introduction

TYPES

ROBERT KOCH

KOCHS POSTULATE

KOCH PHENOMENON

Mycobaterium tuberculosis

staining

Mountex test

culture

How the tubercle granuloma is formed?

tubercle granuloma

Histology of tuberculosis lymphadenitis

 Tuberculous lymphadenitis Widespread tuberculosis of the lymph nodes is not uncommon in

many areas. It usually involves the nodes of the neck, or less often those of the axilla, iliac region, or groin, mainly in children and young adults, although no age is exempt. All four triangles of neck may contain matted masses of glands. If these are not treated, abscesses may form and discharge through the skin, to leave sinuses which may become secondarily infected. After many months, these abscesses may heal spontaneously, to cause severe fibrosis and lymphatic obstruction in the leg (31.4), arm, breast (31.4), or vulva (20.14). TUBERCULOUS LYMPHADENITIS. Biopsy a lymph node to confirm the diagnosis. You may find that tuberculous lymphadenitis is so common that you cannot biopsy every suspect node. But remember that biopsy is simple, and needs only local anaesthesia. Give chemotherapy (30.1). Don't excise the enlarged nodes. Don't be alarmed if they enlarge temporarily during chemotherapy, or, rarely, after it, without microbiological relapse. This is due to hypersensitivity to tuberculoprotein. All nodes become smaller in time.

Radiographic findings

Symptoms and clinical features

TUBERCULOSIS OF LUNGS OR PUMONARY TB

TB OF KIDNEY

TB OF SPINE

 The spine is the most common and the most

dangerous site for skeletal tuberculosis. It takes two forms: (1) In the first, the patient's general symptoms are mild. The infection usually starts in the anterior part of a disc, and spreads to the adjacent surface of the body of a vertebra, or to two adjacent ones. It seldom involves his neural arches. The result is that, as the bodies of his vertebrae collapse, his spine angles forwards to produce a kyphus (an increase in the normal convex curve of the spine: a scoliosis is a lateral curvature).

The shape of his spinal deformity depends on how many of his vertebrae are diseased. Commonly, as his deformity gets worse, a sharp angle (the gibbus)appears. Uncommonly,the destruction is not symmetrical, so that his spine rotates. (2) In the second form his general symptoms are more severe, several of his vertebrae are involved widely in his spine (including perhaps some in his neck), and his disc spaces may not be narrowed.

SYMPTOMS
His first symptom is pain in his back, and his first sign

is increasing kyphosis. Later, pus from his diseased vertebrae may track along tissue planes to present as a cold abscess in unexpected places, particularly in his groin (psoas abscess). He may become paraplegic (30.4a). In a child spinal tuberculosis is an important cause of back pain. He will probably be unwell and have lost weight, but not always so. He may resent examination, be tender over his low thoracic or upper lumbar spine, and show any of the signs seen in adults.

TREATMENT

TREATMENT

VACCINES

 CHEMOTHERAPY FOR TUBERCULOSIS ISONIAZID (INH). Daily dose 300 mg, children 10 mg/kg.

Intermittent adult dose 15 mg/kg, with pyridoxine 10 mg per dose to prevent neurotoxicity. THIACETAZONE. Daily dose 150 mg, children 4 mg/kg. STREPTOMYCIN. Daily dose: if a patient is less than 50 kg give him 750 mg daily, if he is more than 50 kg give him 1 g daily if he is under 40, and 750 mg daily if he is over 40; children 20 mg/kg. The disadvantage of streptomycin is that it has to be injected, but in some communities injections are best. RIFAMPICIN. Daily dose: less than 50 kg give the patient 450 mg, more than 50 kg give him 600 mg; children 10 to 20 mg/kg. Intermittent adult dose 600 to 900 mg. PYRAZINAMIDE. Daily dose, less than 50 kg give him 1.5 g, more than 50 kg give him 2.0 g; children 30 mg/kg. Intermittent dose 3 times a week: give him 2.0 g if he is less than 50 kg, and 2.5 g if he is more than 50 kg. Intermittent dose twice a week: give him 3.0 g if he is less than 50 kg, and 3.5 g if he is more than 50 kg. ETHAMBUTOL. Daily dose 25 mg/kg for 2 months, then 15 mg/kg; children as for adults if aged 12 years or more. Intermittent dose three times a week 30 mg; twice a week 45 mg.

REGIMES
(1) Daily throughout. The common regime in India and in East and Central

Africa is daily streptomycin for 60 days at 20 mg/kg. Starting at the same time, give thiacetazone and INH as a compound tablet (Thiazina' or Msozone Forte') for 12 or 18 months. For an adult this contains thiacetazone 150 mg (3 mg/kg) and INH 300 mg (6 mg/kg). It has a 92% success rate in previously untreated casesif he completes the course. The drugs for the entire course cost $30. You may occasionally have to admit him to give him his streptomycin, which will add to the cost, but the cost of 2 months' admission is low compared with the cost of rifampicin. (2) Daily throughout. Two months of daily streptomycin, isoniazid, rifampicin, and pyrazinamide, followed by 6 months of daily isoniazid and thiacetazone. Total duration 8 months, success rate 98%. (3) Partly intermittent. Streptomycin, isoniazid, rifampicin, and pyrazinamide daily for 2 months. Then streptomycin, isoniazid, and pyrazinamide twice a week for 6 months. Total duration 8 months. (4) Intermittent throughout. Streptomycin, isoniazid, rifampicin, and pyrazinamide 3 times a week for 4 months, then isoniazid, rifampicin, and pyrazinamide 3 times a week for 2 months. Total duration 6 months.