Tuberculosis

Pathophysiology and diagnosis

Dr. Aditya Jindal

Interventional Pulmonologist & Intensivist
Jindal Clinics
SCO 21, Sec 20D, Chandigarh
DM Pulmonary and Critical Care Medicine (PGI Chandigarh),
FCCP
Course of TB infection
 Types of TB
• Primary tuberculosis
– is a form of disease that develops in a previously unexposed and therefore
unsensitized person

• Secondary tuberculosis
– is the pattern of disease that arises in previously sensitized or infected host.
 Primary TB
• Infection of an individual who has not been previously infected or immunized.

• The inhaled bacilli implant in the distal airspaces of lower part of upper lobe or
upper part of lower lobe close to the pleura

• As sensitization develops, a gray-white inflammatory consolidation is formed

Ghon focus
 Sites of Primary TB
• Most common - Lungs

• Other sites: Tonsils, adenoids

Site of BCG vaccination
GIT – ileum, colon etc
GUT
 Ghon’s complex
• Consists of 2 components

– Pulmonary component
• lesion in the lung (Ghon focus or primary focus)
• 1-2cm solitary area located peripherally in the subpleural focus in the lower part of upper
lobe or upper part of lower lobe
• Micro: the lung lesion show tuberculous granuloma with caseous necrosis

– Lymphatic component
• lymphatics draining lung lesion containing phagocytes with M. tuberculosis bacilli
Ghon complex
 Fate of Primary complex

• Heal by fibrosis calcification

• Progressive primary tuberculosis

• Primary miliary tuberculosis

 Secondary TB
• The infection of an individual who has been previously infected or
sensitized

• The infection may be acquired from

– Endogenous source  reactivation of dormant primary complex
– Exogenous source
 Pathological lesions of Secondary TB

• The initial lesion is a small focus of consolidation of <2cm in diameter

within 1 to 2cm of apical pleura

• Gross: sharply circumscribed, firm, gray white to yellow with variable

amount of central caseation necrosis

• Micro: coalescent tuberculous granulomas with central caseation

necrosis.
 Fate of secondary TB
• The lesion may heal with fibrous scarring and calcification

• Fibrocaseous tuberculosis (progressive pulmonary TB )

• Tuberculous caseous pneumonia

• Miliary tuberculosis
 Pathology of TB
Granuloma formation is the hall-mark of pathology of TB

Granuloma is a:
i. Rounded tight collection of chronic inflammatory cells
ii. Central Caseous necrosis
iii. Active macrophages - epithelioid cells
iv. Outer layer of lymphocytes & fibroblasts
v. Langhans giant cells – joined epithelioid cells
TB Pathology
• Bacterial entry
• T Lymphocytes.
• Macrophages.
• Epithelioid cells.
• Proliferation.
• Central Necrosis.
• Giant cell formation.
• Fibrosis.
Granuloma Histopathology
Caseation necrosis
 Causes of granuloma formation
• Tuberculosis
• Other mycobacterial infections, Leprosy
• Bacterial infections: Brucellosis
• Other infections: Fungal, viral, protozoal
• Non-infectious causes
- Sarcoidosis
- Foreign bodies
- Lymphomas
 Miliary TB
• Occurs when organisms drain through lymphatics into lymphatic ducts
venous return on the right side of heart pulmonary arteries

• Individual lesions are either microscopic or small, visible (2mm) foci of yellow-
white consolidation scattered through the lung parenchyma (resembling millet
seeds)

• Micro: the lesion shows structure of granuloma with minute areas of caseous
necrosis.
Miliary TB
Course of TB infection
Tuberculosis

Diagnosis
• Clinical Features
• Sputum Examination
• Chest Radiology
• Bronchoscopy
• Mantoux test
• Indirect laboratory tests
 Clinical Symptoms

1. Prolonged fever, malaise, weakness, wt. loss etc.

2. Pulmonary: Cough, sputum, haemoptysis – persistent

3. Lymphadenopathy, organ enlargement, others

• Clinical Features

• Sputum Examination

• Mantoux test

• Chest Radiology

• Bronchoscopy

• Indirect laboratory tests

 Sputum examination

• Smear examination (Sputum, other secretions)

• Auramine- Rhodamine staining

• Culture of material/ tissues

 Myco-bacteria
Myco (fungus like) Bacterium (bacteria)

Ability to resist decolourization by a weak mineral acid after staining with an aryl-
methane dyes (acid-fastness)

Slender, straight or slightly curved, rod shaped

Length 2-4 u, Breadth 0.2-0.8 u
Occur singly, in pairs or small groups
Long, filamentous, club-shaped (rarely branching)
 MYCOBACTERIAL DEMONSTRATION

1. Smear: Easiest, quickest

Requires > 10000 AFB/ml
Sensitivity 50-60%; Specificity: High

2. Culture: More sensitive; 10 AFB/ml

Traditional 6-8 wks
Septi Chek: Biphasic; High yield
Radiometric: BACTEC

3. Others:
Animal pathogenicity
Antimicrobial sensitivity
M tb in sputum smear
• Rapid culture methods

– BACTEC system
– MycobactGrowth Indicator Tube(MGIT)

– MB/BacT system
– Septi-chek
– ESP culture system
– Microscopic observation of broth/slide cultures
M tb Colonies on culture
(LJ medium)
• BACTEC System

– Radiometric method

– 14C labelled palmitic acid added to liquid 7H12 medium

– Detects MTB by metabolism rather than growth

– 14CO2 produced detected

– Growth index(GI) measured

– Results available in 7-14 days (87-96%)

• MGIT

– Automated system

– Capable of analyzing 960 specimens

– Metabolism of MTB produces O2

– Fluorescence of dye with oxygen measured

– Results available in 7-14 days

– Cost effective for high load micro labs

• Clinical Features
• Sputum Examination
• Chest Radiology
• Bronchoscopy
• Mantoux test
• Indirect laboratory tests
 Chest radiology

I. Chest: Upper Lobes/Diffuse miliary

Infiltrates/Exudates/Fibrosis
Multiple, thin walled cavities
Lymphadenopathy, Pl.effusion

II. Others: Enlargement of organs

Erosions/Effusions
Caseations/collections
 Role of Chest X-ray
 No chest X-ray pattern is absolutely typical of TB

 10-15% of culture-positive TB patients not diagnosed by X-ray

 40% of patients diagnosed as having TB on the basis of x-ray alone do not have
active TB

 X-ray is unreliable for diagnosing and monitoring treatment of

tuberculosis
• Clinical Features
• Sputum Examination
• Chest Radiology
• Bronchoscopy
• Mantoux test
• Indirect laboratory tests
 Role of bronchoscopy

• Valuable in early diagnosis of strongly suspected sputum-negative TB

• Diagnosis of endobronchial TB/miliary TB

• TBLB yield is greater (82%) than BAL (26%)

• TBNA has a role in mediastinal lymph nodal tuberculosis with negative

sputum smears
 ESR?

NO ROLE IN DIAGNOSIS
• Clinical Features
• Sputum Examination
• Chest Radiology
• Bronchoscopy
• Mantoux test
• Indirect laboratory tests
 Tuberculin (Mantoux) Test
• Infection with mycobacterium tuberculosis leads to delayed hypersensitivity
reaction which can be detected by Mantoux test

• About 2 to 4 weeks after infection

• Intracutaneous injection of purified protein derivative (PPD) of M.tuberculosis

• Induces a visible and palpable induration that peaks in 48 to 72 hours

 How to do the test?
• Sub cutaneous
• Weal formation
• Itching – no scratch
• Read after 72 hours
• Induration size.
• 5-10-15mm
Positive test
 Interpretation

• Induration less than 5 mm –> no exposure to tubercular bacilli

• Induration between 5-9 mm –> this can be due to atypical mycobacteria or BCG
vaccination. It may suggest infection in immunocompromised children such as HIV
infection or other immunosuppression

• Induation 10 mm or more –> in a child with symptoms of tuberculosis should be

interpreted as tubercular disease
 Clinical significance

• Denotes infection

• Does not differentiate infection from active disease

• A strongly positive Mantoux can support a clinical diagnosis

• Better negative than positive predictive value

• Cut-off for a positive test?

• Clinical Features

• Sputum Examination

• Chest Radiology

• Bronchoscopy

• Mantoux test

• Indirect laboratory tests

 Indirect Tests
1. Biochemical tests
1. LDH, Proteins
2. Adenosine Deaminase
3. Bromide Partition Test
4. Gas Chromatography – Fatty acids, alcohols etc

2. Immuno-diagnosis tests
1. Skin test (Mantoux)
2. Detection of Antibodies (Tests banned)

3. Genetic/ molecular studies

1. Antigen detection
2. Lipo arabinomannan
3. Nucleic Acid Probes
4. Ligase Chain Reaction
5. Polymerase Chain Reaction
6. Gene Xpert
 Serological Tests
• Low turn around time

• Limitation

– Low sensitivity in
smear negative patients
HIV positive cases,
In disease -endemic countries with a high infection rate

– Poor standardization

Banned in 2012.
• Interferon-γ release assays

– An alternative to the TST in the form of a new type of in-vitro T-cell-based

assay
(Test-tube TST)
Gold IGRA
Elispot T test

– T cells of individuals sensitized with tuberculosis antigens produce interferon-γ

when they re-encounter mycobacterial antigens

– High level of interferon-γ production - presumptive of tuberculosis infection

• IGRA in LTBI

– In the absence of a gold standard for diagnosis of Latent TBI, the sensitivity and
specificity cannot be directly estimated

– IGRA have higher specificity than TST

– Better correlation with surrogate markers of exposure to M tuberculosis (in low-

incidence setting countries)

– Less cross reactivity as a result of BCG vaccination than TST

• PCR

– Synthesis of dsDNA by hybridization of oligonucleotides to targets s-DNA

– Uses thermal cycler to denature the target DNA

– Thermostable polymerase for DNA amplification

– Repeated cycles by varying temp for primer annealing (70-72 C) and

denaturation (94-96 C)

– Amplified product are then detected by southern blotting and

fluorescent/radiolabelled probes hybridization
• Gene X-pert Test

– Detection and identification of mycobacteria

directly from clinical samples

– Uses real‐time polymerase‐chain reaction (PCR) assay to amplify an MTB‐specific sequence of

the rpoB gene

– Cartridge based, PCR test for detection of mycobacteria and Rifampicin resistance

– Rapid test. Results within hours.

– Costly

– Continuous electric supply and temperature maintenance

– ? Field feasibility, sensitivity and specificity in India

• Integrates sample processing and PCR

• Reagents required for bacterial lysis, nucleic acid extraction, amplification and
amplicon detection are present in a disposable plastic cartridge

• Only manual step ‐‐ addition of a bactericidal buffer to sputum before transferring a

defined volume to the cartridge

• MTB/RIF cartridge is then inserted into the GeneXpert device

• Results within 2 hours

 Diagnosis of Extra Pulmonary TB
• Sputum or other smears are often Negative

• These are difficult to use for diagnosis and start of treatment

Follow up
Monitoring
End point
Recurrence / Relapse

• Mostly clinico-radio-histo/cytological

• Invasive procedures frequently required to obtain tissue, fluids, etc. to look for
T.b. and/or histo-cytological criteria.
 Difficulties of specimens testing for EPTB

• Specimen
– Relevance of a particular sample

• Method of collection
– Contamination/ inappropriate site

• Processing
– Technique, Standardization and calibration of Instrument/procedure

• Clinical interpretation
– Disease ?
 How to confirm the Diagnosis?
LEVELS OF DIAGNOSIS OF TB

I. Suggestive
Clinical/Epidemiological
Radiological

II. Presumptive/Possible
Therapeutic response
Immunological
Markers

III. Definitive
Demonstration of Myco tuberculosis (smear/ culture)
Histo/Cytological criteria
 EPT: DIAGNOSIS
Site Empirical/ Suggestive Possible Definitive

1 Lymph Nodes Clinical FNAC AFB on FNAC

(Granuloma)
2. Pl. Effusion Clinico-radiological A.D.A. Pl. biopsy
Exudative AFB positivity
P.C.R.
3. Pericarditis As above As above As above
4. Peritoneal As above As above As above
5. Intestinal Clinical Biopsy AFB positivity
Radiological Granuloma
6. Genitourinary Endoscopy Biopsy AFB positivity
As above Granuloma
7. Bones & Joints Clinical FNAC As above
Radiology Biopsy
8. Meningeal As above CSF (Biochem.) CSF – PCR
AFB
 Comparison of Various Diagnostic Tests for Diagnosis of TB
Microscopy LED GeneXpert LAMP Solid Liquid Culture
Microscopy MTB/RIF Culture

Threshold 10,000 - 131 (106-176) - ~100 10-50

(CFU/ml)

Turnaround 1-2 days 1day 90 min - 4-8 week Days - 2 week

time
Sensitivity 50-60 % 10% >than ZN ~90 % 88 % Reference Reference
staining

Specificity 98% 94 % Reference Reference

Technical Required Required Minimal Required Required Required

expertise
Biosafety Better than
Microscopy
Other Prone to
contamination

- Boehme CC et al. Semin Respir Crit Care Med 2013;34:17 – 31.

- Lawn SD et al. Lancet Infect Dis 2013; 13: 349–61.
Absence of evidence is not the evidence of absence

Carl Sagan
THANK YOU