Tuberculosis

• still a major worldwide concern

• it is uncommon in the United States

• disease of the elderly, the urban poor, minority groups, and

patients with AIDS

• Mode of infection:
• Via inhalation of Mycobacterium tuberculosis, which
incites a granulomatous pulmonary reaction

• In more than 90 percent of patients, infection is contained

and is dormant for long periods.
• Manifestations:
• cough with minimal sputum production,
• low-grade fever,
• Hemoptysis
• weight loss.

• Chest radiograph: presence of a variety of infiltrative

patterns with associated cavitation or mediastinal
lymphadenopathy.

• Stained smears of sputum: Acid-fast bacilli are seen in about

two thirds of culture-positive patients.

• Extrapulmonary tuberculosis:
• may occur in any organ, and almost 40 percent of
affected HIV-positive patients have disseminated disease
Treatment:
• Cure rates with 6-month short-course directly observed therapy—DOT—
approach 90 percent for new infections.

• Strains of multidrug-resistant tuberculosis (MDR-TB) increased rapidly as

TB incidence fell during the 1990s.
• Because of this, the Centers for Disease Control and Prevention (2003a)
now recommends a four-drug regimen for initial empirical treatment of
patients with symptomatic tuberculosis.
• Isoniazid, rifampin, pyrazinamide, and
ethambutol
• Other second-line drugs may need to be added.

• In 2005, there was a worldwide emergence of extensively drug-resistant

tuberculosis—XDR-TB.
• defined as resistance in vitro to at least the first-line drugs isoniazid and
rifampin as well as to three or more of the six main classes of second-line
drugs—aminoglycosides, polypeptides, fluoroquinolones, thioamides,
cycloserine, and para-aminosalicylic acid (Centers for Disease Control
and Prevention, 2009b).
 Tuberculosis and Pregnancy
• Jana and colleagues (1994) from India and Figueroa-Damian and
Arrendondo-Garcia (1998) from Mexico City reported that active
pulmonary tuberculosis was associated with increased incidences of:
• preterm delivery,
• low-birthweight
• growth-restricted infants,
• perinatal mortality.

• From her review, Efferen (2007) cited twofold increased rates of low-
birthweight and preterm infants as well as preeclampsia.

• The perinatal mortality rate was increased almost tenfold.

• Adverse outcomes correlate with late diagnosis, incomplete or

irregular treatment, and advanced pulmonary lesions.
• Extrapulmonary tuberculosis is less common.
• Jana and co-workers (1999) reported outcomes in 33 pregnant
women with renal, intestinal, and skeletal tuberculosis, and a third
had low-birthweight newborns.

• Prevost and Fung Kee Fung (1999) reviewed 56 cases of

tuberculous meningitis, which were associated with maternal death
in a third.

• Other presentations have included cervical spine tuberculosis with

paraplegia, widespread intraperitoneal tuberculosis simulating
ovarian carcinomatosis and degenerating leiomyoma, and
hyperemesis gravidarum from tubercular meningitis (Kutlu, 2007;
Moore, 2008; Nanda, 2002; Sherer, 2005, and all their colleagues).
Diagnosis:
• Current guidelines from the Centers for Disease
Control and Prevention (2005a) include:
• skin testing of pregnant women who are in any of the high-risk
groups shown in Table 46-5.
Table 46-5. Groups at High Risk for Having
Latent Tuberculosis Infection
Healthcare workers
Contact with infectious person(s)
Foreign-born
HIV-infected
Working or living in homeless shelters
Alcoholics
Illicit drug use
Detainees and prisoners
 preferred antigen is purified protein derivative (PPD) of intermediate
strength of 5 tuberculin units.

 If the intracutaneously applied test is negative, no further evaluation is

needed.

 A positive skin test measures 5 mm in diameter and requires

evaluation for active disease, including a chest radiograph (Centers
for Disease Control and Prevention, 2005b).

 For very high-risk patients—HIV-positive, those with abnormal chest

radiography, or those who have a recent contact with an active case—
5 mm or greater is considered treatable.

 For those at high risk—foreign-born individuals, intravenous drug

users who are HIV-negative, low-income populations, or those with
medical conditions that increase the risk for tuberculosis—10 mm or
greater is considered treatable.

 For persons with none of these risk factors, 15 mm or greater is

• The in vitro QuantiFERON-TB Gold test is
recommended by the Centers for Disease Control
and Prevention (2005a, b) for the same indications
as skin testing to diagnosis latent infection.
• It has not been evaluated as extensively as tuberculin skin testing.
• Both the QuantiFERON-TB Gold test and the new T-Spot TB have
been extensively reviewed by Lalvani (2007) and shown to be
useful in identifying patients with latent TB and at risk for
progression to active disease.
• They also distinguish between immune responses due to infection
and responses resulting from bacille Calmette-Guérin (BCG)
vaccination (Ernst and colleagues, 2007).

• Essential laboratory methods for detection or

verification of infection—both active and latent—
include:
• microscopy, culture, nucleic acid amplification assay, and
drug-susceptibility testing (Centers for Disease Control and
Prevention, 2009b).
TB Treatment
• Different schemes are recommended for
latent and active tuberculosis.
Latent Infection
Nonpregnant tuberculin-positive patients:
• < 35 years and who have no evidence of active disease
• isoniazid, 300 mg OD for 1 year
• safe for pregnancy (Briggs and colleagues, 2005).
• Compliance is a major problem
• care for tuberculosis is given in health systems
different from prenatal care
• isoniazid therapy be delayed until after delivery (3-
6mons)
• possibly increased isoniazid-induced hepatitis risk
in postpartum women
• There are exceptions to delayed treatment in pregnancy.
• Known recent skin-test convertors are treated
antepartum because the incidence of active infection
is 3 percent in the first year.
• Skin-test-positive women exposed to active infection
are treated because the incidence of infection is 0.5
percent per year.
• HIV-positive women are treated because they have
an 8-percent annual risk of active disease (Brost and
Newman, 1997).
Active Infection
• Recommended initial treatment for active tuberculosis in
pregnant patients:
• Isoniazid, rifampin, and ethambutol
• Pyrazinamide is added to high IRTb.
• If the organism is susceptible, the regimen is given for 9
months
• Reports of MDR-TB during pregnancy are few(Lessnau and
Qarah (2003))

• Breast feeding is not prohibited during antituberculous therapy.

• Pregnant women receiving isoniazid should also be given

pyridoxine, 25 mg/day orally, to decrease hepatic toxicity.
For HIV-infected women
• Rifampin or rifabutin may be contraindicated if certain
protease inhibitors or non-nucleoside reverse
transcriptase inhibitors are being administered.

• Pyrazinamide therapy is given for Rifampin resistant

• Second line: Aminoglycosides—streptomycin,

kanamycin, amikacin, and capreomycin—are ototoxic to
the fetus and are contraindicated (Briggs and associates,
2005).
Neonatal Tuberculosis
• Tubercular bacillemia:
• Can infect the placenta
• congenital tuberculosis (few cases)
• newborns who are infected by aspiration
during delivery
• Each route of infection constitutes about
half of the cases
• Neonatal tuberculosis simulates other
congenital infections and manifests with
hepatosplenomegaly, respiratory distress,
fever, and lymphadenopathy (Smith, 2002).
• Cantwell and associates (1994) reviewed 29 cases of
congenital tuberculosis reported since 1980. Only 12 of
the mothers had active infection, and tuberculosis was
commonly demonstrated by postpartum endometrial
biopsy.
• Adhikari and colleagues (1997) described 11 South
African postpartum women whose endometrial biopsy
was culture-positive. Six of their neonates had congenital
tuberculosis.
• Neonatal infection is unlikely if
• Active disease has been treated before delivery
• her sputum culture is negative.

• Because the newborn is susceptible to tuberculosis

• recommend isolation from the mother suspected of
having active disease.

• If untreated, the risk of disease in the infant born to a

woman with active infection is 50 percent in the first year
(Jacobs and Abernathy, 1988).