TUBERCULOSIOS

1. TUBERCULOSIS
BY Dr.AVINASH.D DNB Resident GEN
SURG

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• In India, each year, approx. 220,000 deaths are
reported due to Tuberculosis.
• India accounts for about a quarter of the global
TB burden
• Each year, we recognize World TB Day on March
24. This annual event commemorates the date in
1882 when Dr. Robert Koch announced his
discovery of Mycobacterium tuberculosis, the
bacillus that causes tuberculosis (TB). World TB
Day is a day to educate the public about the
impact of TB around the world.

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• Tuberculosis (TB) , a multisystemic disease
with myriad presentations and manifestations,
is the most common cause of infectious
disease–related mortality worldwide.

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DEFINITION
It is infectious disease caused by
Mycobacterium tuberculosis and
characterized by the formation of tubercles
(round nodules) or granulomas in lungs. It
may be transmitted to other body parts such
as meningitis, bones, kidneys, lymph nodes.

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Mtb complex
• M. tuberculosis is part of a complex that has at
least 9 members: M. tuberculosis sensu
stricto, M. africanum, M. canetti, M. bovis, M.
caprae, M. microti, M. pinnipedii, M.
mungi, and M. orygis

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Atypical mycobacterium
Atypical Mycobacterium are mycobacterial
species other than M.tuberculosis and leprare.
They are also called asNontuberculous
mycobacteria (NTM)
Eg:Mycobacterium abscessus, Mycobacterium
avium ,Mycobacterium intracellulare,
Mycobacterium marinum.

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Can atypical tb cause symptoms ?
• Four distinct clinical syndromes account for
most infections with NTM[4] and include (1)
pulmonary disease, (2) lymphadenitis, (3) skin
or soft-tissue infections (SSTIs), [5] and (4)
disseminated disease.

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RISK FACTORS FOR TB
• Intravenous (IV) drug abuse
• Alcoholism
• Diabetes mellitus (3-fold risk increase)
• Silicosis
• Immunosuppressive therapy
• Tumor necrosis factor–alpha (TNF-α) antagonists
• Cancer of the head and neck

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• Hematologic malignancies
• End-stage renal disease
• Intestinal bypass surgery or gastrectomy
• Chronic malabsorption syndromes
• Low body weight - In contrast, obesity in elderly
patients has been associated with a lower risk for
active pulmonary TB[27]
• Smoking - Smokers who develop TB should be
encouraged to stop smoking to decrease the risk of
relapse[28]
• Age below 5 years

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Latent TB & Active TB

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What is ETB?
• Extrapulmonary tuberculosis (EPTB)
is tuberculosis outside of the lungs. EPTB
includes tuberculosis meningitis,
abdominal tuberculosis (usually with ascites),
skeletal tuberculosis, Pott's disease (spine),
scrofula (lymphadenitis), and genitourinary
(renal) tuberculosis.

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TUBERCULOUS LYMPH NODE
• Spread to lymph nodes is the most
common.[4] An ulcer originating from nearby
infected lymph nodes may occur and is
painless, slowly enlarging and has an
appearance of "wash leather".[5]

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Classic clinical features associated with active
pulmonary TB are as follows :
• Cough
• Weight loss/anorexia
• Fever
• Night sweats
• Hemoptysis
• Chest pain (can also result from tuberculous acute
pericarditis)
• Fatigue

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WORKUP
• Haematological and biochemical
abnormalities in pulmonary tuberculosis are
common and may be valuable aids in
diagnosis. There was elevated level of ESR in
all the patients to substantial level whereas
• Haemoglobin (Hb) was lower in most of the
patients presenting anaemic situation.

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WORKUP
• Haematological and biochemical
abnormalities in pulmonary tuberculosis are
common and may be valuable aids in
diagnosis. There was elevated level of ESR in
all the patients to substantial level whereas
• Haemoglobin (Hb) was lower in most of the
patients presenting anaemic situation.

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SCREENING TESTS
• MANTOUX TEST
• INTERFERON GAMMA ASSAY.

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MANTOUX
• 5 UNITS OF PPD OR 0.1 ML INTRADERMAL
• 48-72 HRS
• BASED ON DELAYED HYPERSENSITIVITY
• False poitive in BCG vac , prior mantoux test
individuals .

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Population-based criteria for PPD positivity are
as follows:

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INFERON GAMMA ASSAY
• Quantiferon TB gold – Based on ELISA .
• T spot Tb – Based on ELISPOT.
• Igra measures Tcell interferon gamma
response to antigens that are highly specific
for MTB and absent from BCG and M avium .
• High cost
• Independant of BCG vac .
• Single patient visit .

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CXR
• Pattern to see on CXR –
• Cavity formation –high viral load
• non calcified roung inflitrates – may be
confusd with ca lung .
• Homogenious calcified nodules –may
represent old infection
• Milary tb –numerous small lesions like millet
seeds

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Solitary pulmonary nodules ?
• TB ???????????? OR Ca lung ??????????????
• Do a 99m tc methoxy isobutyl isonitrile single
photon emmission CT scan .

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Sputum AFB
• ZEIL NELSON STAINING :
• COLLECTION : Two sputum specimens are
collected over a day or two consecutive days;
one is collected on the spot and the other is
an early morning at home .

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Why early morning sample ?
• Over night secrection built up in air ways so
there is more chance of detecting bacillius .

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Rodamine auramin stain is currently
used

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Min 10000 bacilli/ml are required to
prove positive

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CBNAAT
• Based on PCR .
• Identifies specific DNA sequences specific for
MTB .
• Can detect 10-1000 bacillli per ml also .
• Its a gold standard now .
• 24 hr – result .
• ALSO CALLED AS GENE XPERT

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Cultute methods
• LJ MEDIUM - takes 3-4 weeks .
• Bactec radiometric system – 10-14 days .
• Other rapd tests :
• Bactec 460 , ligase chain reation
• Luciferase report assay

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Latest diagnosis methods
• Truenaat – tests MDR tb with in 1 hr .
• Gene xpert – tb and rifampacin resistance
with in 48 hrs .

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BACTEC SYSTEM

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TRUNAT

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What is MDR TB ?
• Mono resistance tb – resistace to one first line
drugs .
• Poly drug resistance - resistance to more than
one first line drug .
• Multidrug resistance – resistance to isonizaid
and rifampacin
• Extenssive drug resistance – resistance to one
fluroquinolone and atleasst one injectable
drug .

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Diagnosis of MDR AND XDR TB
• All the below methods use PCR to detect gene
mutation .
• Genexpert /rif
• Mtb dr plus , mtb rsl assay
• Innolipa , rif tb line probe assay
• Fast plaque tb rif
• Rifampacin resistance can be consisdered
diagnostic for MDR because most rifampacin
resistance patient also exbit resistance to
isoniazid too .

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TREATMENT

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Directly observed treatment short course
• Advantages :
• Fast bacterological conversion .
• Prevents frequency of emergence of
resistance
• Lower the failure rates .

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Dosage
• H.Isonoazid 5mg/kg
• R.Rifamapacin 10 mg /kg
• Z.Pyrizanamide 25 mg /kg
• E.Ethambutol 15mg / kg
• S.Streptomycine 15 mg / kg
• H 75 R150 Z400 E275

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TREATMENT OF MDR TB
• RNTCP will be using a Standardized Treatment
Regimen for the treatment of MDR-TB cases
(and those with rifampicin resistance) under the
program.
• Regimen comprises of six drugs kanamycin,
ofloxacin (levofloxacin)†, ethionamide,
pyrazinamide, ethambutol and cycloserine
during six to nine months of the Intensive Phase
and four drugs levofloxacin, ethionamide,
ethambutol and cycloserine during the 18
months of the Continuation Phase.

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RNTCP MDR TB REGIME

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TREATMENT FOR XDR TB
• This regimen is given XDR-TB. The drugs are
Linezolid, Moxifloxacin, INH, Clarithromycin,
Capreomycin, Ethambutol, clofazimine,
amoxicillin/clavulanate, thioacetazone,
imipenem/cilastatin and pyrazinamide. These
drugs are given daily for 3 years.

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RNTCP XDR REGIME

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ATYPICAL MYCOBACTERIUM
• Mycobacterial species other
than Mycobacterium
tuberculosis and Mycobacterium leprae are
classified as atypical mycobacteria,
nontuberculous mycobacteria (NTM), or
environmental mycobacteria.

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• The genus consists of more than 190
species, [1] many of which are ubiquitous and can be
found in water (including tap water), soil, animals,
birds, plants, food (dairy products), vegetation, and
human feces.
• Transmitted by inhalation, ingestion, and
percutaneous penetration.

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• Four distinct clinical syndromes account for
most infections with NTM[4] and include
• (1) pulmonary disease, (2) lymphadenitis, (3)
skin or soft-tissue infections (SSTIs), [5] and (4)
disseminated disease

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EVAULATION
• The minimum evaluation of a patient suspected of
NTM lung disease should include (1) a chest
radiograph or, in the absence of cavitation, chest
high-resolution CT scan; (2) three or more sputum
specimens for acid-fast bacilli analysis; and (3)
exclusion of other disorders, such as tuberculosis. [4]

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• polymerase chain reaction (PCR) restriction
fragment length polymorphism analysis, real-
time PCR, line probe hybridization, DNA
sequencing, and matrix-assisted laser
desorption ionization–time of flight
spectrometry aid in detecting the diagnosis
earlier.
• CULTURE METHODS

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TREATMENT
• Appropritae anti tubercular drugs and
antibiotics are given based on the culture and
sensitivity

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Cold abcess

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How smoking is risk factor for tb?
• Smoking damages the lungs and impacts the body’s
immune system, making smokers more susceptible
to TB infection. The occurrence of TB has been
shown to be linked to altered immune response and
multiple defects in immune cells such as
macrophages, monocytes and CD4 lymphocytes (4).
Other mechanisms, such as mechanical disruption of
cilia function and hormonal effects, could also
appear secondarily to smoking (5). Therefore, all
these factors may contribute to the increased
susceptibility of an individual to develop TB
infection.

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• Thank you ...................