2. History of the Disease
3200-2800 BC - Ancient indians: „Consumption“
400 BC - Hippocrates: „Phthisis“
19th century - peak incidence in western Europe and
North America
1882 - M. tuberculosis identificated by Koch
1920 - „sanatorium regimen“, collapse therapy,
thoracoplasty
1960 - chemotherapy
Introduction
3. Mycobacteria genus
• over 40 species (mostly saphrophytes)
• tuberculosis complex:
• M. tuberculosis
• M. bovis (reactivation disease in elderly
people)
• M. africanum
• M. microti - not pathogenic except under
special circumstanes
• BCG - not pathogenic except under special
circumstanes
Etiology
4. Bacteriology
• acid (alcohol, alkalis)
fasteness
• slow rate of growth
• sensitive to heat and UV
irradiation
• nonmotile
• nonsporulating
Etiology
5. 1/3 of the global world population is infected
7-9 million new cases / year
Annual mortality 1.3 million people (2012)
Mortality without specific therapy: 70% of smear-
positive patients within 10 years
90 million new cases worldwide in the 1990s
30 million deaths worldwide in the 1990s
2000-2020 one billion people will be newly
infected
2000-2020 200 million people will get sick
2000-2020 35 million people will die
1 new infection every second
Epidemiology
16. Risk of the infection
Exposure
• Living in the
household of a
tuberculosis case
• Immigration from an
endemic area (Asia,
Latin America)
• Exposure in
congregate living
facilities (jails, shelters,
health care facilities)
• Older age
• Residence in higher
incidence location
(inner cities)
Susceptibility
• HIV+ PPD 5 mm
• Drug users
• Close contacts of person known or suspected to
have TB, sharing the same household or other
enclosed enviroment PPD 5 mm
• Documented recent converters (PPD increase
10 mm within 2 years for those under age 35 or
15 mm - 35 years old and over)
• Medical risk factors (+PPD 10 mm):
– silicosis
– weight of 10% or more below ideal body
weight
– chronic renal failure
– diabetes mellitus
– prolonged corticosteroid therapy
– Persons from areas with high TB prevalence
35 years old + PPD 10 mm
– Any skin test reactor less than 15 years old
(PPD 10 mm)
Epidemiology
17. Risk of the infection
Group Annual risk of TB
HIV 3-10%
PPD Converters 2-5%
Abnormal CXR 2-4%
Diabetes mellitus 0,3%
No risk factor 0,01-0,1%
Epidemiology
20. Proportion of HIV-attributed Tuberculosis Cases
in the World (Estimates for 1990, 1995, 2000)
0,315 0,739 1,418 1,1
7,5
8,8
10,2
7,6
0
2
4
6
8
10
12
14
1990 1995 2000 2011
Not related to HIV
HIV-attributable
Estimated Cases [Millions]
4,2%
8,4%
13,9%
Epidemiology
12,6%
21. Proportion of HIV-attributed Tuberculosis Cases
in the World (Estimates for 1990, 1995, 2000)
0,315 0,739 1,418
7,5
8,8
10,2
0
2
4
6
8
10
12
14
1990 1995 2000
HIV-attributable
Not related to HIV
Estimated Cases [Millions]
4,2%
8,4% 13,9%
Epidemiology
23. Primary infection
• in patients without specific immunity
• phagocytosis by alveolar macrophages
• primary lesion (Ghon focus) - mid or lower lung
zones
• marked tendency to central liquefaction and
cellular breakdown
• spread through lymphatic to regional lymph
nodes - marked reaction
• spread into blood stream - possible settling
throughout body
Pathogenesis
25. Primary infection
• in patients without specific immunity
• phagocytosis by alveolar macrophages
• primary lesion (Ghon focus) - mid or lower lung
zones
• marked tendency to central liquefaction and
cellular breakdown
• spread through lymphatic to regional lymph
nodes - marked reaction
• spread into blood stream - possible settling
throughout body
Pathogenesis
27. Primary infection
• in patients without specific immunity
• phagocytosis by alveolar macrophages
• primary lesion (Ghon focus) - mid or lower lung
zones
• marked tendency to central liquefaction and
cellular breakdown
• spread through lymphatic to regional lymph
nodes - marked reaction
• spread into blood stream - possible settling
throughout body
Pathogenesis
28. Primary infection
lipoarabinomannan
mannose receptor
complement
receptor
phagosome
lysosome
•inhibition of Ca2+ signals
•blockage of recruitment
and assembly of fusion
mediating proteins
Pathogenesis
transport to lymph
nodes
dissemination by
blood stream
AM
APC
IL12
Th1
CD4+
CD8+
CD4-8-
•epitheloid cell
•granuloma formation
•killing of intracellular
mycobacteria
(NO,NO2,HNO3)
IFNγ
Fas dependent
Fas independent,
granule dependent
caseating
granulomas
acidic environment
stop growth of MTB
30. Primary infection
• the younger the age at which the primary
infection occurs, the more likely it is to be
associated with significant disease, miliary
TB and TB meningitis
• after 3 weeks - 3 months - specific
immunity (tuberculin skin test conversion)
• healing of the primary lesion (scar,
calcification)
Pathogenesis
32. Post-primary disease
• 3-5 years after primary infection
• consequence of hematogenous primary spread
(reinfection???)
• site: lung, bone, lymph nodes
• greater cellular response
• less tendency to caseation
• less response in the regional lymph nodes
• less common hematogenous spread
• more prominent fibrosis
• bronchial involvement („asymptomatic“ bronchiectasis)
• at the start – appearance of a small irregular „pneumonia“
• clinical course – different (according immune-status)
Pathogenesis
34. General symptoms
• Fever (active, progressive disease,
inverse temperature chart)
• Night sweats
• Loss of appetite, weight loss
• Other symptoms: amenorhea, stool
disturbances, hoarseness,
arrhytmias, erythema nodosum,
phlyctenular conjuctivitisP
Clinical
manifestation
