• Mycobacterium tuberculosis (MTB)• Two kinds discussed today: Mycobacterium tuberculosis(the most common reason) Mycobacterium bovis (0.5~7.2%)• Africa (HIV/AIDS/malnutrition+TB)> India (malnutrition) > China (malnutrition and DR/drug resistance)• Why the MTB is called anti-fast bacillus? Ziehl-Neelsen staining Background: blue MTB: red
• Cough• Chief and/or first symptoms• More serious in the night than daytime• Incidence: 71%• Cough and blood-stained sputum continuing more than 2 weeks indicating TB strongly• Typical cough of TB: Dry cough or irritating dry cough Rough cough and a little frothy sputum Cough and blood-stained sputum• Other type of cough with: White sticky phlegm purulent sputum
• Sputum• Incidence: 40%• White mucous phlegm (white frothy sputum)• If the quantity of (purulent) sputum increased obviously, it means ： Accompanyed with infection: 50~60% is general bacteria yellow purulent sputum (>100ml/d) With bronchiectasis Pyothorax and bronchopleural fistula (Acute or Chronic)
• Hemoptysis• What is Massive Hemoptysis: >300ml per time or >500ml/24hr• More than 30% patients have died of Hemoptysis in China• Type: Blood; Blood-stained sputum
• Chest pain• Approximately 30%• No specificity; Not means exacerbation of TB• Mechanism: TB invades parietal pleura Adhesion or fraction of pleura Patients with pleural effusion may suffer slight feeling of pain A tips: Pulmonary tissue doesn’t know pain
• Dyspnea• Not usual• If patients has this symptom, it means: Trachea or/and main bronchi are oppressed by enlarging lymph nodes of mediastinum Something in trachea or/and main bronchi obstructing them Massive pleural effusion (constricting lungs obviously) Accompanying with penumothorax Hematogenous disseminated pulmonary tuberculosis and ARDS (acute respiratory distress syndrome) Accompanying with PE (pulmonary Embolism) (dyspnea, hemoptysis and chest pain) Accompanying with acute exacerbation of Asthma or/and severe infection Extensive lung involved in
• Systemic poisoning symptoms• Fever (tidal fever)• Night sweating• Obvious or serious fatigue• Obvious weight loss• Abnormality of hematologic system (decrease of RBC, Plt and WBC)• Endocrine disturbance (paramenia ； amenorrhea)• Insomnia• Systemic anaphylactic reaction
• Fever• 60%• TB is active• Usually with night sweating and cheeks flush (like drunk looks)• Slight to moderate is common• Hyperpyrexia: TBM (tubercular meningitis) TBP (tuberculous pleuritis) CP (caseous pneumonia) Acute hematogenous disseminated pulmonary TB• What is “Tidal fever”?
• Auxiliary examination• 5 standard unit PPD test (purified protein derivation)• ESR (Erythrocyte Sedimentation Rate)• CRP (C-reaction protein)• Try to find MTB in the sputum by smear or/and culture; Biopsy• TB antibody in blood• TB-DNA through PCR (Polymerase Chain Reaction)• CXR• CT• Others items: CBC (complete blood count / Blood routine) Measurement of liver and kidneys function Lumbar puncture and CSF examination (TBM) Thoracic/Abdomen puncture and effusion examination (TBP)
• Diagnostic criteria ：• MTB has been found by any way• No direct evidence of TB ； but we can take no account of other diseases
• Type——based on pathogenesis• Type I: Primary complex• Type II: Acute/Subacute/Chronic hematogenous disseminated pulmonary TB• Type III: Secondary pulmonary TB• Type IV: TBP (tubercular pleuritis)• Type V: Extrapulmonary TB: Bone TB (vertebral body Abdominal TB Tuberculosis of Celiac Lymph Node Tuberculous peritonitis Intestinal TB
• Management: based on the guideline of China• Drugs belong 1st line: Isoniazide-INH-H; Rifampicin-RFP-R Ethambutol-EMB-E; Pyrazinamide-PZA-Z Streptomycin-SM-S• Drugs belong 2nd line: Protionamide-1321Th; Dipasic-D (INH+PAS) Ofloxacin-OFLX-O (can representing Moxifloxacin and Levofloxacin) Amikacin-Am-K• Drugs belong 3rd line: Capreomycin-Cap-C; Rifabutin-RFB-B Clarithromycin-Cla; Amoxicillin and clavulanate potassium tablets; Imipenem and Cilastatin Sodium-IMP; Linezolid/Zyvox-Lzd
• Stages of management: Intensive period Maintenance period IE: 2HREZ/7HRE 2HL2EZ/7HRE Means biw (twice per week)
• What is the indications of stopping to take drugs?• Symptoms disappear completely?• No fever?• MTB can’t be found in the sputum?• ESR is normal?• Imageology is normal?
• Persons with no TB ， but need to be carefully monitored ：• Glucocorticoids (GCs) ；• Immunosuppressant• HIV/AIDS• DM• Carcinoma• Severe malnutrition• Organ transplantation recipient• CTD (Connective Tissue Disease)• Other conditions