, in a progression stage (Knechel, 2009). Macrophages and T lymphocytes are bodys natural defenses, which act together in an attempt to degrade, and contain the bacteria. Moreover, this leads to a formation of granulomas around the M tuberculosis organisms, in persons with intact cell-mediated immunity (Knechel, 2009). The initial immune process continues for two to twelve weeks; the microorganisms continue to grow until they reach sufficient numbers to fully elicit the cell-mediated immune response, which can be detected by a skin test (Knechel, 2009, p. 36). In two to three weeks, the accumulation of activated T lymphocytes and macrophages has formed nodular-type lesions; thus, it leads to an early solid necrosis at the center of the lesion, referred to as caseous necrosis (Knechel, 2009). Lesions in persons with an adequate immune system generally undergo fibrosis and calcification, . . . less effective immune systems progress to primary progressive tuberculosis . . . For less immunocompetent . . . the necrotic tissue undergoes liquefaction, and the fibrous wall loses structural integrity; indeed, the bacilli are able to escape and spread to other alveoli and other organs (Knechel, 2009, p. 36).

AN INVESTIGATION AND MANAGEMENT OF TUBERCULOSIS

The clinical manifestation of TB is different in each stage since it is determined by persons immunity level. The different stages of TB include early infection, latency, primary disease, primary progressive disease, and extrapulmonary disease (Knechel, 2009). In early stages of infection, person may have fever, paratracheal lymphadenopathy, or dyspnea because the bodys immune system is fighting against the infection. Generally, the infection proceeds without showing any signs or symptoms, and may not yet advance onto an active disease at this stage (Knechel, 2009). At latent stage, mycobacteria persist in the body; indeed, a person is also susceptible to reactivation of the disease when immunosuppression occurs. Person may not have any signs or symptoms; though, granulomatous lesions calcify and become fibrotic, as it becomes apparent on chest radiographs (Knechel, 2009, p. 37). In primary disease, a person may have nonspecific signs and symptoms such as nonproductive cough, fatigue, weight loss, or fever. Furthermore, the disease exists subclinically; although, there are limited findings that are supported from the assessments, chest radiographs, and sputum smears, since results may be normal or negative (Knechel, 2009). In primary progressive tuberculosis, the signs and symptoms are becoming more evident as the disease progresses. The cough becomes predominant with rales and hemoptysis, as well as, continuous weight loss, fatigue, anemia, and leukocytosis can also occur in response to the infection (Knechel, 2009). Lastly, extrapulmonary TB is the advanced stage, where the infection progresses onto most serious places such as the central nervous system, which may result in meningitis or space-occupying tuberculomas (Knechel, 2009). Since the infection becoming systemic, there are other locations where it may spread, that include the area of lymph, bones, joints, pleura, and genitourinary system (Knechel, 2009).

AN INVESTIGATION AND MANAGEMENT OF TUBERCULOSIS

There are laboratory and diagnostic studies to detect and evaluate an active and latent TB. The radiographs may show the characteristic findings of infiltrates with cavitation in the upper and middle lobes of the lungs (Knechel, 2009, p. 38). The sputum smear is a traditional lab test that is used to detect acid-fast bacilli within twenty-four hours of the specimen collection (Knechel, 2009). The most accurate test to identify M tuberculosis is the sputum culture. It takes about three to six weeks for a detectable growth on solid media and four to fourteen days to confirm the disease on a high-pressure liquid chromatography. There is also a newer diagnostic technique for faster detection of TB. One method is the polymerase chain reaction assay, which can be used to differentiate M tuberculosis from other myobacteria on the basis of genetic information and provides results within hours (Knechel, 2009, p. 40). The tuberculin skin test (TST), also known as Mantoux test is highly used to detect exposure to mycobacteria. It requires the intradermal injection of 0.1 mL of 5 purified protein derivate (PPD) into the surface of the forearm (Sia & Wieland, 2011). The test result is recorded as the diameter of transverse induration in millimeter 48 to 72 hours after administration (Sia & Wieland, 2011, p. 352). The test can turn false positive if someone is vaccinated with Bacille Calmette-Guerin (BCG) in their early years. Other factors for false positive may include, presence of active TB, presence of other bacterial, fungal, and viral infections, live virus vaccination, immunosuppressive therapy, long-standing renal failure, malnutrition, lymphoid diseases, and age (Sia & Wieland, 2011, p. 352). Moreover, patients who are likely to test positive PPD because of a booster effect on immunologic memory should consider TST 1 to 4 weeks after initial negative findings on the first TST (Sia & Wieland, 2011). This 2-step method should be considered for persons from countries with a high incidence of TB, for those with a

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history of BCG vaccination, and for those who need periodic retesting, such as health care workers (Sia & Wieland, 2011, p. 352). The induration is again observed on the second test. There is a high cost QuantiFERON-TB Gold test which measures the immune reactivity to M tuberculosis. This test requires a blood withdrawal and it provides the results in less than 24 hours. It has no affect on prior BCG and it detects both active and latent tuberculosis (Knechel, 2009). Results are indeterminate in those who are immunosuppressed and are under five years of age (Sia & Wieland, 2011). The treatment for latent TB is recommended for person at high risk of developing an active TB (Sia & Wieland, 2011). The treatment with Isoniazid (INH) 5 mg/kg (300 mg) for 9 months is the preferred regimen for most patients; in addition, Pyridoxine supplementation (25 mg/d) to INH is recommended for patients at an increased risk of neuropathy, nutritional deficiency, diabetes mellitus, HIV infection, renal failure, alcoholism, or thyroid disease and those who are pregnant or breast-feeding (Sia & Wieland, 2011, p. 354). Patients with active TB should be treated with multiple agents to achieve bacterial clearance, to reduce the risk of transmission, and to prevent the emergence of drug resistance (Sia & Wieland, 2011, p. 355). These drugs are classified as first-and-second line drugs. The first-line drugs are Isoniazid (INH), Rifampin (RIF), Ethambutol (EMB), and Pyrazinamide (PZA). The second-line drugs are Aminoglycosides Streptomycin, Kanamycin, and Amikacin (Sia & Wieland, 2011). Four treatment regimens are recommended for patients with drugsusceptible disease (Sia & Wieland, 2011, p. 355). These include INH, RIF, EMB, and PZA to ensure effectiveness and to overcome the drug resistance (Sia & Wieland, 2011). The normal duration for culture positive TB is 6 months; however, the treatment is extended to 9 months

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without PZA (Sia & Wieland, 2011). Conversely, the treatment is designed for 4 months for culture-negative pulmonary TB with combination of INH-RIF regimen. Completion of anti-TB treatment is determined by both the total number of doses taken and the duration of therapy (Sia & Wieland, 2011, p. 355). It is very necessary and crucial to do follow-up during the subscribe treatment regimens, and clinical evaluations at least once monthly to assess the possible adverse effects, outcomes, and the adherence to therapy; in addition, laboratory monitoring for platelet count, hepatic and renal functions are important for those at risk for toxicity (Sia & Wieland, 2011). The sputum microscopy and culture test should perform at least once a month until it meets 2 consecutive negative cultures; moreover, chest radiography after 2 months with final completion of treatment is also voluntary (Sia & Wieland, 2011). Diagnosis of latent TB infection in the newborn presented even with greater challenge; indeed, due to the lack of reliable diagnostic tests, risk of vertical transmission, and the need for chemoprophylaxis (Schutter, Schepers, Singh, Mascart, & Malfroot, 2010, p. 1155). It is very important to properly control and manage TB since it is highly contagious, and the infection spreads easily in the air in seconds. Active TB is frequently treated in the outpatient setting; although, one must wear a simple surgical mask, especially when going to public places and near other people (Sia & Wieland, 2011). Isolation is necessary for patients who are acutely ill, along with other comorbidities, and infectious patients who do not respond to therapy; and therefore, treatment is provided in a negative-pressure isolation room in the hospital (Sia & Wieland, 2011). Patients may be removed from isolation when clinical improvement is seen on effective therapy and 3 consecutive sputum samples on separate days are AFB smear-negative

AN INVESTIGATION AND MANAGEMENT OF TUBERCULOSIS (Sia & Wieland, 2011, p. 358). All persons who came into close contact with the infected individuals are also initiated on the therapy as a safe measure (Sia & Wieland, 2011). Tuberculosis is a very infectious disease which accounts for millions of deaths worldwide. It is very crucial to properly manage and safeguard the spread of the disease, especially in the areas where there is a high risk. It is easily spread in the air as micro air

droplets, and one can catch it from any unknown source. Therefore, it is important to understand the disease pathophysiology, and the related clinical manifestations, as well as management strategies in protecting everyone.

AN INVESTIGATION AND MANAGEMENT OF TUBERCULOSIS References

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Knechel, N. (2009). Tuberculosis: pathophysiology, clinical features, and diagnosis. Clinical Care Nurse, 29, 34-43. doi:10.4037/ccn2009968 Schutter, I., Schepers, K., Singh, M., Mascart, F., Malfroot, A. (2010). Latent tuberculosis in a newborn: diagnostic challenges. Springer-Verlag, 169, 1155-1158. doi:10.1007/s00431010-1177-8 Sia, I., Wieland, M. (2011). Current concepts in the management of tuberculosis. Mayo Clin Proc, 86(4), 348-361. doi:10.4065/mcp. 2010.0820

Nursing Diagnoses Ineffective airway clearance

Interventions -maintain patient airway -place patient in high or semi-fowlers position -assess breath (rate, rhythm, & depth) and lung sounds (rhonchi and wheezes) -use of accessory muscles -note mucus (COCA) and cough -use suction as necessary -maintain fluid intake to help thin secretions -provide O2 therapy -administer medications as ordered -educate patient about TB -instruct the proper medication regimen -teach the importance of TB medications -advocating patient for necessary follow-ups with healthcare provider -teach about TB prevention and spread -assess patient level of understanding -discuss outcomes, risks, and adverse effects -teach in monitoring vital signs

Deficient knowledge regarding treatment