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
    • 1/3 rd of humanity (2 billion people) infected
    • One new infection every second
    • 8.8 million new cases per year
    • 1.6 million deaths/year
    • Kills more humans per year than any other infectious disease
  • 3. TB – worldwide distribution
  • 4.   Estimated Tuberculosis Case Rates, 1997
    • India 1,799,000
    • China: 1,402,000
    • Indonesia: 583,000
    • Bangladesh: 300,000
    • Pakistan: 261,000
    • Nigeria 253,000
    • Philippines 222,000
    • South Africa 170,000
    • Russian Federation 156,000
    • Ethiopia 156,000
    • Vietnam 145,000
    • Democratic Republic of Congo 129,000 
    • 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.
  • 5. TB global stats
    • 1/3 rd of all new incident cases in Asia
    • ½ of all deaths from tb occur in Asia
    • In Africa, grew rapidly over last two decades due to HIV
    • Period of decline, altered by worldwide epidemic of HIV
  • 6. Bach Christian Hospital TB stats (2002)
    • 141 new cases of tuberculosis
      • (over 11 new cases per month)
    • 840 total TB patients under treatment
    • 100 patients discharged having completed treatment
  • 7. TB and HIV
  • 8. Tuberculosis and HIV
    • - over 8 million coinfected
    • - reactivation rates 20 times higher than in non HIV-infected persons
    • - 50% with dual infection develop active tb
  • 9. Tuberculosis - resistance
    • ½ of all new cases have some resistance
    • Worst in 6 Asian countries of Bangladesh, China, India, Indonesia, Pakistan and Philippines
    • Every country has resistance to at least one single drug
  • 10. MDR Tuberculosis
    • Defined as resistance to at least INH and rifampicin
    • 450,000 cases per year
    • XDR – extensive drug resistance
      • Generally where there is also HIV
  • 11. Tuberculosis MDR distribution
    • Highest in former USSR and China
  • 12. Mycobacterium others, generally opportunistic and assoc. with HIV
    • M. Avium Intracellulare
    • M. Asiaticum
    • M. Flavenscens
    • M. fortuitum complex
    • M. Heamophilum
    • M. Kanasasii
    • M. Malmoense
    • M. Marinum
    • M. Scrofulaceum
    • M. Simiae
    • M. Genavense
    • M. xenopi
  • 13. Mycobacterium tuberculosis- the pathogen – AFB staining
  • 14. Mycobacterium tuberculosis – immune response
    • 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
    • Caseous necrosis and calcium deposition
  • 15. Tuberculosis - pathology
    • Caseous necrosis in kidney
  • 16. Tuberculosis – clinical presentation
    • Primary tb in childhood
      • Inhalation of organisms
      • Formation of hilar LAD
      • Only 5% develop symptomatic disease
      • 30% develop established infection
      • 3-5% chance of reactivation
      • 1/3 rd of adult presentations due to new infection
  • 17. Primary Tuberculosis -hilar adenopathy and infiltrate
  • 18. Pulmonary Tuberculosis
    • Most cases reactivation of disease acquired years earlier
    • Predominant symptoms of cough (78%), weight loss (74%), fatigue (68%), fever (60%), night sweats (55%), hemoptysis (33%)
  • 19. Pulmonary Tuberculosis – CXR findings
    • Apical lesions – mod. and severe w/cavity
  • 20. Chest X-Ray findings, atypical
    • Pneumonic consolidation
  • 21. Pulmonary Tuberculosis – pleural effusion
    • Usually appear 3-6 months after primary disease
    • With or without lung infection
    • Usually unilateral
    • Predominance of lymphs
    • Exudative w/protein >3 gms/dl
    • Often AFB neg, cx positive
  • 22. Miliary tuberculosis
    • In immune-suppressed
    • Follows blood-borne dissemination
    • May present as FUO
    • High mortality rate
  • 23. Miliary Tuberculosis - choroidal
  • 24. Extra-pulmonary TB Scrofula (lymphadenitis)
    • most frequent extrapulmonary manifestation
    • 80% cervical
    • Nearly always PPD positive
    • Granulomas on biopsy
    • Persistent nodes after tx common
  • 25. Extrapulmonary tb - GI
    • Anywhere from mouth to anus
    • 70% w/advanced pulmonary get GI
    • Small bowell- ileocecal valve
    • Perforations common
    • Responds well to tx
  • 26. tapeworms roundworms
  • 27. Extrapulmonary TB - peritonitis
    • Ascites, pain, +/- fever, wt. loss
    • Ascitic fluid seldom AFB positive
    • Culture positive in only 25%
    • Need tissue biopsy
    • Diagnosis often delayed
  • 28. Extrapulmonary TB - meningitis
    • In early childhood, post-primary
    • May present with subtle symptoms
    • 3/4ths with miliary pattern on CXR
    • AFB positive in 37% initially, 90% after 4 th spinal tap
  • 29. Extrapulmonary TB – osteomyelitis
    • Pott’s most common – 50% of all osteo
    • Low thoracic most common
    • Anterior destruction
  • 30. Extrapulmonary TB - arthritis
    • Chronic, progressive, monoarticular
    • Usually hip or knee
    • AFB positive in only 1/4 th
    • Ideally, synovial biopsy
  • 31. Extrapulmonary TB – cold abscesses
  • 32. Extrapulmonary TB - urogenital
    • Often asymptomatic, but kidney most commonly affected
    • May present with cystitis symptoms, sterile pyuria
    • Cultures 90% sensitive
    • Males – scrotal mass, oligospermia
    • Female – infertility with hematogenous focus in endosalpinx
  • 33. Tuberculosis – laboratory investigations
    • AFB – inexpensive
    • Cultures – expensive, sensitivities helpful in MDR
    • PCR – out of reach in poorer countries
    • ESR – inexpensive and helpful, decreases with treatment
    • Anemia of chronic disease
  • 34. Tuberculosis - PPD
    • 10mm – 90% infected
    • >15mm – virtually all
    • 5-10mm – may be result of BCG
    • Unless recent BCG administration, if >10mm, then not from BCG
  • 35. BCG vaccine
    • Routinely administered in much of the world
    • Efficacy 60-80%, though not uniformly
  • 36. Tuberculosis - treatment
    • INH (isoniazid) – bactericidal
      • Most common side effect hepatotoxicity
      • Check LFTs (20% of patients)
      • If occurs, may reintroduce one med at a time
      • Other side effect – peripheral neuritis, prevented by coadministration of piridoxine
  • 37. Tuberculosis - treatment
    • Rifampin
      • Bactericidal
      • Many interactions with other drugs
      • Hepatotoxicity
  • 38.  
  • 39. Tuberculosis - treatment
    • Pyrizinimide
      • GI intolerance
      • Hepatotoxicity – from elevated transaminases to liver failure
  • 40. Tuberculosis - treatment
    • Ethambutol
    • -bactericidal
    • -side effect – retrobulbar neuritis, presenting initially with blurred vision
  • 41. Tuberculosis – treatment
    • Streptomycin
      • First antituberculous med
      • Side effects of ototoxicity, nephrotoxicity
      • Given IM
  • 42. Tuberculosis – treatment Second line drugs
    • Ethionamide
    • Ciprofloxacin
    • Capreomycin
    • Kanamycin
    • Amikacin
    • Cycloserine
    • Thiacetazone
  • 43. Tuberculosis – treatment
    • Bacteria killed over 6-mo period, but patient clinically improves in a few weeks
    • Can do a 1-3 month interval AFB or culture evaluation
    • Can follow ESR/weights
  • 44. Tuberculosis - treatment
    • Variety of regimens
    • BCH regimen
    • - for first 2 months, four drugs (INH/rifampin, pyrizinamide, ethambutal
    • - next four months, only INH/rifampin
    • - CNS – 12 months
    • - depending on clinical scenario
    • DOTS
    • Use of steroids
  • 45. Leprosy
    • Organism – mycobacterium leprae
    • Infection of skin and nerves
  • 46. Leprosy
    • Prevalence
    • - 10-15 million in 1950s
    • - 600,000 in 2000
    • Countries affected (>1/10,000)
    • 122 in 1985
    • 15 in 2000
    • 83% in India, Brazil, Myanmar, Madagascar, Nepal, Mozambique
  • 47. Leprosy - transmission
    • Generally nasal secretions, particularly in lepromatous
    • Importance of proximity, but most cases sporadic
  • 48. Leprosy - presentation
    • Subclinical more common than clinical, as incubation 4-10 years
    • Clinical – tuberculoid vs. lepromatous
  • 49.  
  • 50. Leprosy – clinical presentation
    • Tuberculoid – limited by vigorous cell-mediated response
    • Lepromatous – proliferation of bacteria with extensive skin and nerve involvement
  • 51. Leprosy - tuberculoid
  • 52. Leprosy - lepromatous
  • 53. Leprosy - lepromatous
  • 54.  
  • 55. Leprosy – borderline tuberculoid
  • 56. Leprosy – mid borderline
  • 57.  
  • 58. Leprosy – clinical presentation
    • Reversal reactions
      • Occur in all forms except polar tuberculoid
      • Sometimes after initiation of treatment
      • Inflammation of existing lesions or new skin lesions, may present with acutely swollen nerves
      • Respond to steroids
  • 59. Leprosy – reversal reactions
  • 60. Leprosy - treatment
    • Combination therapy with dapsone, rifampin, clofazimine, quinolones, minocycline, azithromycin
    • Multibacillary vs. paucibacillary
    • High dose steroids for reversal reactions