lecture of 47 slide

1. Tuberculosis
BY
DR. Magdy Shafik
Senior Pediatric Consultant
M.S ,Ph.D of Pediatric

2. ‫للدرن‬ ‫العالمي‬ ‫اليوم‬
‫العالمي‬ ‫اليوم‬ ‫يمثل‬‫للدرن‬‫في‬24‫آذار‬/‫مارس‬،‫عام‬ ‫كل‬ ‫من‬
‫مستوى‬ ‫إلذكاء‬ ‫فرصة‬‫الوعي‬‫ب‬‫هائل‬ ‫عبء‬ ‫من‬ ‫السل‬ ‫يمثله‬ ‫ما‬.
1.5،‫سنويا‬ ‫بالسل‬ ‫ترتبط‬ ‫وفاة‬ ‫مليون‬
‫إ‬
‫يمثل‬‫المناعي‬ ‫العوز‬ ‫لفيروس‬ ‫المصاحب‬ ‫والسل‬ ،‫السل‬
،‫البشري‬‫لألدوية‬ ‫المقاوم‬ ‫والسل‬‫واألمن‬ ‫للتنمية‬ ‫تهديدا‬ ‫المتعددة‬
‫العالمي‬ ‫الصحي‬.

3. ‫فرصة‬ ‫اليوم‬ ‫هذا‬‫الضوء‬ ‫لتسليط‬‫العالمية‬ ‫الجهود‬ ‫على‬
،‫المستدامة‬ ‫التنمية‬ ‫أهداف‬ ‫مظلة‬ ‫تحت‬ ‫والمبذولة‬ ،‫النشطة‬
‫السل‬ ‫وباء‬ ‫على‬ ‫للقضاء‬‫عام‬ ‫بحلول‬2030
‫تهدف‬‫العالمية‬ ‫الصحة‬ ‫منظمة‬ ‫استراتيجية‬"‫استراتيجي‬‫ة‬
‫السل‬ ‫على‬ ‫القضاء‬"‫إلى‬‫بحلول‬ ‫السل‬ ‫وباء‬ ‫على‬ ‫القضاء‬
‫عام‬2030،‫السل‬ ‫من‬ ‫خال‬ ‫عالم‬ ‫ورؤية‬‫والوصول‬
‫الصفر‬ ‫درجة‬ ‫إلى‬ ‫والمعاناة‬ ‫والمرض‬ ‫بالوفيات‬.

4. ‫مرض‬‫الدرن‬‫مصر‬ ‫جمهورية‬ ‫فى‬‫العربية‬
‫انخفض‬‫انتشار‬ ‫معدل‬‫الدرن‬‫من‬85‫لكل‬ ‫مريض‬100
‫لعام‬ ‫السكان‬ ‫من‬ ‫ألف‬1990‫إلى‬26‫لكل‬ ‫مريض‬100‫ألف‬
‫عام‬ ‫السكان‬ ‫عدد‬ ‫من‬2014،
‫انخفض‬‫المرض‬ ‫حدوث‬ ‫معدل‬‫من‬34‫لكل‬ ‫مريض‬100
‫لعام‬ ‫السكان‬ ‫من‬ ‫ألف‬1990‫إلى‬15‫لكل‬ ‫مريض‬100‫ألف‬
‫عام‬ ‫السكان‬ ‫عدد‬ ‫من‬2014،
‫انخفض‬‫الوفيات‬ ‫معدل‬‫المرض‬ ‫من‬4‫لكل‬100‫ألف‬
‫لعام‬ ‫السكان‬ ‫من‬1990‫إلى‬0.3‫لكل‬ ‫مريض‬100‫من‬ ‫ألف‬
‫عام‬ ‫السكان‬ ‫عدد‬2014

5. ‫عدد‬ ‫بلغت‬‫المكتشفة‬ ‫الحاالت‬7177‫بكل‬ ‫مريض‬
‫أنواع‬‫الدرن‬‫عام‬2015‫و‬8132‫عام‬ ‫خالل‬ ‫حالة‬
2015‫بنسبة‬64%‫بالنسبة‬ ، ‫الحاالت‬ ‫من‬
‫لحاالت‬‫الدرن‬‫المقاوم‬‫لألدوية‬
‫لقاح‬‫جي‬ ‫سي‬ ‫البي‬‫من‬ ‫اكثر‬ ‫منذ‬ ‫استعماله‬ ‫يتم‬ ‫لقاح‬ ‫هو‬
‫بلغت‬ ‫قد‬ ‫و‬ ،‫مضت‬ ‫عاما‬ ‫ثمانين‬‫التغطية‬ ‫نسبة‬‫مصر‬ ‫فى‬ ‫به‬
‫حوالى‬98-99%‫التطعيمات‬ ‫مجموعة‬ ‫ضمن‬ ‫من‬ ‫هو‬ ‫و‬
‫فى‬ ‫يعطى‬ ‫و‬ ‫لألطفال‬ ‫اإلجبارية‬‫الوالدة‬ ‫بعد‬ ‫األول‬ ‫الشهر‬
‫مباشرة‬.‫و‬‫اإلصابة‬ ‫من‬ ‫اللقاح‬ ‫يقي‬‫أشكاال‬ ‫بأشد‬‫لدرن‬‫مثل‬
‫التهاب‬ ‫الدخني‬ ‫والدرن‬ ‫الدرني‬ ‫السحايا‬.

6. ‫عام‬ ‫منذ‬ ‫تتوافر‬ ‫للدرن‬ ‫المضادة‬ ‫األدوية‬1940
‫يمكن‬ ‫اليوم‬ ‫و‬ ،‫الحيوية‬ ‫بالمضادات‬ ‫الفعالة‬ ‫المعالجة‬
‫من‬ ‫المرضى‬ ‫شفاء‬ ‫بسهولة‬‫الدرن‬‫المعالجة‬ ‫باستخدام‬
‫المباشر‬ ‫اإلشراف‬ ‫تحت‬ ‫األمد‬ ‫القصيرة‬ ‫الكيميائية‬
(DOTS ).

7. Background
 Tuberculosis (TB) is the most common
cause of infection-related death worldwide
 Mycobacterium tuberculosis is the most
common cause of TB
 Very rare causes are Mycobacterium
bovis and Mycobacterium africanum
 It is a very hardy bacillus that can survive
under adverse environmental conditions

8. Pathophysiology
 The main determinant of the pathogenicity
of TB is its ability to escape host defense
mechanisms
 The infective droplet nucleus is very small,
measuring 5 micrometers or less, and may
contain approximately 1-10 bacilli.
 5-200 inhaled bacilli are usually necessary
for infection

9. Pathophysiology
 The small size of the droplets allows them to
remain suspended in the air for a prolonged
period of time
 The risk of infection is increased in small
enclosed areas and in areas with poor
ventilation
 the alveolar macrophages phagocytose the
inhaled bacilli. However, these are unable to kill
the mycobacteria, and the bacilli continue to
multiply unimpeded.

10. ‫الدرن‬ ‫ميكروب‬ ‫صفات‬ ‫من‬
‫لمدة‬ ‫يعيش‬‫سنوات‬‫االماكن‬ ‫في‬ ‫وخصوصا‬‫وسيئة‬ ‫المظلمة‬
.‫التهوية‬
‫ل‬ ‫تعرض‬ ‫اذا‬‫لشمس‬‫خالل‬ ‫في‬ ‫عليه‬ ‫فيقضي‬5‫دقائق‬
‫اما‬ ‫الميكروب‬ ‫علي‬ ‫يقضي‬‫بالحرق‬‫الملوثة‬ ‫االشياء‬ ‫غلي‬ ‫او‬
‫لمدة‬5‫دقائق‬
‫الميكروب‬ ‫علي‬ ‫يقضي‬‫الكيميائية‬ ‫بالمطهرات‬‫مثل‬
‫الكلور‬(1)%
‫اما‬ ‫البقري‬ ‫الميكروب‬ ‫علي‬ ‫يقضي‬‫بالبسترة‬ ‫او‬ ‫اللبن‬ ‫بغلي‬

11. Frequency
 to the WHO, more than 8 million new
cases of TB occur each year
 Currently, 19-43.5% of the world's
population is infected with M tuberculosis
 TB occurs disproportionately among
disadvantaged populations, such as
homeless individuals, malnourished
individuals, and those living in crowded
areas

12. Frequency
 According to the WHO, developing
countries including India, China,
Pakistan, Philippines, Thailand, Indonesia,
Bangladesh, and the Democratic Republic
of Congo account for nearly 75% of all
cases of TB.

13. Mortality/Morbidity
 . In 1953, the mortality rate was 12.5 per
100,000 individuals
 MDR-TB cases have a reported fatality
rate of greater than 70%.
 Worldwide, deaths due to TB are
estimated at 3 million per year

14. ‫الدرن‬ ‫بعدوي‬ ‫االصابة‬ ‫علي‬ ‫تساعد‬ ‫التي‬ ‫العوامل‬
1-‫بالدرن‬ ‫مصابين‬ ‫بمرضي‬ ‫االختالط‬
2-‫التغذية‬ ‫سؤء‬ ‫بسب‬ ‫الطبيعية‬ ‫المناعة‬ ‫ضعف‬
‫التطعيم‬ ‫اهمال‬ 3-‫بسب‬ ‫المكتسبة‬ ‫المناعة‬ ‫ضعف‬

15. ‫المرض‬ ‫حدوث‬ ‫علي‬ ‫تساعد‬ ‫التي‬ ‫العوامل‬
‫السن‬:‫من‬ ‫اقل‬ ‫االطفال‬5‫عرضة‬ ‫اكثر‬ ‫سنوات‬
‫الجنس‬:‫الحمر‬ ‫الهنود‬
‫الصناعية‬ ‫المناطق‬ ‫في‬ ‫والعمل‬ ‫المدن‬ ‫الي‬ ‫الهجرة‬
‫الفقر‬ ‫مثل‬ ‫االجتماعية‬ ‫العوامل‬‫سيئة‬ ‫والمنازل‬ ‫التغذية‬ ‫وسؤء‬
‫التهوية‬
‫,والتمريض‬ ‫الوظيفة‬:‫االطباء‬
‫اخري‬ ‫امراض‬:‫السكر‬-‫االيدز‬

16. ‫الدرن‬ ‫بمرض‬ ‫العدوي‬ ‫طرق‬
1-‫التنفسي‬ ‫الجهاز‬ ‫طريق‬ ‫عن‬:
‫بالدرن‬ ‫مريض‬ ‫شخص‬ ‫من‬ ‫المتطاير‬ ‫الرذاذ‬
‫المتطاير‬ ‫الغبار‬
‫الشيشة‬ ‫مثل‬ ‫التدخين‬ ‫ادوات‬ ‫تناول‬
2-‫الهضمي‬ ‫الجهاز‬ ‫طريق‬ ‫عن‬:
‫اللبن‬ ‫وخصوصا‬ ‫بالميكروب‬ ‫ملوثة‬ ‫ومشروبات‬ ‫ماكوالت‬ ‫تناول‬
‫المغلي‬ ‫غير‬
‫الطعام‬ ‫وادوات‬ ‫اواني‬ ‫في‬ ‫الدرن‬ ‫مريض‬ ‫مشاركة‬

17. Pathogenesis of TB
 Stage 1
 Exposure has occurred, implying that the child has
had recent contact with an adult who has contagious
TB
 The child has no physical signs or symptoms and has
a negative TST result
 Not all patients who are exposed become infected,
and it may take 3 months for the TST result to
become positive
o children younger than 5 years may develop disseminated TB
in the form of miliary disease or tubercular meningitis before
the TST result becomes positive. Thus, a very high index of
suspicion is required when a young patient has a history of
contact.

18.  Stage 2
o : This stage is heralded by a positive TST result.
No signs and symptoms occur, although an
incidental CXR may show the primary complex.

19.  Stage 3
o Tuberculous disease occurs and is characterized
by the appearance of signs and symptoms
depending on the location of the disease.
Radiographic abnormalities also may be seen.

20.  Stage 4
TB with no current disease
This implies that the patient has a history of
previous episodes of TB
 stable radiographic findings with a significant
reaction to the TST and negative bacteriologic
studies. No clinical findings suggesting current
disease are present.

21. Pulmonary TB
 Pulmonary TB may manifest itself in several
forms
 endobronchial TB with focal lymphadenopathy
 progressive pulmonary disease
 pleural involvement
 reactivated pulmonary disease
 Symptoms of primary pulmonary disease in the
pediatric population often are meager
 Fever, night sweats, anorexia, nonproductive cough,
failure to thrive, and difficulty gaining weight may
occur

22. Extrapulmonary TB
 Extrapulmonary TB includes
 peripheral lymphadenopathy,
 tubercular meningitis,
 miliary TB,
 skeletal TB,
 and other organ involvement.

23. Congenital TB
 Congenital TB is a rare entity.
 Symptoms typically develop during the second
or third week of life
 poor feeding
 poor weight gain
 cough
 lethargy
 irritability
 Other possible symptoms include fever, ear
discharge, and skin lesions

24. Congenital TB
 the infant should have proven TB lesions
and at least one of the following:
Lesions in the first week of life
Documentation of TB infection of the placenta
or the maternal genital tract
Presence of a primary complex in the liver
Exclusion of the possibility of postnatal
transmission

25. Lab Studies
 the diagnosis of TB in children is extremely
challenging because of difficulty in isolating M
tuberculosis
 initial step is to obtain appropriate specimens for
bacteriologic examination
 Gastric aspirates are used in lieu of sputum in
very young children (<6 y)
 An early morning sample should be obtained,
before the child has had a chance to eat or ambulate,
as these activities dilute the bronchial secretions
accumulated during the night

26. Lab Studies
 Staining of the specimen
 Conventional growth techniques
 Nucleic acid probes
 Polymerase chain reaction (PCR)

27. TST
 Immediate skin testing is indicated for the
following children
 Those who have been in contact with persons with
active or suspected TB
 Immigrants from countries in which TB is endemic (eg,
Asia, Middle East, Africa, Latin America) or children with
travel histories to these countries
 Those who have radiographic or clinical findings
suggestive of TB

28. TST
 Annual TST is indicated for the following
children
 Children who are infected with HIV or those living in a
household with persons infected with HIV
 Performing an initial TST before the
initiation of immunosuppressive therapy is
recommended in any patient

29. TST
 5 TU
 intradermally into the volar aspect of the
forearm
 A wheal should be raised and should
measure approximately 6-10 mm in
diameter

30. TST
Induration of 5 mm or more is considered
positive :
 Children having close contact with known or
suspected contagious cases of the disease
 Children with immunosuppressive conditions
(eg, HIV) or children who are on
immunosuppressive medications
 Children who have an abnormal CXR finding
consistent with active TB, previously active TB,
or clinical evidence of the disease

31. TST
Induration of 10 mm or more is considered
positive:
 Children who are at a higher risk of
dissemination of tuberculous disease
 younger than 5 years
 immunosuppressed
 diabetes mellitus
 malnutrition
 those who were born in or whose parents were
born in high-prevalence areas of the world
 those with travel histories to high-prevalence
areas of the world

32. TST
 Induration of 15 mm or more is
considered a positive TST result in
children aged 5 years or older without
any risk factors for the disease

33. TST
 False-positive reactions often are
attributed to asymptomatic infection by
environmental nontuberculous
mycobacteria (due to cross-reactivity)

34. TST
 False-negative results may be due to
vaccination with live-attenuated virus,
immunosuppression,
 immune deficiency,
 malnutrition.
subcutaneous injection
injection of too little antigen improper storage
 PPD has been recognized to have an
initial false-negative rate of 29%

35. Treatment
 The ultimate goal of treatment is to
achieve sterilization of the TB lesion in the
shortest possible time
 the regimens for the treatment of TB
always should consist of multiple drugs.
 directly observed therapy (DOT) is
recommended for treatment of TB
 MDR

36. Outpatient Care
 Public health authorities should be notified of all
cases of TB
 DOT is mandatory for the treatment of patients
with coexistent HIV disease, those with MDR-TB,
and those who may be noncompliant.
 A regular follow-up appointment every 4-8 weeks
should be scheduled to ensure compliance and
to monitor the adverse effects of and response to
the medications administered

37. Outpatient Care
 Monitoring of liver function test
 miliary TB,
tubercular meningitis,
coexistence of other hepatic disorders
with concomitant hepatotoxic drug therapy

38. Outpatient Care
 Follow-up CXR may be obtained after 2-
3 months of therapy to observe the
response to treatment in patients with
pulmonary TB. However, hilar
lymphadenopathy may take several
years to resolve. Thus, a normal CXR is
not required for termination of therapy

39. Prevention
o The risk of acquisition of TB is particularly
high in very young children (<5 y) and in the
adolescent population. Thus, patients in
these age groups with a positive TST
result and no other manifestations should
receive INH therapy. Active TB should be
excluded carefully prior to the initiation of
preventive therapy.

40. Prevention
 For recent contacts of patients with
contagious TB (ie, in the past 3 mo),
INH therapy is indicated even if the TST
result is negative. This is especially true
for contacts who are infected with HIV or
for household contacts younger than 5
years.

41. Prevention
 The recommendations of the AAP are to
administer 9 months of preventive therapy.
The drug of choice is INH.
 A period of treatment of 12 months is
recommended for patients with HIV
infection.
 For the management of contacts of INH-
resistant cases, rifampin is recommended
for 6 months in children

42. Vaccination
 BCG is a live vaccine prepared from
attenuated strains of M bovis
 Although BCG vaccine has been in use
since 1921 and approximately 3 billion
doses have been administered, its efficacy
continues to be debated

43. Vaccination
 Vaccine is efficacious against miliary and
meningeal TB. Controversy exists about
the efficacy of BCG against pulmonary TB
 The major role of BCG is the prevention
of serious and life-threatening disease
such as disseminated TB and tubercular
meningitis in children. BCG vaccine does
not prevent infection with M tuberculosis

44. Vaccination
 From birth to age 2 months, administration
of BCG does not require a prior TST.
Thereafter, a TST is mandatory prior to
vaccination

45. Vaccination
 Adverse reactions due to the vaccine
include subcutaneous abscess formation
and the development of lymphadenopathy.
Rare complications, such as osteitis of the
epiphyses of the long bones and
disseminated TB, may necessitate
administration of antitubercular therapy,
except for pyrazinamide

46. Vaccination
 Contraindications
 immunosuppressed conditions
Steroid
HIV infection.
 However, in areas of the world where the
risk of TB is high, the WHO recommends
using the BCG vaccine in children who
have asymptomatic HIV infection

47. Thank you