Social pharmacy

2. Definition
Tuberculosis (TB) is a potentially fatal contagious
disease that can affect almost any part of the body but is
mainly an infection of the lungs.
Round nodule/Swelling
Condition
“Tubercle”
“Osis”

3. CausativeOrganisms
Mycobacterium tuberculosis
Human
Mycobacterium Bovis
Animals

4. Other causative organisms
⚫Mycobacterium africanum
⚫Mycobacterium microti
⚫Mycobacterium avium
⚫Mycobacterium asiaticum

5. Classification
Extra pulmonary
i. Lymph node TB
ii. Pleural TB
iii. TB of upper airways
iv. Skeletal TB
v. Genitourinary TB
vi. Miliary TB
vii. Pericardial TB
viii. Gastrointestinal TB
ix. Tuberculous Meningitis
Pulmonary TB
-Primary Disease
-Secondary Disease

6. ⚫In 2011,therewere an estimated 8.7million incidence cases
of TB globally.
⚫Itsequivalent to 125 cases in 1,00,000 population.
Asian :
African :
59%
26%
Eastern Mediterranean Region: 7.7%
The European Region : 4.3%
Region of the America : 3%
Epidemiology

7. Spread ofTuberculosis
•Close contact with infected person
•Immunocompromised
•Substance abuse
•Immigration
•Pre-existing medical condition
•Living in overcrowded house etc.

8. Clinical manifestations/ Symptoms
Persistentcough (dry, mucopurulent, blood-more
than 3 weeks)
Chest pain
Coughing with bloody sputum
Shortnessof breath
Urinediscoloration
Cloudy & reddish urine
Fever with chills.
Fatigue
Weight loss
Fluid around lungs

9. Pathogenesis

10. Types
A. Pulmonary TB :-
1. Primary Tuberculosis :-
The infection of an individual who has not been previously infected or
immunised is called Primary tuberculosis or Ghon’s complex or
childhood tuberculosis.
Lesions forming after infection is peripheral and accompanied by hilar
which may not be detectable on chest radiography.
2. Secondary Tuberculosis :
The infection that individual who has been previously infected or sensitized is
called secondary or post primary or reinfection or chronic tuberculosis.

11. B. Extra Pulmonary TB
20% of patients of TB Patient
Affected sites in body are :-
1) Lymph node TB ( tuberculuous lymphadenitis)
Seen frequently in HIV infected patients.
2) Pleural TB
Involvement of pleura is common in Primary TB
and results from penetration of tubercle bacilli into
pleural
space.

12. 3) TB of Upper airways
Involvement of larynx, pharynx and epiglottis.
Symptoms :- Dysphagia, chronic productive cough
4)Genitourinary TB
• 15% of all Extra pulmonary cases.
• Any part of the genitourinary tract get infected.
• Symptoms :- Urinary frequency, Dysuria, Hematuria.
5)Skeletal TB
• Involvement of weight bearing parts like spine, hip, knee.
• Symptoms :- Pain in hip joints n knees, swelling of knees,
trauma.
6)Gastrointestinal TB
Involvement of any part of GI Tract.
Symptoms :- Abdominal pain, diarrhea, weight loss

13. 7) TB Meningitis & Tuberculoma :-
5% of All Extra pulmonaryTB
8) TB Pericardiatis :-
• 1- 8% of All Extra pulmonaryTB cases.
• Spreads mainly in mediastinal or hilar nodes or from lungs.
9) Miliary ordisseminated TB :-
• Results from Hematogenous spread of Tubercle Bacilli.
•Spread isdue toentry of infection into pulmonaryvein producing
lesions in different extrapulmonary sites.
10) Lesscommon Extra PulmonaryTB
uveitis, panophthalmitis, painfull Hypersensitivity related
phlyctenularconjuctivis.

14. Diagnosis
1.Bacteriological test:
a. Zeihl-Neelsenstain
b. Auraminestain(f luorescence microscopy)
2. Sputumculture test:
a. Lowenstein –Jensen(LJ) solid medium: 4-18 weeks
b. Liquid medium : 8-14 days
c. Agar medium : 7 to 14 days

15. 3.Radiography
:
ChestX-Ray(CXR)
4.Nucleic acid amplification:
⚫ Species identification ; several hours
⚫ Low sensitivity, high cost
⚫ Most useful for the rapid confirmation of tuberculosis in persons with
AFB-positive sputa
⚫ Utility
⚫ AFB-negative pulmonary tuberculosis
⚫ Extra pulmonary tuberculosis

16. 5.Tuberculin skin test (PPD)
 Injection of fluid into
the skin of the lower
arm.
 48-72 hours later –
checked for a reaction.
 Diagnosis is based on
the size of the wheal.
1 dose = 0.1 ml contains 0.04µg
Tuberculin PPD.

17. Tuberculin test interpretation

18. 6. Other biological examinations
 Cell count(lymphocytes)
 Protein(Pandyand Rivalta tests) – Ascites, pleural
effusion and meningitis.

19. Preventive measures
1) Mask
2) BCG vaccine
3) Regular medical follow up
4) Isolation of Patient
5) Ventilation
6) Natural sunlight
7) UV germicidal irradiation

21. BCG vaccine
⚫ Bacille Calmette Guerin (BCG).
⚫ First used in 1921.
⚫ Onlyvaccine available today forprotectionagainst tuberculosis.
⚫ It is mosteffective in protecting children from thedisease.
⚫ Given 0.1 ml intradermally.
⚫ Durationof Protection 15 to 20 years
⚫ Efficacy 0 to 80%.
⚫ Should begiven toall healthy infantsas soonas possibleafterbirth
unless thechild presented with symptomatic HIV infection.

22. Management

23. Drugs MOA Diagram
Isoniazid Inhibits mycolic acid synthesis.
RIFAMPICIN Blocks RNA synthesis by blocking
DNA dependent RNA polymerase
PYRAZINAMIDE •Bactericidal-slowly metabolizing
organism within acidic
environment of Phagocyte or
caseous granuloma.

24. Drugs MOA Diagram
ETHAMBUTOL •Bacteriostatic
•Inhibition of Arabinosyl
Transferase
STREPTOMYCIN •Inhibition of Protein
synthesis by disruption of
ribosomal function

25. ADRs and its
Management

26. Dosage regimen
 Intensivephase + continuation phase
 HREZ (2 months) + HRE (4 months)

27. Treatment regimen according to WHO
ISONIAZID (H) RIFAMPICIN (R) PYRAZINAMIDE (Z)
ETHAMBUTOL (E) STREPTOMYCIN (S)

28. DOTS
DOTS - Directlyobserved treatment, short-course
⚫ DOT means that a trained health care worker or other designated
individual provides the prescribed TB drugsand watches the patient
swalloweverydose.

29. Multi-Drug ResistanceTB
TB caused by strains of Mycobacterium
tuberculosis that are resistant toat least isoniazid
and rifampicin, the mosteffectiveanti- TB drug.
Globally, 3.6% are estimated to have MDR-TB.
Almost 50% of MDR-TB cases worldwide are
estimated tooccur in China and India.

30. Extensively drug resistanceTB
⚫Extensivelydrug-resistantTB (XDR-TB) is a form of TB
caused by bacteria that are resistant to isoniazid and
rifampicin (i.e. MDR-TB) as well as any fluoroquinolone
and any of the second-line anti-TB injectable drugs
(amikacin, kanamycin orcapreomycin).

31. Tuberculosis and HIV
⚫Worldwide the numberof people infected with both
HIV and TB is rising.
⚫The HIV virusdamages the body’s immunesystemand
accelerates the speed at which TB progresses from a
harmless infection toa life threatening condition.
⚫Theestimated 10% activationof dormantTB infection
overthe life span of an infected person, is increased to
10% activation in one year, if HIV infection is
superimposed.
⚫It is theopputunistic infection that most frequently
kills HIV-positive people.

32. Epidemiological Impact
⚫Reactivation of latent infection- People who are
infected with both HIV and TB are 25 to 30 times more
likely to develop TB again than people only infected
with TB.
⚫Primary Infection- New tubercular infection in
peoplewith HIV can progress toactivediseasevery
quickly.
⚫Recurring infection- in peoplewhowerecured of
TB.

33. Diagnosis ofTB in people with
HIV
⚫HIV positive people with pulmonary TB may have a
higher frequencyof having sputum negativesmears.
⚫The tuberculin test often fails to work, because the
immunesystem has been damaged by HIV; It may not
even showa responseeven though the person is
infected with TB.
⚫ChestXraywill show lesscavitation.
⚫Casesof Extra pulmonaryTB are morecommon.