Tuberculosis and Leprosy

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Tuberculosis and Leprosy, treatment, management, chinese version, pathophysiology of the disease

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Tuberculosis and Leprosy

  1. 1. Tuberculosis – an overview Presented by: Dave Jay S. Manriquez RN. February 1, 2009
  2. 2. TB - Prevalence <ul><li>1/3 rd of humanity (2 billion people) infected </li></ul><ul><li>One new infection every second </li></ul><ul><li>8.8 million new cases per year </li></ul><ul><li>1.6 million deaths/year </li></ul><ul><li>Kills more humans per year than any other infectious disease </li></ul>
  3. 3. TB – worldwide distribution
  4. 4.   Estimated Tuberculosis Case Rates, 1997 <ul><li>India 1,799,000 </li></ul><ul><li>China: 1,402,000 </li></ul><ul><li>Indonesia: 583,000 </li></ul><ul><li>Bangladesh: 300,000 </li></ul><ul><li>Pakistan: 261,000 </li></ul><ul><li>Nigeria 253,000 </li></ul><ul><li>Philippines 222,000 </li></ul><ul><li>South Africa 170,000 </li></ul><ul><li>Russian Federation 156,000 </li></ul><ul><li>Ethiopia 156,000 </li></ul><ul><li>Vietnam 145,000 </li></ul><ul><li>Democratic Republic of Congo 129,000  </li></ul><ul><li>Adapted from Dye C, Scheele S, Dolin P, et al. Consensus statement. Global burden of tuberculosis : Estimated incidence, prevalence, and mortality by country. WHO Global Surveillance and Monitoring Project. JAMA. 1999;282:677–686. </li></ul>
  5. 5. TB global stats <ul><li>1/3 rd of all new incident cases in Asia </li></ul><ul><li>½ of all deaths from tb occur in Asia </li></ul><ul><li>In Africa, grew rapidly over last two decades due to HIV </li></ul><ul><li>Period of decline, altered by worldwide epidemic of HIV </li></ul>
  6. 6. Bach Christian Hospital TB stats (2002) <ul><li>141 new cases of tuberculosis </li></ul><ul><ul><li>(over 11 new cases per month) </li></ul></ul><ul><li>840 total TB patients under treatment </li></ul><ul><li>100 patients discharged having completed treatment </li></ul>
  7. 7. TB and HIV
  8. 8. Tuberculosis and HIV <ul><li>- over 8 million coinfected </li></ul><ul><li>- reactivation rates 20 times higher than in non HIV-infected persons </li></ul><ul><li>- 50% with dual infection develop active tb </li></ul>
  9. 9. Tuberculosis - resistance <ul><li>½ of all new cases have some resistance </li></ul><ul><li>Worst in 6 Asian countries of Bangladesh, China, India, Indonesia, Pakistan and Philippines </li></ul><ul><li>Every country has resistance to at least one single drug </li></ul>
  10. 10. MDR Tuberculosis <ul><li>Defined as resistance to at least INH and rifampicin </li></ul><ul><li>450,000 cases per year </li></ul><ul><li>XDR – extensive drug resistance </li></ul><ul><ul><li>Generally where there is also HIV </li></ul></ul>
  11. 11. Tuberculosis MDR distribution <ul><li>Highest in former USSR and China </li></ul>
  12. 12. Mycobacterium others, generally opportunistic and assoc. with HIV <ul><li>M. Avium Intracellulare </li></ul><ul><li>M. Asiaticum </li></ul><ul><li>M. Flavenscens </li></ul><ul><li>M. fortuitum complex </li></ul><ul><li>M. Heamophilum </li></ul><ul><li>M. Kanasasii </li></ul><ul><li>M. Malmoense </li></ul><ul><li>M. Marinum </li></ul><ul><li>M. Scrofulaceum </li></ul><ul><li>M. Simiae </li></ul><ul><li>M. Genavense </li></ul><ul><li>M. xenopi </li></ul>
  13. 13. Mycobacterium tuberculosis- the pathogen – AFB staining
  14. 14. Mycobacterium tuberculosis – immune response <ul><li>Principle response is formation of a granuloma – monocyte and t cells are with multi-nucleated giant cells on the edge of an area of caseation </li></ul><ul><li>Caseous necrosis and calcium deposition </li></ul>
  15. 15. Tuberculosis - pathology <ul><li>Caseous necrosis in kidney </li></ul>
  16. 16. Tuberculosis – clinical presentation <ul><li>Primary tb in childhood </li></ul><ul><ul><li>Inhalation of organisms </li></ul></ul><ul><ul><li>Formation of hilar LAD </li></ul></ul><ul><ul><li>Only 5% develop symptomatic disease </li></ul></ul><ul><ul><li>30% develop established infection </li></ul></ul><ul><ul><li>3-5% chance of reactivation </li></ul></ul><ul><ul><li>1/3 rd of adult presentations due to new infection </li></ul></ul>
  17. 17. Primary Tuberculosis -hilar adenopathy and infiltrate
  18. 18. Pulmonary Tuberculosis <ul><li>Most cases reactivation of disease acquired years earlier </li></ul><ul><li>Predominant symptoms of cough (78%), weight loss (74%), fatigue (68%), fever (60%), night sweats (55%), hemoptysis (33%) </li></ul>
  19. 19. Pulmonary Tuberculosis – CXR findings <ul><li>Apical lesions – mod. and severe w/cavity </li></ul>
  20. 20. Chest X-Ray findings, atypical <ul><li>Pneumonic consolidation </li></ul>
  21. 21. Pulmonary Tuberculosis – pleural effusion <ul><li>Usually appear 3-6 months after primary disease </li></ul><ul><li>With or without lung infection </li></ul><ul><li>Usually unilateral </li></ul><ul><li>Predominance of lymphs </li></ul><ul><li>Exudative w/protein >3 gms/dl </li></ul><ul><li>Often AFB neg, cx positive </li></ul>
  22. 22. Miliary tuberculosis <ul><li>In immune-suppressed </li></ul><ul><li>Follows blood-borne dissemination </li></ul><ul><li>May present as FUO </li></ul><ul><li>High mortality rate </li></ul>
  23. 23. Miliary Tuberculosis - choroidal
  24. 24. Extra-pulmonary TB Scrofula (lymphadenitis) <ul><li>most frequent extrapulmonary manifestation </li></ul><ul><li>80% cervical </li></ul><ul><li>Nearly always PPD positive </li></ul><ul><li>Granulomas on biopsy </li></ul><ul><li>Persistent nodes after tx common </li></ul>
  25. 25. Extrapulmonary tb - GI <ul><li>Anywhere from mouth to anus </li></ul><ul><li>70% w/advanced pulmonary get GI </li></ul><ul><li>Small bowell- ileocecal valve </li></ul><ul><li>Perforations common </li></ul><ul><li>Responds well to tx </li></ul>
  26. 26. tapeworms roundworms
  27. 27. Extrapulmonary TB - peritonitis <ul><li>Ascites, pain, +/- fever, wt. loss </li></ul><ul><li>Ascitic fluid seldom AFB positive </li></ul><ul><li>Culture positive in only 25% </li></ul><ul><li>Need tissue biopsy </li></ul><ul><li>Diagnosis often delayed </li></ul>
  28. 28. Extrapulmonary TB - meningitis <ul><li>In early childhood, post-primary </li></ul><ul><li>May present with subtle symptoms </li></ul><ul><li>3/4ths with miliary pattern on CXR </li></ul><ul><li>AFB positive in 37% initially, 90% after 4 th spinal tap </li></ul>
  29. 29. Extrapulmonary TB – osteomyelitis <ul><li>Pott’s most common – 50% of all osteo </li></ul><ul><li>Low thoracic most common </li></ul><ul><li>Anterior destruction </li></ul>
  30. 30. Extrapulmonary TB - arthritis <ul><li>Chronic, progressive, monoarticular </li></ul><ul><li>Usually hip or knee </li></ul><ul><li>AFB positive in only 1/4 th </li></ul><ul><li>Ideally, synovial biopsy </li></ul>
  31. 31. Extrapulmonary TB – cold abscesses
  32. 32. Extrapulmonary TB - urogenital <ul><li>Often asymptomatic, but kidney most commonly affected </li></ul><ul><li>May present with cystitis symptoms, sterile pyuria </li></ul><ul><li>Cultures 90% sensitive </li></ul><ul><li>Males – scrotal mass, oligospermia </li></ul><ul><li>Female – infertility with hematogenous focus in endosalpinx </li></ul>
  33. 33. Tuberculosis – laboratory investigations <ul><li>AFB – inexpensive </li></ul><ul><li>Cultures – expensive, sensitivities helpful in MDR </li></ul><ul><li>PCR – out of reach in poorer countries </li></ul><ul><li>ESR – inexpensive and helpful, decreases with treatment </li></ul><ul><li>Anemia of chronic disease </li></ul>
  34. 34. Tuberculosis - PPD <ul><li>10mm – 90% infected </li></ul><ul><li>>15mm – virtually all </li></ul><ul><li>5-10mm – may be result of BCG </li></ul><ul><li>Unless recent BCG administration, if >10mm, then not from BCG </li></ul>
  35. 35. BCG vaccine <ul><li>Routinely administered in much of the world </li></ul><ul><li>Efficacy 60-80%, though not uniformly </li></ul>
  36. 36. Tuberculosis - treatment <ul><li>INH (isoniazid) – bactericidal </li></ul><ul><ul><li>Most common side effect hepatotoxicity </li></ul></ul><ul><ul><li>Check LFTs (20% of patients) </li></ul></ul><ul><ul><li>If occurs, may reintroduce one med at a time </li></ul></ul><ul><ul><li>Other side effect – peripheral neuritis, prevented by coadministration of piridoxine </li></ul></ul>
  37. 37. Tuberculosis - treatment <ul><li>Rifampin </li></ul><ul><ul><li>Bactericidal </li></ul></ul><ul><ul><li>Many interactions with other drugs </li></ul></ul><ul><ul><li>Hepatotoxicity </li></ul></ul>
  38. 39. Tuberculosis - treatment <ul><li>Pyrizinimide </li></ul><ul><ul><li>GI intolerance </li></ul></ul><ul><ul><li>Hepatotoxicity – from elevated transaminases to liver failure </li></ul></ul>
  39. 40. Tuberculosis - treatment <ul><li>Ethambutol </li></ul><ul><li>-bactericidal </li></ul><ul><li>-side effect – retrobulbar neuritis, presenting initially with blurred vision </li></ul>
  40. 41. Tuberculosis – treatment <ul><li>Streptomycin </li></ul><ul><ul><li>First antituberculous med </li></ul></ul><ul><ul><li>Side effects of ototoxicity, nephrotoxicity </li></ul></ul><ul><ul><li>Given IM </li></ul></ul>
  41. 42. Tuberculosis – treatment Second line drugs <ul><li>Ethionamide </li></ul><ul><li>Ciprofloxacin </li></ul><ul><li>Capreomycin </li></ul><ul><li>Kanamycin </li></ul><ul><li>Amikacin </li></ul><ul><li>Cycloserine </li></ul><ul><li>Thiacetazone </li></ul>
  42. 43. Tuberculosis – treatment <ul><li>Bacteria killed over 6-mo period, but patient clinically improves in a few weeks </li></ul><ul><li>Can do a 1-3 month interval AFB or culture evaluation </li></ul><ul><li>Can follow ESR/weights </li></ul>
  43. 44. Tuberculosis - treatment <ul><li>Variety of regimens </li></ul><ul><li>BCH regimen </li></ul><ul><li>- for first 2 months, four drugs (INH/rifampin, pyrizinamide, ethambutal </li></ul><ul><li>- next four months, only INH/rifampin </li></ul><ul><li>- CNS – 12 months </li></ul><ul><li>- depending on clinical scenario </li></ul><ul><li>DOTS </li></ul><ul><li>Use of steroids </li></ul>
  44. 45. Leprosy <ul><li>Organism – mycobacterium leprae </li></ul><ul><li>Infection of skin and nerves </li></ul>
  45. 46. Leprosy <ul><li>Prevalence </li></ul><ul><li>- 10-15 million in 1950s </li></ul><ul><li>- 600,000 in 2000 </li></ul><ul><li>Countries affected (>1/10,000) </li></ul><ul><li>122 in 1985 </li></ul><ul><li>15 in 2000 </li></ul><ul><li>83% in India, Brazil, Myanmar, Madagascar, Nepal, Mozambique </li></ul>
  46. 47. Leprosy - transmission <ul><li>Generally nasal secretions, particularly in lepromatous </li></ul><ul><li>Importance of proximity, but most cases sporadic </li></ul>
  47. 48. Leprosy - presentation <ul><li>Subclinical more common than clinical, as incubation 4-10 years </li></ul><ul><li>Clinical – tuberculoid vs. lepromatous </li></ul>
  48. 50. Leprosy – clinical presentation <ul><li>Tuberculoid – limited by vigorous cell-mediated response </li></ul><ul><li>Lepromatous – proliferation of bacteria with extensive skin and nerve involvement </li></ul>
  49. 51. Leprosy - tuberculoid
  50. 52. Leprosy - lepromatous
  51. 53. Leprosy - lepromatous
  52. 55. Leprosy – borderline tuberculoid
  53. 56. Leprosy – mid borderline
  54. 58. Leprosy – clinical presentation <ul><li>Reversal reactions </li></ul><ul><ul><li>Occur in all forms except polar tuberculoid </li></ul></ul><ul><ul><li>Sometimes after initiation of treatment </li></ul></ul><ul><ul><li>Inflammation of existing lesions or new skin lesions, may present with acutely swollen nerves </li></ul></ul><ul><ul><li>Respond to steroids </li></ul></ul>
  55. 59. Leprosy – reversal reactions
  56. 60. Leprosy - treatment <ul><li>Combination therapy with dapsone, rifampin, clofazimine, quinolones, minocycline, azithromycin </li></ul><ul><li>Multibacillary vs. paucibacillary </li></ul><ul><li>High dose steroids for reversal reactions </li></ul>

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