My.tuberculosis
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My.tuberculosis Presentation Transcript

  • 1. 1
    Genus MYCOBACTERIUM
  • 2. 2
    Long, slender bacilli
    with branching filamentous forms.
    Obligate pathogens, Saprophytic and Opportunistic.
    Lipid-rich waxy cell wall.
    Responsible for Chronic granulomatous lesions.
    In 1882 Robert Koch :
  • 3. 3
    CLASSIFICATION
    Tubercle bacilli:
    a. Human : M. tuberculosis, M. africanum
    b. Bovine : M. bovis
    c. Murine : M. microti.
    d. Avian : M. avium.
    e. Cold blooded: M.marinum
    Lepra bacilli:
    a. Human : M. leprae
    b. Rat : M. leprae murium
  • 4. 4
    3. Mycobacteria from skin ulcers.
    M. ulcerans, M. balnei, M. buruli.
    4. Atypical Mycobacteriae:
    5. Jhone’s bacillus:
    M. para tuberculosis.
    ( Chronic specific enteritis in cattle )
    6. Saprophytic Mycobacteria.
    M. butyricum. M. smegmatis, M.stercoris.
  • 5. 5
    Straight / slightly curved rods
    with occasional branching.
    3 x0.3µm. Non motile,
    Non-capsulated, Non- sporing
    Cell wall structure
    • Lipid-rich waxy cell wall
    • 6. Acid fast ,alcohol fast.
    • 7. Slow growth in culture
    medium.
    • Resistant to antiseptics
    and antibiotics.
    • Clumps in liquid medium.
    • 8. Clot formation
    • 9. Acid fast staining
    Ziehl - Neelsen method.
    Kinyoun’s method.
    • Gram staining : No use.
    LIKE SERPENTINE CORDS.
  • 10. 6
    CULTURAL CHARACTERS
    Doubling time 14 – 15 hrs.
    Optimum temperature 37º C .
    (No growth < 25º C & > 40º C)
    1. Egg media:
    Lowenstein – Jensen medium.
    Dorset egg medium.
    L J medium : 2 - 6 weeks
    Sterilized by Inspissation.
    Glycerol, asparagines.
    Malachite green as selective agent.
    Egg albumen as solidifying agent.
    2. Blood (Tarshis medium ).
    3. Serum (Loeffler’s serum slope ).
  • 11. 7
    LIQUID MEDIA :
    Dubo’s medium.
    Middle –Brook medium.
    Bactec 12B medium.
    Uses :
    Sensitivity tests.
    Chemical tests.
    Preparation of antigens & vaccines.
  • 12. 8
    GROWTH :
    M. tuberculosisM. bovis.
    Heaped up & luxuriant Sparse (dysgonic) growth. (eugonic)
    Dry, rough, tuff Moist, smooth flat
    buff colour. with white colour.
    0.5 % glycerol Sodium pyruate
    ( L J medium)( Stone brink's medium )
    Grows on surface. Grows as band few mm.
    (Aerobe) below the surface
    (Anaerobe)
  • 13. 9
    Growth on Lowenstein- Jensen (LJ) medium.
    SENSITIVITY
    • Pasteurization.
    • 14. Formaldehyde.
    • 15. Glutaraldehyde.
    • 16. Tincture of Iodine
  • 10
    BIOCHEMICAL TESTS
    • Niacin production.
    • 17. Catalase positive.
    • 18. Amidase positive.
    • 19. Nitrate reductase positive.
    • 20. Aryl sulphatase negative
    • 21. Resistant to thiophen – 2 – Carboxylic acid hydrazide (TCH) which is related to INH.
    1. To differentiate M.tuberculosisfrom M. bovis and Atypical mycobacteriae
    2. To identify virulent & avirulent strains.
  • 22. 11
    Antigenic structure:
    • Antigenically homogenous. (Human,Bovine,Murine spp).
    • 23. Two types:
    1.Cell wall insoluble polysaccharide antigens.
    Group specificity.
    2.Cytoplasmic soluble protein antigens.
    Type specificity.
    TUBERCULIN PROTEIN
  • 24. 12
    PATHOGENESIS:
    Pulmonary alveoli.
    Taken up by Macrophages & multiplied.
    Primary site of infection in lower part of upper lobes / upper
    part of lower lobes - Ghon’s focus. With hilar
    lymphadenopathy (PRIMARY COMPLEX)
    Initiates CMI
    Inhalation
    Droplets, aerosols from patients & Cough spray from Animal
  • 25. 13
    Pathogenesis Contd……:
    Activation of specific T - cells (cytokines, gamma
    interferon production)
    DTHImmune response
    Formation of Tubercle. Activate macrophages
    ( Avascular granuloma) (Inhibits multiplication).
    Consumes much of O2 & produces acidosis.
    Most of the bacilli are killed.
    Resolution Some remain dormant.
    Protective Immunity. Post – primary disease.
  • 26. 14
    Avascular granuloma
    Central Zone of Caseous (Cheese like ) material
    dead T &B cells and macrophages surrounded by
    different types of cells.
    IL 2: Proliferation of
    Ag-primed T cells
    Gama INF: Enhances
    activity of macrophages &
    NK cells.
    TNF-ά (Cachectin): Induces
    cytokine secretion in the
    inflammatory area.
    Muscle wasting, fever.
  • 27. 15
    Expanding large Avascular granuloma
    (Tuberculomata).
    Erodes through wall of bronchus.
    Liquified contents discharged into the
    bronchus.
    CAVITY formed.
    Shelter for huge number of bacilli.
    Gets access to sputum Open case of TB.
    ( Transmissible case of TB )
  • 28. 16
    2. Ingestion : Unpasteurised milk
    Primary complex
    in tonsils, cervical LN &
    Ileocaecal region ( Mesenteric LN ).
    Initiates CMI.
    3. Inoculation : Rare
    ( Occupational in anatomists , pathologists ).
    Skin with involvement of regional LN.
    Prosector’s warts.
  • 29. 17
    Clinical features
    • Persistent dry cough
    • 30. Tiredness, weakness. 
    • 31. Weight loss 
    • 32. Poor appetite 
    • 33. Sweating at night, in spite of cold 
    • 34. Chest  pain.
    • 35. Shortness of breath 
    • 36. Coughing up blood
  • 18
    Progression of disease
    Lesion breaks down
    Bacilli released and spread
    Through blood & lymph
    Spleen, liver, lungs, BM, Kidney,
    Adrenal glands, Eyes ,CNS .
    Chronic pneumonitis,
    Tuberculous osteomyelitis, Tuberculous meningitis
    Milliary tuberculosis
  • 37. 19
    Lymphadenitis:
    Children.
    Painless neck swelling.
    Genitourinary TB:
    Renal TB: Symptoms of UTI.
    Sterile pyuria.
    Scrotal mass.
    Tubo-ovarian mass ( Sterility ).
  • 38. 20
    POST-PRIMARY CUTANEOUS TB
    1. Lupus vulgaris
    Affects face & Neck.
    Gross scarring & deformity.
    2. Scrofuloderma
    Sinus formation
    between affected
    lymph node & skin.
  • 39. 21
    IMMUNITY & DTH (Allergy):
    CMI is useful.
    6 – 8 weeks after infection :
    Tuberculin test reaction occurs.
    Described by Koch’s Phenomenon.
  • 40. 22
    INJECTED with TU antigen SC 4-6 wks later.
    GUINEA PIGINFECTEDWITH TB BACILLI.
    After 1 – 2 days
    Indurated lesion at the site of Injection.
    Undergoes rapid necrosis.
    Shallow ulcer
    Heals rapidly without involvement of
    regional lymph nodes.
    Koch’s phenomenon
  • 41. 23
    TUBERCULIN TEST
    Clemens von Pirquet (1907) : OT.
    Seibert (1939) : Purified Ag by
    Ammonium sulphate fractionation (PPD).
    Strength of PPD expressed in TU.
    A measured amount ( 5 – 10 TU ) is injected.
  • 42. 24
    MONTOUX TEST
    5 TU of PPD injected
    Intradermally in Flexor
    aspect of forearm.
    (Tuberculin syringe)
    No scratch on itching.
    Read after 48 - 72 hrs .
    Induration.
    Only erythema not
    considerable.
    >10mm - Significant
  • 43. 25
    EPIDEMIOLOGY
    Transmissionamong
    households.
    Dusty environment ,
    Hill dwellers (Silica) .
    Low Socio-economic
    status, Malnutrition.
    (A barometer of social welfare )
    Asia & sub- Saharan nations are
    more prone.
  • 44. 26
    Every minute someone dies of TB in India. >5,00,000 die every year. If there is no effective action, 5 million may die of TB in the next few years. 1.8 million new cases every year. India has the highest burden of the disease in the world.
    Dr L S Chauhan, Director General (TBCP)Nov’ 6 2006 India Together
  • 45. 27
    RNTCP or Revised National Tuberculosis Control Program is the State-run Tuberculosis Control
    Initiative of the Government of India .
    It incorporates the principles of Directly observed treatment Short course (DOTS) - the global TB control strategy of the WHO. The program provides free of cost, quality Anti-Tubercular drugs through the PHCsand the private-sectorDOTS-providers.
  • 46. 28
    The DOTS strategy is cost-effective and is
    today the international standard for TB control programmes.
    To date, more than 180 countries are
    implementing the DOTS strategy.
    India has adapted the DOTS strategy in
    various parts of the country since 1993,
    with excellent results, and by March 2006
    nationwide DOTS coverage has been achieved.
  • 47. 29
    Rapid DOTS expansion in India
    In 2000 , 2001 and 2002 more than a million patients were treated in this way in India. As a result nearly 2,00,000 lives were saved.
    Extensively drug-resistant TB (XDR-TB) in > 30 countries since 2006, multidrug-resistant TB (MDR-TB) and XDR-TB have recently become a particular focus of international concern.
  • 48. 30
    LAB. DIAGNOSIS
    1.Primary TB
    If productive: Sputum
    If not productive:
    Bronchial washings/
    brushings/ biopsy.
    2.Secondary/Post Primary TB
    a. CSF
    b. Pleural fluid
    c. Synovial fluid.
  • 49. 31
    Decontamination & concentration methods.
    1. Petroff’s method:
    Equal volumes of sputum & 4% NaoH
    Keep at 37º C with intermittent shaking
    for 20 mts.
    Neutralized with (Potassium dihydrogen orthophosphate).
    Centrifuge at 3000 rpm for 30mts.
    Deposit: Microscopy
    Culture.
  • 50. 32
    2.Non centrifugation & Non neutralization method:
    Equal volumes of sputum +
    2% Cetrimonium bromide & 4% NaoH
     5 mtsculture.
    Materials used for Homogenization:
    a. Diluted acids ( 6% H2 SO4, 3 % HCl )
    b. N-Acetyl Cystein with NaoH.
    c. Pancreatin.
    d. Cetrimide.
  • 51. 33
    MICROSCOPY
    Minimum of 10,000 bacilli / ml of sputum.
    100 fields must be examined .
    1.Kinyoun’s method
    2.Ziehl - Neelsen technique.
    3.Fluorescent dye technique.
    Auramine Phenol,
    AuramineRhodamine dye.
  • 52. 34
    INTERPRETATION
    3-9 bacilli in entire smear:1+
    or more /entire smear: 2+
    10 or more / field: 3+
    Beaded forms: M.tuberculosis
    Uniform: M.bovis
  • 53. 35
    2. CULTURE :
    A. Conventional method:
    Concentrated sample.
    L -J medium 35 - 37º C.
    Inspect weekly up to 8 weeks.
    B. Rapid diagnosis of growth:
    Bactec system: Radiometric detection of CO2.
  • 54. 36
    C. Fluorescent dye methods
    Activation of fluorescent dye by the released CO2
    3.Nucleic acid technology:
    1.Nucleic acid probes : Not sensitive
    2.PCR: Conventional PCR is best.
    4. Tuberculin test:
    5. Serology:
    PHA .
    Ig M, Ig G and Ig A estimation
    ( Specific but not sensitive tests).
  • 55. 37
    X-Ray findings of pulmonary TB
    Primary complex in the hilar region
  • 56. 38
    PREVENTIVE MEASURES
    1.General measures:
    Adequate nourishment.
    Good housing .
    Health education.
    Contact tracing.
    2.Chemoprophylaxis:
    INH
  • 57. 39
    The basic methods of preventing TB transmission
    • Preventing the release of the
    organism.
    • Preventing the inhalation, through
    masks.
    • Use of high-efficiency particulate
    air (HEPA) filters in the entry
    ways.
    • Chemoprophylaxis for suspected
    cases.
  • 58. 40
    3.IMMUNOPROPHYLAXIS:BCG
    Live attenuated vaccine.
    Bovine strain (Danish 1331 by 239 serial subcultures on
    Glycerin bile potato medium).
    Freeze dried vaccine (Normal saline).
    At birth / within 6 weeks of age.
    Intradermally over deltoid region.
    Dose : 0.1 mg in 0.1 ml. volume.
    Efficacy : 0 – 80 %.
  • 59. 41
    EVENTSAFTERINJECTION :
    Papule within 2 – 3 weeks.
    Enlarges to 4 – 8 mm within 5 weeks.
    Subsides and broken into ulcer.
    Heals spontaneously with scar formation
    within 6 - 12 weeks.
    Complications:
    Local : Abscess, indolent ulcer, Keloid.
    Regional:
    Local lymphadenopathy.
    General :
    Fever, mediastinal adenitis,
  • 60. 42
    CONTRAINDICATIONS
    Generalized eczema.
    Infective dermatosis.
    Hypo gamma globulinaemia.
    Immunodeficiency.
    Protection not absolute after vaccination, May
    suffer with milder form of disease.
  • 61. 43
    ANTI TUBERCULOSIS DRUGS
    First-line:
    Rifampicin (R)
    Pyrazinamide (Z)
    Isoniazid ( H ) Ethambutol
    Second-line:
    Amikacin,
    Capreomycin,
    Kanamycin and Ofloxacin,
    Streptomycin (Since 2005)
  • 62. 44
    SHORT COURSE CHEMOTHERAPY
    Drugs Initial Drugs Continuation
    phase phase
    Standard regime.
    RHZ 2M RH 4M
    Intermittent regime.
    RHZ 2M R3 H3 4M
    RHZ 2M R2 H2 4M
    R3H3Z3 2M R3 H3 4M
    Incase of high incidence of initial drug resistance.
    RHZE 2M RH 4M
    RHZS 2M RH 4M
  • 63. 45
    The challenge to Medical profession is to be
    prepared for all infectious diseases that may affect the practice.