TUBERCULOSIS

Cont.
• Tuberculosis is a Chronic necrotizing disease
caused by Mycobacterium tuberculosis complex.
• It usually affects the lungs but almost all organs
can be affected. Thus it is conveniently classified
into:
 Pulmonary TB (PTB): accounts for 80% of all
TB cases.
 Extra-pulmonary TB (EPTB): accounts for 20%
of all TB cases.
 Cont.
Etiology
• The species commonly involved are M.
tuberculosis, M.bovis, M.africanum and M.
microti but of all M.tuberculosis is the
commonest.
• M. tuberculosis is a rod-shaped, non-spore-
forming, thin aerobic bacterium demonstrated
by acid fast staining technique.
 Cont.
Epidemiology
• Tuberculosis is one of the most prevalent diseases
in the world. About one-third of the world’s
population is infected with tuberculosis and thus
at risk of developing active disease (TB).
• It is estimated that 8.4 million people develop
active TB every year and 2.3 million die.
• More than 90 % of TB cases and deaths occur in
developing countries.
 Cont.
• TB has been recognized as major cause of
morbidity and mortality in Ethiopia.
• According to a report from Ministry of health
TB is 3rd leading cause of hospitalization and
1st leading cause of Hospital death.
 Cont.
• Co-infection with HIV significantly increases
the risk of developing Active TB and HIV has
become the most important risk factor to
develop active TB.
• In HIV- infected persons the risk of developing
TB is increased by more than 10 times
compared to those who are HIV negative.
 Cont.
Transmission
• M. tuberculosis is commonly transmitted
through inhalation of droplets excreted via
coughing, sneezing or speaking
• Ingetion of raw milk from M. bovis
 Cont.
Factors that facilitate transmission of pulmonary
TB are;
• Infectivity of the contact (pts with heavy
bacterial load)
• Environment: overcrowding
• Duration of contact (prolonged exposure)
• Intimacy (how close the source and the subject
are)
 Cont.
The presence some disease conditions increase
the risk of developing active TB
• Co-infection with HIV (the commonest)
• Hematologic and other malignancies
• CRF & DM
• Immune suppressive drugs like long-term
steroids
• Malnutrition
 Clinical Manifestations
Cont.
• Early in the course patients may have intermittent
fever, night sweating, weight loss, anorexia &
weakness.
• Most patients have cough, which may be dry at first,
but later becomes productive of whitish sputum; it is
frequently blood streaked.
• Patients may have exertional dyspnea.
• Physical examination may reveal a chronically sick
patient with pallor & clubbing.
• Inspiratory crepitations are seen in some cases.
 TB Symptoms (n=160)
Symptom % with Symptom
Cough 82%
Hemoptysis 30%
Weight Loss 73%
Fever 75%
Chest Pain 54%
Loss of Appetite 61%
Shortness of Breath 42%
Night Sweats 65%
 Cont.
• Laboratory findings may include raised ESR,
anemia or leukocytosis.
• Sputum examination may be positive for AFB.
• Chest x-ray findings are non-specific;
infiltrations, consolidation or cavitory lesions
may be present.
o If untreated, by the end of 5 years;
o 50 % of PTB patients will die,
o 20-25 % will be healthy (self-cured) and,
o 25-30 % will remain ill with chronic infectious
TB.
 Cont.
Extra-pulmonary Tuberculosis: commonly
affected organs are lymph nodes, pleura,
meninges, genitourinary tract, bones, joints &
peritoneum.
– MOST COMMON
• lymphadenitis,
• Pleural TB
• nephritis +/- sterile pyuria,
• osteomyelitis (vertebral Pott’s disease,hip, knee)
– MOST SEVERE
• pericarditis,
• meningitis,
• Disseminated/ Miliary
 Cont.
 1. Lymph-node Tuberculosis (TB
lymphadenitis)
• It is seen more in HIV patients.
• The commonest sites are cervical and
supraclavicular.
• Lymphnodes are typically matted and firm,
sometimes pus may be discharging.
• The diagnosis is made by FNAC or biopsy.
 Cont.
2. Pleural Tuberculosis
• It may be asymptomatic or patients could have
fever, pleuritic chest pain and dyspnea.
• On P/E there will be ↓ed tactile fremitus, dullness
and decreased breath sounds on the affected side.
• Chest x-ray is also helpful in diagnosis; it may
show homogenous opacity with meniscus sign.
• Empyema (pus in the pleural space) may
complicate tuberculosis occasionally.
 Cont.
3. Genitourinary Tuberculosis
• Dysuria, intermittent hematuria and flank pain are
common presentations.
• Urinalysis shows pyuria and hematuria without bacteria
in majority of cases (commonly called sterile pyuria).
• Diagnosis may be reached by culturing urine
repeatedly.
• It affects more females and may present as infertility or
pelvic pain.
 Cont.
4. Skeletal Tuberculosis
• It is usually reactivation of hematogenous site or
extension from a nearby lymph node.
• The most common sites are spine, hips and
knees.
• Spinal TB/Pott's disease/TB spondylitis:- in
adults, lower thoracic and lumbar vertebrae are
commonly affected. Patients may present with
swelling and pain on the back.
 Cont.
• 5 Joint tuberculosis:-
• any joint can be affected but weight bearing
joints; particularly the hip and knee joints are
commonly involved.
• Patients present with progressive joint
swelling, usually with pain and limitation of
movement
 Cont.
6.Tuberculosis Meningitis
• It is commonly seen in children and
immunocompromised people particularly
patients with HIV.
• Patients with TB meningitis present with
headache, behavioral changes & nuchal rigidity
for about two weeks or more.
• Patients may also have cranial nerve palsy and
seizure.
 Cont.
• CSF analysis is the most important modality to
diagnose TB meningitis.
• CSF examination shows increased WBC
count, predominantly lymphocytes, and high
protein and low glucose content.
• .
 Cont.
7. Gastrointestinal Tuberculosis
• Can affect anywhere from the mouth to the anus.
• Bacteria could reach GI by swallowing sputum,
hematogenously or by ingesting raw milk.
• The commonest sites are terminal ileum and caecum.
• Abdominal pain, diarrhea, symptoms of intestinal
obstruction & hematochezia (frank blood on stool) may
be the presenting symptoms.
• There could be associated fever, night sweating, weight
loss & anorexia.
 Cont.
 Tuberculos peritonitis
• Arises from ruptured abdominal lymph node
or hematogenous dissemination.
• Patients usually present with abdominal
swelling & pain, weight loss, fever and night
sweating.
• .
 Cont.
8. TB pericarditis
• It is frequently seen in patients with HIV.
• Patients usually present with fever, retro-
sternal pain, cough, dyspnea and generalized
edema because of pericardial effusion.
• Cardiac tamponade may appear later.
 Cont.
• Diagnosis is usually reached by analyzing the
pericardial effusion which may show
lymphocytosis.
• Chest x-ray may show enlarged heart shadow,
which suggests effusion.
• Ultrasound should be done when available and
it demonstrates effusion.
 Cont.
 Milliary tuberculosis
• This is secondary to hematogenous dissemination of the bacilli.
• It is more common in children and immunocompromised
patients.
• Manifestations are nonspecific with fever, night sweating,
anorexia, weakness, and weight loss.
• Patients may or may not have respiratory symptoms.
• Physical examination findings include seriously sick patient
with hepatomegaly, splenomegaly & lymphadenopathy.
• Chest x-ray usually shows milliary pattern of infiltration
bilaterally.
 Cont.
Work Up
 AFB Microscopy
• AFB is found on microscopy from specimens
like sputum, pleural & peritoneal fluid, CSF
and body discharges, but the yield is different.
 Cont.
 Mycobaterial culture: is the gold standard for
making diagnosis.
 CXR: although any radiographic finding is
possible, typically there will be nodular infiltrates
and cavities in the upper lobe; pleural effusion is
also common. CXR do not confirm Dx of TB.
 ESR: is a very important clue for the diagnosis
when raised even though this is nonspecific.
 Hct: there could also be anemia of chronic illness.
 Cont.
Site of TB (Pulmonary Vs Extra-pulmonary)
• Pulmonary TB (PTB): refers to disease involving
the lung parenchyma.
• Extrapulmonary TB (EPTB): refers to
tuberculosis of organs other than the lungs.
• A patient with both pulmonary and EPTB should
be classified as a case of pulmonary TB.
• Miliary tuberculosis is classified as PTB because
there are lesions in the lungs.
 Cont.
Case definitions
 Tuberculosis suspect: any person who presents with
symptoms or signs suggestive of TB, in particular
cough of long duration (more than 2 weeks)
 Case of tuberculosis: a patient in whom TB has been
bacteriologically confirmed or diagnosed by a
clinician.
 Definite case of tuberculosis: a patient with positive
culture for the M.tuberculosis complex.
 Cont.
• Anti TB drugs are classified in to two groups
 First Line Drugs (Essential Antituberculosis
drugs): There are five drugs in use currently
• Streptomycin (S) in 1gm vial: the only drug given
IM
• Ethambutol (E) 15-25 mg/kg/d
• Isoniazid (INH) 300 mg/d
• Rifampicin (R) 600 mg/day and
• Pyrazinamide (Z) 25 mg/kg/d.
 Four Drug Regimen
• Rifampin 600 mg/d
• Isoniazid (INH) 300 mg/d
• Pyrazinamide (PZA) 25 mg/kg/d
• Ethambutol 15-25 mg/kg/d
• (pyridoxine 25-50 mg/d)
 Cont.
 Second Line Drugs (reserve Anti TB drugs) are used only in
Chronic case of TB
AMINOGLYCOSIDES
• Kanamycin and Amikacin
• Capreomycin (polypeptide)
THIOAMIDES
• Ethionamide
• Protionamide
FLUOROQUINOLONES
• Ofloxacin
• Ciprofloxacin
 Drug resistant TB
• Monoresistance
– resistance to only one drug
• Polyresistance: resistance to at least 2 drugs but not to
both H and R
• MDR: Resistance to at least H and R
• (XDR-TB), in which MDR-TB is compounded
by additional resistance to the most powerful
second-line anti-TB drugs (fluoroquinolones
and at least one of the injectable drugs
amikacin, kanamycin, and capreomycin).
 Definition XDR TB
• MDR + resistance to any fluoroquinolones and
resistance to 1 second-line inject able drug
 Cont.
• Side Effects of common Anti TB
Drugs:
• Anti-tuberculosis drugs cause different side
effects.
Anti TB Drug Severity Side Effects Rx of Side Effects
Isoniazide Minor Peripheral neuropathy Pyridoxine 100 mg
PO daily
Major Jaundice /Hepatitis Stop INH
Rifampicin Minor Orange/red urine Reassurance
Nausea , abd. pain Take drug with meal
Major Hepatitis , ARF Stop Rifampcin
shock , purpura
Ethambutol Minor None

Major Optic neuritis : Visual Stop Ethambutol

impairment
Streptomycin Minor Mild skin rash Symptomatic
Perioral parasthesia treatment
Major Ototoxicity Stop Streptomycin
Pyrazinamide Minor Joint pain Analgesics like
Aspirin
Major Hepatotoxicity Stop Pyrazinamide
 Cont.
• Important points to consider in the treatment of tuberculosis:
• Streptomycin should not be given to pregnant woman, and
patients with renal failure and ear problems. It should be
replaced by Ethambutol.
• Children who are 6 years or below should not be given
Ethambutol because of damage to the eyes and children may
not complain of it.
• Patients should be strictly followed after initiation of the drugs.
• Corticosteroids are added to the anti-TB in TB meningitis,
pericarditis, and spinal TB. Adrenal TB patients should have
replacement therapy.
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