PEMICU 3B

BATUK
BERDARAH

Ronald Chrisbianto Gani

BLOK
405090223
SISTEM RESPIRASI FK UNTAR 2009
TUBERCULOSIS
 TUBERCULOSIS
• Caused by Mycobacterium Tuberculosis
complex
• Usually affects lung, but in 1/3 case, can affect
other organs
• Transmissions via droplet nuclei
• If untreated, maybe fatal in 5 years in 50-65%
cases

Harrison’s Principle of Medicine

17th ed Volume 1
 ETIOLOGIC AGENT
• Caused by Mycobacterium Tuberculosis, the complex
includes
– M. Bovis (unpasteurized milk)
– M. Caprae (related to M. Bovis)
– M. Africanum (in West, East and Central Africa)
– M. Microti
– M. Pinnipedii
– M. Canetii
• Rod shaped, non-spore, thin aerobic bacterium
measured 0,5um – 3um. Often neutral in gram staining.

Harrison’s Principle of Medicine

17th ed Volume 1
 ETIOLOGIC AGENT

Mycobacterium Tuberculosis, Ziehl-Neelsen Staining

Harrison’s Principle of Medicine

17th ed Volume 1
EPIDEMIOLOGY

Harrison’s Principle of Medicine

17th ed Volume 1
 EPIDEMIOLOGY
• Mostly in developing country
• In US, TB usually associated with elderly, HIV-
infected, immigrants, and poor people
• TB usually associated with poor hygiene and
ventilation

Harrison’s Principle of Medicine

17th ed Volume 1
EPIDEMIOLOGY

Harrison’s Principle of Medicine

17th ed Volume 1
 RISK FACTORS
• HIV disease
• Diabetes
• Silicosis
• Immunosupression
• Gastrectomy
• Malnutrition
• Presence of fibrotic lesion

Harrison’s Principle of Medicine

17th ed Volume 1
 PATHOGENESIS
• Droplet  masuk ke saluran napas (10% ke paru, sisanya
disaring)  netrofil  makrofag  kebanyakan mati dan
dikeluarkan
• Bila menetap  berkembang biak dalam sitoplasma
makrofag  membentuk fokus gohn limfangitis lokal +
limfadenitis regional = kompleks primer (Ranke), setelah itu
dapat:
– Sembuh total tanpa bekas (kebanyakan)
– Sembuh dengan meimbulkan bekas
– Berkomplikasi dan menyebar melalui
• Per kontinuitatum
• Bronkogen
• Limfogen
• hematogen Buku Ajar Ilmu Penyakit Dalam
Edisi V Jilid III
 CLINICAL MANIFESTATIONS
• Pulmonary
– Primary disease
– Post–Primary Disease
• Extra Pulmonary
– Tuberculous Lymphadenitis (>40%)
– Pleural Tuberculosis (20%)
– Tuberculosis of Upper Airways
– Genitourinary Tuberculosis (15%)
– Skeletal Tuberculosis (10%)
– Tuberculous Meningitis and Tuberculoma (5%)
– Percardial Tuberculosis
– Miliary or Disseminated Tuberculosis
Harrison’s Principle of Medicine
17th ed Volume 1
 PULMONARY
CLINICAL MANIFESTATIONS
• Primary Disease
– Occurs soon after initial infection, often in children
– Affects middle and lower lobes lung zones
– May cause lesion that can heal spontaneously and later
seen as small calcified nodule (Gohn lesion)
– In immunosupressed patients and children, disease may
progress with cavitation, pleural efusion, hematogenous
dissemination
– Enlarged lymph nodes  compress bronchi  lobar
collapse
– May develop miliary tuberculosis and/or tuberculosis
meningitis Harrison’s Principle of Medicine
17th ed Volume 1
 PULMONARY
CLINICAL MANIFESTATIONS
• Post-Primary Disease
– Also called adult-type, reactivation, secondary
– Localized to the posterior segment of upper lobes and
superior segements of lower lobes
– Early symptoms : fever, night sweats, weight loss, anorexia,
malaise
– In majority cases : Cough and purulent sputum, often with
blood streaks
– Pleuritic chest pain, rochi, pallor and clubbing finger may
occur in some cases
– Hematologic findings : Mild Anemia and leukocytosis
Harrison’s Principle of Medicine
17th ed Volume 1
 EXTRAPULMONARY
CLINICAL MANIFESTATIONS
• Lymphadenitis
– Painless swelling of cervical and supraclavicular nodes (scrofula)
– Fine needle aspiration or surgical biopsy for diagnosis (AFB smear
50%, culture 70-80%)
– DD : infectious conditions, neoplastic diseases (lymphomas and
metastatic carcinomas), disorders (Kikuchi disease, Kimura disease,
Castleman disease)
• Pleural Tuberculosis
– Fluid is straw-colored and exudative, protein level >50%, Glucose
Level : Normal or Low, pH 7.3, MN cells common, PMN in early
stages, Biopsy for diagnosis
– Empyema results from rupture of a cavity
Harrison’s Principle of Medicine
17th ed Volume 1
 EXTRAPULMONARY
CLINICAL MANIFESTATIONS
• Genitourinary
– Urinary frequency, dysuria, nocturia
– Urinalysis : pyuria and hematuria
– Genital TB more common among women, Fallopian Tube and uterine
disease can cause infertility
• Skeletal disease
– Most common in spine, hips, and knees
– May cause collapse of vertebral bodies and become kyphosis and
gibbus
• Meningitis
– Cranial nerve involvement  may cause coma, hydrocephalus, and
intracranial hypertension
– CSF may have High Lymphocyte, elevated protein level, low glucose.
Culture (+) in 80% cases Harrison’s Principle of Medicine
17th ed Volume 1
 EXTRAPULMONARY
CLINICAL MANIFESTATIONS
• Gastrointestinal disease
– Affects terminal ileum and ceccum  abdominal pain and
diarrhea
– Palpable mass on bowel may occur
– TB peritonitis  fever, abdominal pain, ascites exudative, need
peritoneal biopsy
• Pericarditis
– Acute/subacute fever, dull retrosternal pain, friction rub, effusion
is common, chronic  fatal
• Miliary / disseminated tuberculosis
– Lesion are small granulomas, non spesific
– Hepatomegaly, splenomegaly, lymphadenopaty, choroidal
tubercles of the eye may occur Harrison’s Principle of Medicine
17th ed Volume 1
 DIAGNOSIS
• AFB Microscopy
• Mycobacterial Culture
• Nucleic Acid Amplification
• Drug Suspectibility Testing
• Radiographic Procedure
• Additional Diagnostic Procedures
• Serologic and other diagnostic test
– Tuberculin Skin Test (TST)
– IFN – Gamma Release Assays (IGRAs)
Harrison’s Principle of Medicine
17th ed Volume 1
 DIAGNOSIS
• AFB Microscopy
– Smear of expectorated sputum or tissue
– Most modern : auramine-rhodamine staining and fluorescence
microscopy
– Traditional Method : Ziehl-neelsen staining
– Three sputums preferaby in the morning
• Mycobacterial Culture
– Agar-based medium, incubated at 37o C, 4-8 weeks
– Biochemical test to speciate mycobacterial isolates
– New methods : molecular method or high-pressure liquid of
chromatography of mycolic acid  2-3 weeks
Harrison’s Principle of Medicine
17th ed Volume 1
 DIAGNOSIS
• Nucleic Acid Amplification
– Amplification of mycobacterial nucleic acid
– Ready in several hours
– High specificity and sensitivity
• Drug Suspectibility Testing
– Tested for isoniazid, rifampin, and ethambutol
• Radiographic Procedures
– Classic X-ray : infiltrates and cavities
– CT-Scan : diagnose extrapulmonary TB
– MRI : Diagnose intracranial TB Harrison’s Principle of Medicine
17th ed Volume 1
 DIAGNOSIS
• Additional Diagnostic Procedures
– Sputum induction by ultrasonic nebulization of hypertonic saline
– Fiberoptic bronchoscopy
– In children who cannot expectorate sputum, specimen from early
morning gastric lavage for culture
• Serologic test
– Based on detection of antibodies
– Marketed in developing countries, not in US
• TST
– Skin test with Tuberculin PPD
– False negative in immunosupressed pts
– False positive in BCG vaccinated pts
Harrison’s Principle of Medicine
17th ed Volume 1
 DIAGNOSIS
• IGRAs
– Measuring T cells release of IFN gamma in
response to stimulation with highly tuberculosis
spesific antigents ESAT-6 and CFP-10
– More spesific and less cross reaction to BCG
vaccine and non-tuberculosis mycobacteria
– Ex : QUANTIferon-TB Gold (ELISA) and T-SPOT.TB
(ELISpot)

Harrison’s Principle of Medicine

17th ed Volume 1
Harrison’s Principle of Medicine
17th ed Volume 1
Harrison’s Principle of Medicine
17th ed Volume 1
Harrison’s Principle of Medicine
17th ed Volume 1
 MANAGEMENT
KATEGORI REGIMEN PENGOBATAN TB
DIAGNOSTIK TB Fase Awal Fase Lanjutan

Kategori I Anjuran Utama Anjuran Utama

2 HRZE 4HR atau 4(HR)3
Opsional Opsional
2(HRZE)3 or 2HRZE 4(HR)3 or 6HE
Kategori II Anjuran Utama Anjuran Utama
2HRZES / 1HRZE 5HRE
Opsional Opsional
2(HRZE)3 / 1HRZE3 5(HRE)3
Kategori III Anjuran Utama Anjuran Utama
2HRZE 4HR or
4(HR)3
Opsional Opsional
2(HRZE)3 4(HR)3 OR
6HE
Kategori IV Dirancang khusus

Farmakologi dan Terapi Edisi V

 MANAGEMENT
• Kategori I
– Pasien baru sputum BTA (+)
– Pasien baru TB-paru BTA (-) dg infeksi parenkim paru berat (ekstensif)
– TB-Paru dg penyakit HIV atau TB ekstraPulmonal
• Kategori II
– Pasien TB-Paru BTA (+) yg pernah diobati
• Kambuh
• Pengobatan gagal
– Pasien kategori I yg gagal diobati dg
• Program pengobatan yg adekuat
• Data yang representatif mengenai TB-MDR menunjukkan angka tinggi
– Tersedia pengobatan IV

Farmakologi dan Terapi Edisi V

 MANAGEMENT
• Kategori III
– Pasien baru TB paru dengan BTA (-), selain kategori
I dan TB ektraparu ringan
• Kategori IV
– Kronik (Sputum BTA masih positif sesudah
pengobatan ulang)
– Terbukti atau suspek kasus TB-MDR

Farmakologi dan Terapi Edisi V

MANAGEMENT

Katzung’s Basic & Clinical Pharmacology 11th ed

MANAGEMENT

Harrison’s Principle of Medicine 17th ed Volume 1