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Pulmonary Tuberculosis

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ptb diagnosis, management and updates.

ptb diagnosis, management and updates.

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  • 1. Pulmonary Tuberculosis http://crisbertcualteros.page.tl
  • 2. Pulmonary Tuberculosis
    • Etiology:
    • 1.1 Mycobacterium tuberculosis
    • 1.2 Mycobacterium bovis , rarely
  • 3. Epidemiology
    • Philippine Statistics: FHSIS –DOH 2001
    • Respiratory TB, 6 th leading cause of morbidity with 110,841 cases and rate of 142.2/100,000 population
    • TB meningitis with 466 cases or rate of 0.6/100,000 population
    • Other forms of TB, 11,494 cases with a rate of 14.7/100,000 population
  • 4. Epidemiology
    • Source:
    • Usually sputum form an infected adult; occasionally exudate from draining sinuses and urine
    • Mode of transmission:
    • Inhalation of droplet nuclei as a rule
    • Occasionally, by ingestion of contaminated milk (M. bovis)
    • Direct contamination of open wounds (pathologist
    • and lab personnel)
  • 5. Epidemiology
    • Period of communicability:
    • Only if associated with open lesions of PTB, draining sinuses or renal involvement; as long as tubercle bacilli are found in sputum, exudate or urine, respectively
    • Children with active PTB are rarely contagious because of the nature of pulmonary lesion, the low baterial output and because sputum is often swallowed.
    • A patient is non-infectious within 2-4 weeks of starting adequate therapy
  • 6. Risk Factors
    • Age: infants and adolescents are at highest risk of disease
    • Close contact with an untreated sputum positive patient
    • Impaired host defenses: immunodeficiency states, particularly that associated with HIV infection; immunosuppression related to accompanying viral infection, or drug induced; malnutrition.
    • Other disease staes: Hodgkin’s lymphomas, diabetes mellitus, leukemia, malignancy (head and neck) severe kidney disease, silicosis, prolonged treatment with corticosteroids
  • 7. Risk Factors
    • 5. Persons whose tuberculin skin test results converted to (+) in the past 1-2 years
    • 6. Persons who have CXR suggestive of old TB
  • 8. Portal of Entry
    • Usually respiratory tract (inhalation of aerosolized particles containing 1-3 tubercle bacilli); rarely, skin, gastrointestinaltract, mucous membrane, transplacentally from mother to fetus or via infected amniotic fluid
  • 9. Incubation Period
    • From 3 to 8 weeks
  • 10. CLASSIFICATION
    • Class I (TB exposure)
        • (+) exposure
        • (-) Mantoux tuberculin test
        • (-) signs and symptoms suggestive of TB
        • (-) chest radiograph
  • 11. CLASSIFICATION
    • Class II (TB infection)
        • (±) exposure
        • (+) Mantoux tuberculin test
        • (-) signs and symptoms suggestive of TB
        • (-) chest radiograph
  • 12. CLASSIFICATION
    • Class III (TB disease)
      • Has three or more of the ff. criteria
        • (+) history of exposure to an adult/adolescent with active TB disease
        • (+) Mantoux tuberculin test
        • (+) signs and symptoms suggestive of TB
          • Cough/wheezing > 2 weeks; fever > 2 weeks
          • Painless cervical and/or other lymphadenopathy
          • Poor weight gain; failure to make a quick return to normal after an infection (measles, tonsillitis, whooping cough) or failure to respond to approriate antibiotic therapy (pneumonia, otitis media)
        • Abnormal Chest radiograph
        • Laboratory findings suggestive of TB (histological, cytological, biochemical, immunological or molecular)
  • 13. CLASSIFICATION
    • Class IV (TB inactive)
      • A child/adolescent with or without history of previous TB and any of the ff:
        • (±) previous chemotherapy
        • (+) radiographic evidence of healed/calcified TB
        • (+) Mantoux tuberculin test
        • (-) signs and symptoms suggestive of TB
        • (-) smear/culture for M. tuberculosis
  • 14. Clinical Forms of Tuberculosis
    • Pulmonary/endothoracic
      • Asymptomatic or Latent TB infection
      • Primary TB/primary complex
        • Primary focus, lymphangitis and regional lymphadenitis
        • Most common clinical symptoms
          • Non-productive cough
          • Mild dyspnea
          • Cervical lymphadenopathies
  • 15. Clinical Forms of Tuberculosis
      • Pleurisy with effusion
        • Accompanies primary focus
        • Considered a component of the primary complex
        • Onset is usually abrupt
        • Fever, chest pain, shortness of breath
        • Dullness to flatness and diminished breath sounds
        • Obliteration of costophrenic sulcus on CXR (minimal)
        • Layering of fluid density (moderate effusion)
        • Occupy one hemithorax (massive effusion)
  • 16. Clinical Forms of Tuberculosis
      • Progressive primary tuberculosis
        • More severe fever, malaise, cough, weight loss
        • Classical signs of cavitation
        • Crepitant rales, diminished breath sounds, lymphadenopathy
      • Endobronchial TB
        • Bronchial obstruction due to enlargement of peribronchial lymph nodes
          • Sudden death by asphyxia
          • Emphysema
          • Atelectasis
  • 17. Clinical Forms of Tuberculosis
      • Miliary TB
        • Generalized hematogenous tuberculosis due to massive invasion of the blood stream by the tubercle bacilli
        • Arises from a discharge of a caseous focus often from a lymph node into the blood vessel (pulmonary vein)
        • High fever, cough, dyspnea
        • Crepitant rales, splenomagly, hepatomegaly, signs of menigeal irritation
  • 18. Clinical Forms of Tuberculosis
      • Chronic TB
        • Reinfection or adult TB
        • Apical or infraclavicular infiltrates often with cavitation and no hilar lymphadenopathy
        • Persistent cough, prlonged fever, chest pain, hemoptysis and supraclavicular adenitis
      • Tuberculoma
      • Pericardial TB
  • 19. Clinical Forms of Tuberculosis
    • Extrapulmonary TB
      • TB of the cervical lymph nodes/Scrofula
        • Involved LN are painless, firm, discrete, movable becoming adherent to each other and anchored to the surrounding tissues and skin as they enlarge
        • Scofuloderma (when left untreated and ruptures resulting in a draining sinus tract
      • TB of the CNS
        • TB meningitis
        • TB abscess
  • 20. Clinical Forms of Tuberculosis
      • Skeletal TB
        • TB of the bones and joints
        • TB of the spine or Pott’s
      • GI TB
        • TB enteritis
        • TB peritonitis
        • Hepatobiliary TB
        • TB of the pancreas
      • Cutaneous TB
      • Ocular TB
      • GUT TB
      • TB of the Middle Ear
  • 21. Diagnostic Tests
    • Mantoux Testing/Tuberculin skin test
      • Most widely used method to determine latent TB infection
      • Standard method for screening
      • positive if ≥ 8 mm induration size
      • A dose of 0.1 ml of 2-TU PPD-RT23 or 0.1 ml of 5-TU PPD-S
      • Provides a general measure of a person’s cellular response
  • 22. Diagnostic Tests
    • Mantoux Testing/Tuberculin skin test
      • Features of reaction
        • Delayed course reaching a peak of more than 24h after injection of antigen
        • Indurated character
        • Occasional vesiculation and necrosis
    • A pale wheal of 6 to 10mm in diameter should be evident after injection
    • Read within 48-72hrs from the time of administration
  • 23. Diagnostic Tests
    • Mantoux Testing/Tuberculin skin test
      • False positive
        • Nontuberculous mycobacteria
        • BCG vaccination
          • Reaction develops 6-12 weeks after vaccination
          • Wanes after 5 years from immunization
      • False negative
        • Anergy
        • Very young age (< 6 months)
        • Recent TB infection or overwhelming TB disease
        • Live-virus vaccination
          • postpone for at least 4 – 6 weeks after immunization or do it on the same day of vaccination
  • 24. Diagnostic Tests
    • AFB smears (microscopic examination)
      • Provides presumptive diagnosis of active TB
      • Gives a quantitative estimation of the number of bacilli on the smear
      • Implies infectiousness of the patient
      • Low sensitivity (51.8 – 53.1%)
      • High specificity (97.5 – 99.8%)
      • 10 4 bacilli per ml of sputum : lowest concentration that can be detected
  • 25. Diagnostic Tests
    • Culture : gold std.
      • Solid media: 4-6 weeks for isolation and another 2-4 weeks for susceptibility testing
        • Middlebrook 7H-11 7H-10 (agar-based)
        • Lowenstein-Jensen (egg-based)
      • Liquid media
        • Bactec : as few as 7 to 10 days; carbon-14 (marker of bacterial growth)
        • Middlebrook broth
        • Septi-check AFB
        • BBL mycobacteria growth incubator tube
  • 26. Diagnostic Tests
    • Specimens collected for demonstration of tubercle bacilli
      • Sputum
        • for older children able to expectorate
        • Series of three early morning specimens on different days before starting chemotherapy
        • Make sure brought up from the lungs
  • 27. Diagnostic Tests
    • Specimens collected for demonstration of tubercle bacilli
      • Gastric aspirate
        • For infants and children who cannot expectorate even with aerosol inhalation
        • 5-10 ml of gastric contents aspirated early in the morning after the person has fasted for at least 8 – 10 hours preferably before the child arises and peristalsis empties the stomach of respiratory secretions swallowed overnight
  • 28. Diagnostic Tests
    • Specimens collected for demonstration of tubercle bacilli
        • Bronchial washings
        • Urine
          • First morning-voided midstream specimen
        • Other body fluids and tissues
          • Bone marrow, lung and liver biopsy in patients with hematogenous spread/disseminated disease must be considered
  • 29. Diagnostic Tests
    • Radiographic Findings
      • No pathognomonic findings in childhood TB
      • Lateral projections are important wherein partially calcified mediastinal nodes may be visible
      • Most common cause of calcification in children
      • Uniform stippling of both lungs found in miliary tuberculosis
      • Lobar or lobular consolidations
      • Common findings: Enlarged retrocardiac lymphadenopathy (70%), hilar adenopathy with pulmonary infiltrates (20%), and pleural effusion
  • 30. Initial Empiric Therapy of Tuberculosis in Infants, Children and Adolescents Immediately prophylaxis controversial for those 5 years, but is recommended by some experts specially if with risk factors e.g. malnutrition, immunocom-promised states 3 months INH
    • Class I TB Exposure
    • <5 years
    • 5 years
    Remarks Regimen Category
  • 31. Initial Empiric Therapy of Tuberculosis in Infants, Children and Adolescents
    • Corticosteroids (usually prednisone at 1 mkday for 6-8 weeks with gradual tapering) beneficial for the following: meningitis, pericarditis, pleuritis, endobronchial TB, miliary TB
    2 months HRZ + E or S ffd by 10 months HR ± E/S given once daily or as DOT 3x weekly Same regimen as pulmonary disease
    • Extrapulmonary
    • Severe, life-threatening disease: disseminated/ miliary, meningitis, bone/joint disease
    • Other extrapulmonary sites
  • 32. Initial Empiric Therapy of Tuberculosis in Infants, Children and Adolescents In the presence of primary INH resistance, use Rifampicin 9 months INH 9 months INH 9 months INH
    • Class II TB infection
    • PPD conversion within past 1-2 years, (-) CXR
    • PPD (+) not due to BCG,(-)CXR, (-) previous treatment
    • PPD (+) with stable/ healed lesion, (-) previous treatment
  • 33. Initial Empiric Therapy of Tuberculosis in Infants, Children and Adolescents 1-2 mos For the duration of immunosup-pression 12 Months INH
    • Class II TB infection
    • PPD (+) with stable / healed lesion, (+) previous treatment, at risk of reactivation due to:
    • Measles, pertussis, etc
    • Conditions/drugs inducing immunosuppression (IDDM leukemia chronicdialysis)
    • HIV infection/ persons at risk for infection but HIV status unknown
  • 34. Initial Empiric Therapy of Tuberculosis in Infants, Children and Adolescents
    • Streptomycin preferred in children < 6 years of age, where visual acuity/color perception cannot be monitored reliably
    • In immunocompromised patients, continuation phase extended to 7 months (total duration of therapy:9 months) or for at least 6 months after sputum conversion (if applicable) whichever is longer. If susceptibility results anavailable, continue E/S for the entire duration of therapy
    2 months HRZ once daily, ffd by 4 months HR given once daily or as DOT 3x weekly 2 months HRZ plus E or S once daily, ffd by 4 months HR ± E/S given once daily or as DOT 3x weekly
    • Class IIIB TB Disease
    • Pulmonary
    • Fully susceptible: based on culture results of index case,
    • (-) previous treatment, <10% local prevalence of primary INH resistance
    • (b) Susceptibility unknown or initial drug resistance suspected because of big bacillary population, previous treatment (1 month), close contact with resistant source case, residence in area with >10% primary INH resistance
  • 35. Algorithm for Preventive Therapy of Childhood Tuberculosis
    • TB Exposure
    • Class I
    • yes
    • <5years old Start INH for 3 months
    • No
    • Repeat Mantoux test Yes Radiologic findings Yes TB Disease
    • After 3 months(+) and /or, signs/symptoms (Class III)
    • No No suggestive of TB Multiple drug tx
    • If no Discontinue INH No
    • BCG scar, If no BCG scar, TB Infection
    • Give BCG give BCG (Class II)
    • Continue  6 INH