Facts about TB: • 10.4m cases per year • 1.8m deaths • Most common cause of death among HIV • >4m never get diagnosed and treated Facts about resistant TB • 600 000 Rifampicin resistant cases • Less than 25% are recognized Speaker: Dr. B.P.Singh MD( Pulmonary Medicine), FCCP(U.S.A) Respiratory ,Critical Care & Specialist for Sleep Medicine. Director and President  Midland Health Care and Research Centre  Midland (Erstwhile Aditya clinic) Respiratory Care, Sleep Evaluation & Pulmonary Rehabilitation Centre  Surya Chest Foundation(NGO). Senior Chest Consultant,Lucknow  Globe Medicare Ex- Visiting Consultant, SGPGI. Lucknow

1. TUBERCULOSIS
Speaker:
Dr. B.P.Singh
MD( Pulmonary Medicine), FCCP(U.S.A)
Respiratory ,Critical Care & Specialist for Sleep Medicine.
Director and President
 Midland Health Care and Research Centre
 Midland (Erstwhile Aditya clinic) Respiratory Care, Sleep
Evaluation & Pulmonary Rehabilitation Centre
 Surya Chest Foundation(NGO).
Senior Chest Consultant,Lucknow
 Globe Medicare
Ex- Visiting Consultant, SGPGI. Lucknow.

3. Tuberculosis – the deadliest infectious disease
MDR
Undiagnosed TB
Undiagnosed TB
Untreated TB
All cases of TB
Facts about TB:
• 10.4m cases per year
• 1.8m deaths
• Most common cause of death among HIV
• >4m never get diagnosed and treated
Facts about resistant TB
• 600 000 Rifampicin resistant cases
• Less than 25% are recognized
WHO Global TB report 2017

4. India accounts for 1/5
cases in the world
thof all TB incidence
Source: WHO Global Report 2009
Global annual incidence = 9.4 million
India annual incidence = 1.98 million

6. The burden of EPTB is high
 Ranges from 15– 20% of all TB cases in HIV-negative patients
 Accounts for 40–50% of new TB cases in HIV-positive people
 Lack of evidence-based guidelines on diagnosis and treatment of various types of EPTB
 Absence of adequate infrastructure and resources up to the peripheral level of health
facilities to identify, diagnose and treat EPTB
Epidemiology of Extra-pulmonary TB (EPTB)

7. Sites of EPTB
*Gaur et al., August - September 2017; 6(5): 2773-2778

8.  Mycobacterial stain and culture
 Biopsy
 Body fluid examination
 Nucleic acid amplification test
 Immunological tests
Diagnosis

9. Sputum microscopy
• Provides definitive diagnosis
• Easy to perform
• Replicable
• Cost effective
• 50% of the new pTB pts. expected to be SS+

10. Microscopy is More Objective and Reliable than
X-ray
 Inter-observer variability is much
less with microscopy than with x-
ray
 AFB microscopy provides
information on infectiousness of
the patient, which x-ray does not
 AFB microscopy allows
prioritization of cases, which x-
ray does not
 AFB microscopy is also an
objective method to follow the
progress of patients on treatment

11. Other Diagnostic Tests
 Mantoux gives evidence of infection, not
disease
 ESR is not specific
 Culture is specific, sensitive
 But time consuming, costly, requires specialized labs
 Other tests like PCR, Ig Assays etc.
 No value over conventional techniques
 Highly sensitive, but poor specificity

12. OBJECTIVES
• What are complications of tuberculosis?
• What are various presentations of EPTB?
• Drug resistant tuberculosis
• DOTS & RNTCP

13. COMPLICATIONS

14. COMPLICATIONS
• Local-
• ARDS/respiratory failure
• Bronchiectasis/PTOAD
• aspergilloma
• haemoptysis (symp )
• Pleural -Empyema/pneumo
• Extensive lung destruction
• Rt middle lobe syndrome
• Scar ca

15. • Systemic-
• shock
• amyloidosis
• disseminated tb-(laryngeal tb)
• Cor-pulmonale

16. EPTB
• Common sites:LN,PE
• Any site
• Diagnosis:more difficult

17. LN TB
•LN-site
•painless enlargement
,systemic symptoms<50%
•Matting
•Sinus/fistula
•FNAC/Bx/NAAT/smear/culture

18. Pleural Effusion
• Pain/dyspnea/cough
• Fever/dec appetite
• Radiology
• Pleural fluid analysis

19. SKELETAL TB
•Site
•Pain/joint swelling/dec
range of motion.
•Draining sinuses and
abscesses
•Systemic symptoms
•Radiographic changes
m/b nonspecific

20. CNS TB
• Tuberculous meningitis(MC), intracranial tuberculomas, , cranial
nerve palsies and communicating hydrocephalus , cranial vasculitis
may lead to focal neurologic deficits.
• Malaise, headache, fever, or personality change,A/S,seizures/focal
defects
• CSF –lymphocytic,increased protein,ADA,CB NAAT

21. Koch’s abdomen
•Site-gut/peritoneum/LN
•pain,nausea/vomitting
•altered bowel habbits
•Distension
•Diagnosis:ascetic fluid
analysis/LN
sampling/radiology

22. Miliary
• Fever/dec appetite/wt loss/vague-elderly
• Haematogenous
• Fulminant disease -septic shock, ARDS,MOF
• CXR/Liver/spleen BX/BM
• Haematological-anaemia(NCNC),hyponatremia

23. PRESENTATION(Extra-Pulmonary)
• Genitourinary-infertility, urinary difficulties
• CVS-pericarditis(pain/dyspnea)

24. CLINICAL CLUES-EPTB
• Ascites -lymphocyte predominance and negative bacterial cultures
• Chronic lymphadenopathy (especially cervical)
• CSF -lymphocytic pleocytosis / elevated protein /low glucose
• Pleural effusion -Exudative / lymphocyte predominance/negative bacterial cultures
• Joint inflammation (monoarticular) with negative bacterial cultures
• Persistent sterile pyuria
• Unexplained pericardial effusion, constrictive pericarditis, or pericardial
calcification/Vertebral osteomyelitis involving the thoracic spine

25. MANAGEMENT

26. Principles of chemotherapy
• Variable bacilli population:rapid growers,slow growers,dormant
• Longer duration
• 2 phases of treatment
• Need for multiple drugs to treat(spontaneous resistance)

27. TREATMENT REGIMENS
Type of TB case Intensive Phase Continuation Phase
New(CAT 1) 2RHEZ 4RHE
Retreatment(CAT 2) 2SHREZ/1RHEZ 5RHE
R;rifampicin,H:isoniazid,E:ethambutal,Z:pyrazinamide,S:streptomyci
n
Intermittent regimens
are being changed to
daily regimens under
RNTCP in India

28. • New case:CAT 1
• Smear positive
• Smear negative
• EPTB
• Retreatment:CAT 2
• Relapse
• Defaulter
• failure

29. • CAT 4 :MDR
• CAT 5:XDR
• Definitions
• MDR:R and H
• XDR:R and H,any FQ,any injectables(kanamycin,amikacin,capreomycin)
• Primary & acquired resistance
• Mono/poly drug resistance:DRTB

30. Drug Resistance:Magnitude
• 3% Primary
• 12% Acquired
• XDR 4-20% of MDR

31. Dx in drug resistant Tb
• MDR-TB:
• Rapid Molecular Test ( LPA/ CB-NAAT)
• Liquid Culture & DST
• Solid Culture & DST
• XDR-TB:
• Liquid Culture & DST
• Solid Culture & DST
• LPA(Genotypic methods)

45. OLD

46. Grouping of antiTb drugs(2017 ,RNTCP
guidelines)
FQ Levo/moxi/gati
Injectable agents K/A/C
Other second line drugs Etio/prothio/cycloserine/linezolid
Add on drugs D1:Z/E/H high dose,D2:Bedaquiline/delaminid
D3:PAS,Amoxy-clav,Meropenem,imipenem
cilastatin

47. RNTCP 2017

49. DR TB:Principles of Treatment
• MDR:4 second line drugs /not used
• XDR:7 drugs
• Duration:24(MDR),36(XDR)
DOTS plus previously

50. Second line drugs
• Treatment longer
• Toxic
• Expensive
• Stress:emergence rather than treatment of DRTb
more

51. Newer ATT
• Bedaquiline
• Delaminid
• protaminid

52. MCQ
• A pt on ATT C/O burning soles
• A pt on ATT C/O loss of appetite & vomittings
• A pt on ATT C/O dec vision

53. DOTS & RNTCP

54. Advantages
• Directly observed
• Standardised treatment
• Free of cost

55. TB & HIV
• Increased chances of reactivation/relapse
• Atypical presentations
• Higher ADR/drug interactions
• Priorty to treat Tb first and then ART

56. MIDLAND HEALTHCARE & RESEARCH CENTRE
B-55 & C-42, Mandir Marg, Mahanagar, Lucknow-220 006
Thank You