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Pulmonary Tuberculosis

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Pulmonary Tuberculosis

Pulmonary Tuberculosis

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    Pulmonary Tuberculosis Pulmonary Tuberculosis Presentation Transcript

    • Pulmonary Tuberculosis http://crisbertcualteros.page.tl
    • Pulmonary Tuberculosis
      • Etiology:
      • 1.1 Mycobacterium tuberculosis
      • 1.2 Mycobacterium bovis , rarely
    • 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
    • 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)
    • 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
    • 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
    • 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
    • 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
    • Incubation Period
      • From 3 to 8 weeks
    • CLASSIFICATION
      • Class I (TB exposure)
          • (+) exposure
          • (-) Mantoux tuberculin test
          • (-) signs and symptoms suggestive of TB
          • (-) chest radiograph
    • CLASSIFICATION
      • Class II (TB infection)
          • (±) exposure
          • (+) Mantoux tuberculin test
          • (-) signs and symptoms suggestive of TB
          • (-) chest radiograph
    • 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)
    • 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
    • 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
    • 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)
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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