Pulmonary Tuberculosis

PGI OLIVE G. BRAVO

Table of contents

01 Introduction 04 Treatment

02 Clinical Manifestation 05 Prevention

03 Diagnostics
01 Introduction
Etiology
Mycobacterium tuberculosis complex:
● M. tuberculosis
● M. bovis
● M. africanum
● M. microti
● M. canetti
Transmission
● Inhalation of airborne mucus droplet
nuclei, particles 1-5 um in diameter that
contain M. tuberculosis.
● Chance of transmission is increased when:
○ (+) AFB
○ Extensive upper lobe infiltrate or
cavity
○ Copious production of thin sputum
○ Severe and forceful cough
○ Poor air circulation
 Epidemiology
● Pulmonary TB is the leading cause of death from
infectious disease worldwide since 2015, 95% occur in
the developing worlds.
● In the Philippines, TB has remained to be one of the
most common causes of death among Filipinos.
According to WHO, 32% of the 1.8 million people to
have developed TB in the western pacific region are
from the Philippines.
● The Philippines has one of the highest TB incidence
rates in the Region, estimated at 554 cases per
100,000 in 2016, a rate that has not declined
significantly since 2007.
● Overall, 27.3% of TB notifications for the Philippines
in 2016 pertained to children, adolescents, and young
adults aged 0-24 years.
● Treatment outcomes were favorable, with 81% of
patients being cured or completing treatment.
 Clinical Stages
Exposure
● Significant contact with an
adult or adolescent with
infectious tuberculosis but
lacks proof of infection.
● TST or IGRA: negative
● Chest radiograph, PE:
Normal
Infection
● An individual inhales droplet nuclei
containing M. tuberculosis, which
​ survive intracellularly within the lung
and associated lymphoid tissue.
● Hallmark: Positive TST or IGRA
● Chest radiograph: either normal or
reveals only granuloma or
calcifications.
Disease
● Occurs when signs or symptoms or
radiographic manifestations caused
by M. tuberculosis become
apparent.
● An infected child <1 year old has
a 40% chance of developing TB
disease within 9 months.
Pathogenesis
02 Clinical Manifestations
Clinical Manifestations
Primary Complex
● Includes the parenchymal pulmonary focus and the regional
lymph nodes.
● Hallmark: relatively large size of the regional lymphadenitis
compared with small size of the initial lung focus.
● As delayed-type hypersensitivity develops, the hilar lymph
nodes continue to enlarge in some children, especially infants,
compressing the regional bronchus and causing obstruction.
● Sequence: hilar lymphadenopathy, focal hyperinflation, and
then atelectasis.
● Most cases of tuberculous bronchial obstruction in children
resolve fully with appropriate treatment.
● Up to 50% od infants and children with radiographically
moderate to severe PTB have no physical findings.
● Symptoms: Nonproductive cough, mild dyspnea, fever, night
sweats, anorexia, decreased activity, difficulty gaining weight,
true failure-to-thrive syndrome
Clinical Manifestations
Progressive Primary
Pulmonary Disease Pleural Effusion
● Primary focus enlarges steadily and develops a large ● Originate in the discharge of bacilli into the
caseous center. pleural space from a subpleural pulmonary
● This enlarging focus can slough necrotic debris into the focus or caseated lymph nodes.
adjacent bronchus, leading to further intrapulmonary ● Onset is sudden, characterized by low to high
dissemination.
fever, SOB, chest pain on deep inspiration,
● Symptoms: High fever, severe cough with sputum
and diminished breath sounds.
production, weight loss, and night sweats.
● Signs: Diminished breath sounds, rales, dullness or
egophony over the cavity.
Pericardial Disease
● Pericarditis is the most common form.
● Rare, occurring in 0.5-4% of cases.
Reactivation Tuberculosis ● Arises from direct invasion or lymphatic
● Other children and adolescents with reactivation TB drainage from subcarinal lymph nodes.
are more likely to experience fever, anorexia, ● Pericardial friction rub with pulsus paradoxus
malaise, weight loss, night sweats, productive may be present.
cough, hemoptysis, and chest pain.
● PE findings are usually minor or absent, even in the
presence of cavities or large infiltrates.
Clinical Manifestations
Lymphohematogenous Upper Respiratory Tract
(Disseminated) Disease Disease
● Asymptomatic ● Laryngeal tuberculosis - croup-like cough,
● Clinical picture depends on the burden of organisms sore throat, hoarseness, and dysphagia.
releases from the primary focus to distant sites and ● Tuberculosis of Middle Ear - results from
adequacy of the host’s immune response. aspiration of pulmonary secretions into the
● Multiple organ involvement is common leading to
middle ear. Signs and symptoms include
hepatomegaly, splenomegaly, lymphadenitis in
painless unilateral otorrhea, tinnitus,
superficial or deep nodes, and papulonecrotic tuberculids
on the skin. decreased hearing, facial paralysis, and
● Miliary Disease - massive numbers of tubercle bacilli are perforated tympanic membrane.
released into bloodstream, causing disease in 2 or more
organs.
● The onset id often insidious, with early systemic signs
like anorexia, low-grade fever, and weight loss.
Generalized lymphadenopathy and hepatosplenomegaly
develop within several weeks.
● Cutaneous Lesions - Papulonecrotic tuberculids,
nodules, or purpura
Clinical Manifestations
Lymph Node Disease
● Scrofula - most common form of extrapulmonary TB in
children.
- Tonsillar, anterior cervical, submandibular, and
supraclavicular nodes become involved
- Most often unilateral, but bilateral involvement can
occur.
- They are discrete, nontender, and firm but not hard.
- TST is usually reactive
● Tuberculous Lymphadenitis - diagnosed by fine-needle
aspiration and responds well to anti-tuberculosis therapy,
although the lymph nodes do not return to normal size for
months-years.
- Third: coma, hemi or paraplegia, hypertension,
decerebrate posturing, deterioration od VS and death.
CNS Disease
● Most serious complication in children.
● Tuberculous meningitis - Arises from the
formation of a metastatic caseous lesion in the
cerebral cortex or meninges that develops during
the lymphohematogenous dissemination of the
primary infection.
● Most common in children 6-14 years old.
● Stages:
- First Stage : nonspecific symptoms like fever,
headache, irritability, drowsiness, and malaise.
Focal neurologic signs are absent, but may
experience loss of developmental milestone.
- Second Stage: lethargy, nuchal rigidity, seizure,
positive kernig and brudzinski signs, hypertonia,
vomiting, cranial nerve palsies.
- Hydrocephalus, increased ICP, and
vasculitis
 Clinical Manifestations
Bone and Joint Disease
CNS Disease ● Pott Disease - destruction of the vertebral bodies
● Tuberculoma - tumor-like mass resulting from leads to gibbus deformity and kyphosis
aggregation of caseous tubercles that usually manifests
clinically as brain tumor.
● In children, they are often supratentorial, located at the
base of the brain near the cerebellum.
● Most common symptoms: headache, fever, focal
neurologic symptoms, and convulsions.

Abdominal and GI Disease

● Tuberculous tuberculosis- uncommon in adolescents and rare
in children.
- Arise from subclinical or miliary hematogenous
dissemination caused by direct extension from an
abdominal lymph node.
● Tuberculous enteritis - typical indians include shallow ulcers
that cause pain, diarrhea or constipation, weight loss, low-grade
fever.
- Most common site: jejunum and ileum near peyer’s
patches and appendix
03 Diagnostics
DIAGNOSTIC TOOLS
Tuberculin Skin CT scan
Culture
Testing (TST)
● Intradermal injection of
0.1 mL PPD stabilized Nucleic acid Amplification
with tween 80.
Test
● PCR
Interferon-y Release ● Gene Xpert MTB/RIF
Assay (IGRA)
● T-SPOT.TB abd
QuantiFERON-TB: detect Chest X-ray
ifn-y generation by the
patient’s T cells in response
to M. tuberculosis antigen
 Identification of Presumptive TB
For 15 y/o and above:
1. Cough of at least 2 weeks duration with or
without the following symptoms:
- Significant and unintentional weight
loss;
- Fever;
- -
Bloody sputum (hemoptysis);
- Chest/back pains not referable to any
musculoskeletal disorders;
- Easy fatigability or malaise;
- -
Night sweats; and,
- Shortness of breath or DOB
1. Unexplained cough of any duration in:
- A known contact of active TB case
- High-risk clinical groups
- High-risk populations
For below 15 years old:
1. At least three (3) of the following clinical criteria:
- Coughing/wheezing of 2 weeks or more, especially if
unexplained;
- Unexplained fever of 2 weeks or more after common
causes such as malaria or pneumonia have been excluded;
Loss of weight/failure to gain weight/weight faltering/loss
of appetite;
- Failure to respond to 2 weeks of appropriate antibiotic
therapy for lower respiratory tract infection;
Failure to regain previous state of health 2 weeks after a
viral infection or exanthema (e.g., measles); and,
- Fatigue, reduced playfulness, or lethargy (e.g., child has
lost his/her normal energy).
1. Anyone of the above symptoms in a child with a close contact to
an active TB case.
04 Treatment
Intrathoracic TB

● As recommended by WHO & AAP, the standard therapy for intrathoracic TB in children is a 6
month regimen of isoniazid and rifampin supplemented in the first 2 months of treatment by
pyrazinamide and ethambutol. (2 months HRZE + 4 months HR)
● 9 month of only isoniazid and rifampin are also effective for drug-susceptible tuberculosis.
● When DOT is used, intermittent (twice or thrice weekly) administration of drugs after an initial
period as short as 2 weeks of daily is as effective for drug-susceptible tuberculosis in children as
daily therapy for the entire course.
Extrapulmonary TB

● In general, the treatment for most forms of extrapulmonary TB in children including cervical
lymphadenopathy is the same as for pulmonary TB.
● Exceptions: Bone and Joint, Disseminated TB, and CNS tuberculosis
- Treated for 9-2 months
TB in HIV-infected children

● Most experts believe that HIV-infected children with drug-sesceptible tuberculosis should receive
the standard 4-drug regimen for the first 2 months followed by isoniazid and rifampin, for a total
duration of at least 9 months. However, all treatment shoukd be daily, not intermittent.
Drug-Resistant Tuberculosis
● Primary resistance - occurs when a person is infected with M. tuberculosis that is already
resistant to a particular drug
● Secondary resistance - occurs when drug-resistant organisms emerge as the dominant population
during treatment.
● Treatment of drug-resistant TB is successful only when at least 2 bactericidal drugs are given.
● Isoniazid-resistant TB: 9-month rifampin, pyrazinamide, and ethambutol therapy
● Isoniazid and Rifampin resistant TB: the total duration of therapy is extended to 12-24 months
and intermittent regimens should not be used.
● Second-line treatment for MDR-TB:
- Delamanid
- Bedaquilin
- Linezolid
- Clofazimine
Corticosteroids
● Prednisone 1-2mg/kg/day in 1-2 divided doses for 4-6 weeks, then taper.
● Most beneficial when the host inflammatory reaction contributes significantly to tissue damage or
impairment of organ function.
● Reduce mortality rates and long-term neurologic sequelae in tuberculous meningitis by reducing
vasculitis, inflammation, and intracranial pressure.
● Also effective in endobronchial tuberculosis that causes respiratory distress, localized
emphysema, or segmental pulmonary lesions.
Supportive Care
● Promoting adherence to therapy
● Monitoring for toxic reactions to medications.
● Adequate nutrition
Mycobacterium tuberculosis Infection
● Main TBI treatment regimen:
- 6-9 months of isoniazid (daily or twice daily by DOT)
- 3 months of daily rifampin and isoniazid
- 4-6 months of daily rifampin
- Once-weekly isoniazid and rifapentine for total of 12 doses
● Window prophylaxis - starting isoniazid to children <5 y/o who have negative TST or IGRA
result but who have a known recent exposure to an adult with potentially contagious TB disease.
05 Prevention
● Case finding and treatment - interrupts transmission of infection
between close contacts.
● All children and adults with symptoms suggestive of TB and those
in close contact with an adult with suspected infectious pulmonary
TB should be tested for TBI.
● BCG Vaccination
 Thanks
References:
1. Nelson’s Textbook of Pediatrics 21st edition
2. National Tuberculosis control program Manual
of Procedures 5th edition

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