Tuberculosis

TUBERCULOSIS (TB) is an infectious disease that most often

affects the lungs. TB is caused by a type of bacteria. It spreads
through the air when infected people cough, sneeze or spit.

Tuberculosis also known as Koch's

disease- is a chronic disease of the lungs
that leads to tubercle formation, a
circumscribed Sight elevation of the
skin that is larger than a papule
Causative Agent
Mycobacterium Tuberculosis: (bacterium that resembles a
fungus)
1. Hominis : affects humans 1

2. Bovis : affects cows/cattle* 2

3
3. Avis : affects birds*
4 5
 Mode of Transmission
Droplet:
1. If an infected person expels droplet nuclei by coughing, sneezing, talking or
singing.
2. Person-to-person (between adults)
3. Common route of entry is the respiratory tract (initial lesion is usually
pulmonary)
4. Inhalation of droplets by a susceptible uninfected person.
* Tubercle bacilli are easily destroyed by heat, sunlight, drying and ultraviolet light.
 Mode of Transmission
Two ways by which bacilli gain entry into the body :
1. Inhalation
2. Ingestion

Incubation Period
• 4-6 Weeks
Tuberculosis
The initial lesion formed in tuberculosis
1 TUBERCLE infection which could either be;

One that undergoes scarring fibrosis and

2 HARD TUBERCLE classification.

A current lesions which undergoes a

3 SOFT TUBERCLE necrotic process called caseation.

It is a form of tissue necrosis which

cellular outline are lost of the appearance
4 CASEATION
of which is cheese like.
Clinical Manifestation
I. Primary infection /Primary complex/ Primary Koch infection
• Develops in the childhood years.
• Composed of the soft lesions in the lungs and the regional (hilar) lymph nodes
*Primary complex in children is not contagious because:
1. children tend to swallow their sputum.
2. They don’t produce number of micro organisms enough to contaminate other.
Signs and Symptoms:
1. Fever 2. Cough
3. Loss of Appetite 4. Loss of Weight
5. Early Fatigability
Clinical Manifestation
II. Adult Tuberculosis

1. Primary Infection.
2. Reactivation of a formerly untreated infection
Signs and Symptoms:
1. Afternoon fever 6. Loss of Weight
2. Night sweats 7. Easy fatigability
3. Chest pains
4. Back pains
5. Loss of Appetite
* Initially dry cough becoming productive with yellowish or greenish sputum then becoming
blood-streaked.
Clinical Manifestation
III. Military/ Generalized tuberculosis
• Spread the infection of the different parts of the body through the blood and the
lymphatics (Ex. Pott’s Disease)
• Millets- small sized sites of infection formed in the other parts of the body, usually over
the lung fields.
 Diagnostic Exam
1. Sputum examination for AFB: confirmatory test if sputum contains acid-fast bacilli.
1. Sputum is collected early morning by coughing and expectoration. Patient should use only plain
water for gargle before specimen collection.
2. 3-5 cc of specimen is collected in a 3-series exam for
3 consecutive days.
*Ziehl Nielsen Method : sputum exam method used in active pulmonary
TB in older children and adults.
2. Chest X-ray: are done for the following purposes :
1. To determine the clinical activity of the TB infection :
a. Inactive : treated
b. Active : ongoing infection
2. To determine the size of the lesion/s :
a. Minimal : small, minute, may be negligible
b. Moderately advanced : lesion is 4 cm or smaller.
c. Far advanced : lesion of >4 cm and with cavitation.
Diagnostic Exam
3. Skin test: Mantoux test: the most reliable and useful way
of administering a skin test for tuberculosis. The patient, if exposed to the bacilli
will develop a sensitivity or allergy to the protein substance of the test (PPD:
Purified Protein Derivative).
Procedure
1. 0.1 cc of PPD is injected intradermally into the volar surface of the forearm to form a
wheal.
2. Test is read after 48-72 hours from administration and interpreted by noting the size of the
induration as follows :
a. Negative: < 4 mm in diameter
b. Doubtful: 5-9 mm in diameter because it may be due to :
1. A cross reaction to other mycobacterial infection.
2. Incompletely developed sensitivity or
3. Technical errors.
** If immunosuppressed patient, 5 mm induration is already (+).
c. Positive: 10 mm or more in diameter.
Treatment
I. Old Treatment
1. Short course chemotherapy : duration is 6 months :
a. Sputum test (+)
b. Newly diagnosed cavity
c. Non-cavitary cases
Rifampicin
Ionized (INH)
Pyrazinamide (PZA)
2. Standard regimen : duration is one (1) year.
a. Sputum test (-) but infiltrative
Any combination of anti-TB drugs other than the short course therapy.
Ex. : Ionized (INH) + Streptomycin sulfate
Treatment
II. DOTS : Directly Observed Treatment Short Course Chemotherapy /Tutok Gamutan:
Five elements for DOTS to succeed :
1. Political will to support the program : by virtue of devolution
2. Availability of microscope : patients are to undergo sputum tests every 2 mos
3. Availability of medications/drugs
4. Personnel /treatment partners : staff in the health centers
* Friends /co -workers in the office
* Spouse/parents in the home.
5. Recording/ documentation cards: for appropriate monitoring
Taken orally :
a. Rifampicin } most potent
b. Ionized } anti-TB drugs
c. Pyrazinamide: not given to pregnant women bec effect is unknown
d. Ethambutol: not given to children: they’re too young to report loss of visual acuity
Streptomycin: IM : not given to pregnant women : congenital deafness
** MDR-TB : Multiple Drug Resistant TB
 
Treatment
Side effects :
A. Rifampicin:
1. Red-orange color of urine (red lobster syndrome)
2. Jaundice : due to hepatotoxicity
3. Cthrombocytopenia
4. Urinary disturbance : anuria
5. Muscle weakness
6. Fever
7. Rashes
** Needs referral.
B. Ionized (INH) :
1. Peripheral neuritis ; should be given with Vit B6 (Pyridoxine)
2. Hepatotoxicity
C. Pyrazinamide (PZA) : gouty arthritis-like symptoms
D. Ethambutol :
1. Optic neuritis :
a. blurring of vision
b. color blindness for red and green
Treatment
E. Streptomycin Sulfate: VIII Cranial nerve damage:
1. Vestibular:
a. loss of balance
b. vertigo
2. Cochlear:
a. tinnitus
b. difficulty of hearing
c. deafness

Common causes of failure of treatment:

1. Poor compliance: the reason for coming up with DOTS
2. Selective taking of drugs: solved by fixed-dose combination.
Nursing Care
I. OPD (Domiciliary)/ Ambulatory :
1. Rest : may be allowed light work only
2. Nutrition : well balanced diet
3. Adequate ventilation
4. Early morning sunshine
5. Compliance to drug therapy
II. Acutely ill : Hospitalization is needed.
1. Complete bed rest : to conserve energy
2. In case of hemoptysis :
a. NPO : to avoid aspiration
b. Ice compress on the chest
c. Administration of oxygen, if necessary
d. Tranxenamic acid : taken orally as anti-hemorrhagic drug (as ordered)
Nursing Care
e. Vit K
f. Assess respiration.
g. No chest tapping / back clapping : will cause erosion of the lung debris and may lead to
aspiration.
3. Health teachings:
a. Cover mouth and nose when coughing or sneezing
b. Properly dispose of soiled tissues and secretions
c. Proper personal hygiene.
Prevention
1. Avoid MOT.
2. Immunization: BCG (Bacille Calmette Guerin):
a. Given anytime after birth : 0.5 cc intradermally at right arm.
*Do not alcoholize injection site because bacilli are slow-growing and may be destroyed by alcohol.
b. Next dose at school entrance
*Wheal formed after vaccination:
a. will appear 2-5 hours after injection
b. nodule may develop in 2-3 weeks
c. will develop slight abscess
d. scarring will ensue.
**This whole process will take place in approximately 12 weeks.
* If abscess persists after 12 weeks:
Apply powdered INH (spread over the injection site).