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Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
Tuberculosis and Leprosy
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Tuberculosis and Leprosy

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

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

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  • 1. Tuberculosis – an overview Presented by: Dave Jay S. Manriquez RN. February 1, 2009
  • 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. TB – worldwide distribution
  • 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. 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. 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. TB and HIV
  • 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. 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. 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. Tuberculosis MDR distribution <ul><li>Highest in former USSR and China </li></ul>
  • 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. Mycobacterium tuberculosis- the pathogen – AFB staining
  • 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. Tuberculosis - pathology <ul><li>Caseous necrosis in kidney </li></ul>
  • 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. Primary Tuberculosis -hilar adenopathy and infiltrate
  • 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. Pulmonary Tuberculosis – CXR findings <ul><li>Apical lesions – mod. and severe w/cavity </li></ul>
  • 20. Chest X-Ray findings, atypical <ul><li>Pneumonic consolidation </li></ul>
  • 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 &gt;3 gms/dl </li></ul><ul><li>Often AFB neg, cx positive </li></ul>
  • 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. Miliary Tuberculosis - choroidal
  • 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. 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. tapeworms roundworms
  • 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. 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. 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. 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. Extrapulmonary TB – cold abscesses
  • 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. 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. Tuberculosis - PPD <ul><li>10mm – 90% infected </li></ul><ul><li>&gt;15mm – virtually all </li></ul><ul><li>5-10mm – may be result of BCG </li></ul><ul><li>Unless recent BCG administration, if &gt;10mm, then not from BCG </li></ul>
  • 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. 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. 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. &nbsp;
  • 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>
  • 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>
  • 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>
  • 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>
  • 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>
  • 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>
  • 45. Leprosy <ul><li>Organism – mycobacterium leprae </li></ul><ul><li>Infection of skin and nerves </li></ul>
  • 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 (&gt;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>
  • 47. Leprosy - transmission <ul><li>Generally nasal secretions, particularly in lepromatous </li></ul><ul><li>Importance of proximity, but most cases sporadic </li></ul>
  • 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>
  • 49. &nbsp;
  • 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>
  • 51. Leprosy - tuberculoid
  • 52. Leprosy - lepromatous
  • 53. Leprosy - lepromatous
  • 54. &nbsp;
  • 55. Leprosy – borderline tuberculoid
  • 56. Leprosy – mid borderline
  • 57. &nbsp;
  • 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>
  • 59. Leprosy – reversal reactions
  • 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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