Pulmonary Tuberculosis


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Pulmonary Tuberculosis

  1. 1. Pulmonary Tuberculosis http://crisbertcualteros.page.tl
  2. 2. Pulmonary Tuberculosis <ul><li>Etiology: </li></ul><ul><li>1.1 Mycobacterium tuberculosis </li></ul><ul><li>1.2 Mycobacterium bovis , rarely </li></ul>
  3. 3. Epidemiology <ul><li>Philippine Statistics: FHSIS –DOH 2001 </li></ul><ul><li>Respiratory TB, 6 th leading cause of morbidity with 110,841 cases and rate of 142.2/100,000 population </li></ul><ul><li>TB meningitis with 466 cases or rate of 0.6/100,000 population </li></ul><ul><li>Other forms of TB, 11,494 cases with a rate of 14.7/100,000 population </li></ul>
  4. 4. Epidemiology <ul><li>Source: </li></ul><ul><li>Usually sputum form an infected adult; occasionally exudate from draining sinuses and urine </li></ul><ul><li>Mode of transmission: </li></ul><ul><li>Inhalation of droplet nuclei as a rule </li></ul><ul><li>Occasionally, by ingestion of contaminated milk (M. bovis) </li></ul><ul><li>Direct contamination of open wounds (pathologist </li></ul><ul><li>and lab personnel) </li></ul>
  5. 5. Epidemiology <ul><li>Period of communicability: </li></ul><ul><li>Only if associated with open lesions of PTB, draining sinuses or renal involvement; as long as tubercle bacilli are found in sputum, exudate or urine, respectively </li></ul><ul><li>Children with active PTB are rarely contagious because of the nature of pulmonary lesion, the low baterial output and because sputum is often swallowed. </li></ul><ul><li>A patient is non-infectious within 2-4 weeks of starting adequate therapy </li></ul>
  6. 6. Risk Factors <ul><li>Age: infants and adolescents are at highest risk of disease </li></ul><ul><li>Close contact with an untreated sputum positive patient </li></ul><ul><li>Impaired host defenses: immunodeficiency states, particularly that associated with HIV infection; immunosuppression related to accompanying viral infection, or drug induced; malnutrition. </li></ul><ul><li>Other disease staes: Hodgkin’s lymphomas, diabetes mellitus, leukemia, malignancy (head and neck) severe kidney disease, silicosis, prolonged treatment with corticosteroids </li></ul>
  7. 7. Risk Factors <ul><li>5. Persons whose tuberculin skin test results converted to (+) in the past 1-2 years </li></ul><ul><li>6. Persons who have CXR suggestive of old TB </li></ul>
  8. 8. Portal of Entry <ul><li>Usually respiratory tract (inhalation of aerosolized particles containing 1-3 tubercle bacilli); rarely, skin, gastrointestinaltract, mucous membrane, transplacentally from mother to fetus or via infected amniotic fluid </li></ul>
  9. 9. Incubation Period <ul><li>From 3 to 8 weeks </li></ul>
  10. 10. CLASSIFICATION <ul><li>Class I (TB exposure) </li></ul><ul><ul><ul><li>(+) exposure </li></ul></ul></ul><ul><ul><ul><li>(-) Mantoux tuberculin test </li></ul></ul></ul><ul><ul><ul><li>(-) signs and symptoms suggestive of TB </li></ul></ul></ul><ul><ul><ul><li>(-) chest radiograph </li></ul></ul></ul>
  11. 11. CLASSIFICATION <ul><li>Class II (TB infection) </li></ul><ul><ul><ul><li>(±) exposure </li></ul></ul></ul><ul><ul><ul><li>(+) Mantoux tuberculin test </li></ul></ul></ul><ul><ul><ul><li>(-) signs and symptoms suggestive of TB </li></ul></ul></ul><ul><ul><ul><li>(-) chest radiograph </li></ul></ul></ul>
  12. 12. CLASSIFICATION <ul><li>Class III (TB disease) </li></ul><ul><ul><li>Has three or more of the ff. criteria </li></ul></ul><ul><ul><ul><li>(+) history of exposure to an adult/adolescent with active TB disease </li></ul></ul></ul><ul><ul><ul><li>(+) Mantoux tuberculin test </li></ul></ul></ul><ul><ul><ul><li>(+) signs and symptoms suggestive of TB </li></ul></ul></ul><ul><ul><ul><ul><li>Cough/wheezing > 2 weeks; fever > 2 weeks </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Painless cervical and/or other lymphadenopathy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Poor weight gain; failure to make a quick return to normal after an infection (measles, tonsillitis, whooping cough) or failure to respond to approriate antibiotic therapy (pneumonia, otitis media) </li></ul></ul></ul></ul><ul><ul><ul><li>Abnormal Chest radiograph </li></ul></ul></ul><ul><ul><ul><li>Laboratory findings suggestive of TB (histological, cytological, biochemical, immunological or molecular) </li></ul></ul></ul>
  13. 13. CLASSIFICATION <ul><li>Class IV (TB inactive) </li></ul><ul><ul><li>A child/adolescent with or without history of previous TB and any of the ff: </li></ul></ul><ul><ul><ul><li>(±) previous chemotherapy </li></ul></ul></ul><ul><ul><ul><li>(+) radiographic evidence of healed/calcified TB </li></ul></ul></ul><ul><ul><ul><li>(+) Mantoux tuberculin test </li></ul></ul></ul><ul><ul><ul><li>(-) signs and symptoms suggestive of TB </li></ul></ul></ul><ul><ul><ul><li>(-) smear/culture for M. tuberculosis </li></ul></ul></ul>
  14. 14. Clinical Forms of Tuberculosis <ul><li>Pulmonary/endothoracic </li></ul><ul><ul><li>Asymptomatic or Latent TB infection </li></ul></ul><ul><ul><li>Primary TB/primary complex </li></ul></ul><ul><ul><ul><li>Primary focus, lymphangitis and regional lymphadenitis </li></ul></ul></ul><ul><ul><ul><li>Most common clinical symptoms </li></ul></ul></ul><ul><ul><ul><ul><li>Non-productive cough </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Mild dyspnea </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cervical lymphadenopathies </li></ul></ul></ul></ul>
  15. 15. Clinical Forms of Tuberculosis <ul><ul><li>Pleurisy with effusion </li></ul></ul><ul><ul><ul><li>Accompanies primary focus </li></ul></ul></ul><ul><ul><ul><li>Considered a component of the primary complex </li></ul></ul></ul><ul><ul><ul><li>Onset is usually abrupt </li></ul></ul></ul><ul><ul><ul><li>Fever, chest pain, shortness of breath </li></ul></ul></ul><ul><ul><ul><li>Dullness to flatness and diminished breath sounds </li></ul></ul></ul><ul><ul><ul><li>Obliteration of costophrenic sulcus on CXR (minimal) </li></ul></ul></ul><ul><ul><ul><li>Layering of fluid density (moderate effusion) </li></ul></ul></ul><ul><ul><ul><li>Occupy one hemithorax (massive effusion) </li></ul></ul></ul>
  16. 16. Clinical Forms of Tuberculosis <ul><ul><li>Progressive primary tuberculosis </li></ul></ul><ul><ul><ul><li>More severe fever, malaise, cough, weight loss </li></ul></ul></ul><ul><ul><ul><li>Classical signs of cavitation </li></ul></ul></ul><ul><ul><ul><li>Crepitant rales, diminished breath sounds, lymphadenopathy </li></ul></ul></ul><ul><ul><li>Endobronchial TB </li></ul></ul><ul><ul><ul><li>Bronchial obstruction due to enlargement of peribronchial lymph nodes </li></ul></ul></ul><ul><ul><ul><ul><li>Sudden death by asphyxia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Emphysema </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Atelectasis </li></ul></ul></ul></ul>
  17. 17. Clinical Forms of Tuberculosis <ul><ul><li>Miliary TB </li></ul></ul><ul><ul><ul><li>Generalized hematogenous tuberculosis due to massive invasion of the blood stream by the tubercle bacilli </li></ul></ul></ul><ul><ul><ul><li>Arises from a discharge of a caseous focus often from a lymph node into the blood vessel (pulmonary vein) </li></ul></ul></ul><ul><ul><ul><li>High fever, cough, dyspnea </li></ul></ul></ul><ul><ul><ul><li>Crepitant rales, splenomagly, hepatomegaly, signs of menigeal irritation </li></ul></ul></ul>
  18. 18. Clinical Forms of Tuberculosis <ul><ul><li>Chronic TB </li></ul></ul><ul><ul><ul><li>Reinfection or adult TB </li></ul></ul></ul><ul><ul><ul><li>Apical or infraclavicular infiltrates often with cavitation and no hilar lymphadenopathy </li></ul></ul></ul><ul><ul><ul><li>Persistent cough, prlonged fever, chest pain, hemoptysis and supraclavicular adenitis </li></ul></ul></ul><ul><ul><li>Tuberculoma </li></ul></ul><ul><ul><li>Pericardial TB </li></ul></ul>
  19. 19. Clinical Forms of Tuberculosis <ul><li>Extrapulmonary TB </li></ul><ul><ul><li>TB of the cervical lymph nodes/Scrofula </li></ul></ul><ul><ul><ul><li>Involved LN are painless, firm, discrete, movable becoming adherent to each other and anchored to the surrounding tissues and skin as they enlarge </li></ul></ul></ul><ul><ul><ul><li>Scofuloderma (when left untreated and ruptures resulting in a draining sinus tract </li></ul></ul></ul><ul><ul><li>TB of the CNS </li></ul></ul><ul><ul><ul><li>TB meningitis </li></ul></ul></ul><ul><ul><ul><li>TB abscess </li></ul></ul></ul>
  20. 20. Clinical Forms of Tuberculosis <ul><ul><li>Skeletal TB </li></ul></ul><ul><ul><ul><li>TB of the bones and joints </li></ul></ul></ul><ul><ul><ul><li>TB of the spine or Pott’s </li></ul></ul></ul><ul><ul><li>GI TB </li></ul></ul><ul><ul><ul><li>TB enteritis </li></ul></ul></ul><ul><ul><ul><li>TB peritonitis </li></ul></ul></ul><ul><ul><ul><li>Hepatobiliary TB </li></ul></ul></ul><ul><ul><ul><li>TB of the pancreas </li></ul></ul></ul><ul><ul><li>Cutaneous TB </li></ul></ul><ul><ul><li>Ocular TB </li></ul></ul><ul><ul><li>GUT TB </li></ul></ul><ul><ul><li>TB of the Middle Ear </li></ul></ul>
  21. 21. Diagnostic Tests <ul><li>Mantoux Testing/Tuberculin skin test </li></ul><ul><ul><li>Most widely used method to determine latent TB infection </li></ul></ul><ul><ul><li>Standard method for screening </li></ul></ul><ul><ul><li>positive if ≥ 8 mm induration size </li></ul></ul><ul><ul><li>A dose of 0.1 ml of 2-TU PPD-RT23 or 0.1 ml of 5-TU PPD-S </li></ul></ul><ul><ul><li>Provides a general measure of a person’s cellular response </li></ul></ul>
  22. 22. Diagnostic Tests <ul><li>Mantoux Testing/Tuberculin skin test </li></ul><ul><ul><li>Features of reaction </li></ul></ul><ul><ul><ul><li>Delayed course reaching a peak of more than 24h after injection of antigen </li></ul></ul></ul><ul><ul><ul><li>Indurated character </li></ul></ul></ul><ul><ul><ul><li>Occasional vesiculation and necrosis </li></ul></ul></ul><ul><li>A pale wheal of 6 to 10mm in diameter should be evident after injection </li></ul><ul><li>Read within 48-72hrs from the time of administration </li></ul>
  23. 23. Diagnostic Tests <ul><li>Mantoux Testing/Tuberculin skin test </li></ul><ul><ul><li>False positive </li></ul></ul><ul><ul><ul><li>Nontuberculous mycobacteria </li></ul></ul></ul><ul><ul><ul><li>BCG vaccination </li></ul></ul></ul><ul><ul><ul><ul><li>Reaction develops 6-12 weeks after vaccination </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Wanes after 5 years from immunization </li></ul></ul></ul></ul><ul><ul><li>False negative </li></ul></ul><ul><ul><ul><li>Anergy </li></ul></ul></ul><ul><ul><ul><li>Very young age (< 6 months) </li></ul></ul></ul><ul><ul><ul><li>Recent TB infection or overwhelming TB disease </li></ul></ul></ul><ul><ul><ul><li>Live-virus vaccination </li></ul></ul></ul><ul><ul><ul><ul><li>postpone for at least 4 – 6 weeks after immunization or do it on the same day of vaccination </li></ul></ul></ul></ul>
  24. 24. Diagnostic Tests <ul><li>AFB smears (microscopic examination) </li></ul><ul><ul><li>Provides presumptive diagnosis of active TB </li></ul></ul><ul><ul><li>Gives a quantitative estimation of the number of bacilli on the smear </li></ul></ul><ul><ul><li>Implies infectiousness of the patient </li></ul></ul><ul><ul><li>Low sensitivity (51.8 – 53.1%) </li></ul></ul><ul><ul><li>High specificity (97.5 – 99.8%) </li></ul></ul><ul><ul><li>10 4 bacilli per ml of sputum : lowest concentration that can be detected </li></ul></ul>
  25. 25. Diagnostic Tests <ul><li>Culture : gold std. </li></ul><ul><ul><li>Solid media: 4-6 weeks for isolation and another 2-4 weeks for susceptibility testing </li></ul></ul><ul><ul><ul><li>Middlebrook 7H-11 7H-10 (agar-based) </li></ul></ul></ul><ul><ul><ul><li>Lowenstein-Jensen (egg-based) </li></ul></ul></ul><ul><ul><li>Liquid media </li></ul></ul><ul><ul><ul><li>Bactec : as few as 7 to 10 days; carbon-14 (marker of bacterial growth) </li></ul></ul></ul><ul><ul><ul><li>Middlebrook broth </li></ul></ul></ul><ul><ul><ul><li>Septi-check AFB </li></ul></ul></ul><ul><ul><ul><li>BBL mycobacteria growth incubator tube </li></ul></ul></ul>
  26. 26. Diagnostic Tests <ul><li>Specimens collected for demonstration of tubercle bacilli </li></ul><ul><ul><li>Sputum </li></ul></ul><ul><ul><ul><li>for older children able to expectorate </li></ul></ul></ul><ul><ul><ul><li>Series of three early morning specimens on different days before starting chemotherapy </li></ul></ul></ul><ul><ul><ul><li>Make sure brought up from the lungs </li></ul></ul></ul>
  27. 27. Diagnostic Tests <ul><li>Specimens collected for demonstration of tubercle bacilli </li></ul><ul><ul><li>Gastric aspirate </li></ul></ul><ul><ul><ul><li>For infants and children who cannot expectorate even with aerosol inhalation </li></ul></ul></ul><ul><ul><ul><li>5-10 ml of gastric contents aspirated early in the morning after the person has fasted for at least 8 – 10 hours preferably before the child arises and peristalsis empties the stomach of respiratory secretions swallowed overnight </li></ul></ul></ul>
  28. 28. Diagnostic Tests <ul><li>Specimens collected for demonstration of tubercle bacilli </li></ul><ul><ul><ul><li>Bronchial washings </li></ul></ul></ul><ul><ul><ul><li>Urine </li></ul></ul></ul><ul><ul><ul><ul><li>First morning-voided midstream specimen </li></ul></ul></ul></ul><ul><ul><ul><li>Other body fluids and tissues </li></ul></ul></ul><ul><ul><ul><ul><li>Bone marrow, lung and liver biopsy in patients with hematogenous spread/disseminated disease must be considered </li></ul></ul></ul></ul>
  29. 29. Diagnostic Tests <ul><li>Radiographic Findings </li></ul><ul><ul><li>No pathognomonic findings in childhood TB </li></ul></ul><ul><ul><li>Lateral projections are important wherein partially calcified mediastinal nodes may be visible </li></ul></ul><ul><ul><li>Most common cause of calcification in children </li></ul></ul><ul><ul><li>Uniform stippling of both lungs found in miliary tuberculosis </li></ul></ul><ul><ul><li>Lobar or lobular consolidations </li></ul></ul><ul><ul><li>Common findings: Enlarged retrocardiac lymphadenopathy (70%), hilar adenopathy with pulmonary infiltrates (20%), and pleural effusion </li></ul></ul>
  30. 30. Initial Empiric Therapy of Tuberculosis in Infants, Children and Adolescents Immediately prophylaxis controversial for those 5 years, but is recommended by some experts specially if with risk factors e.g. malnutrition, immunocom-promised states 3 months INH <ul><li>Class I TB Exposure </li></ul><ul><li><5 years </li></ul><ul><li>5 years </li></ul>Remarks Regimen Category
  31. 31. Initial Empiric Therapy of Tuberculosis in Infants, Children and Adolescents <ul><li>Corticosteroids (usually prednisone at 1 mkday for 6-8 weeks with gradual tapering) beneficial for the following: meningitis, pericarditis, pleuritis, endobronchial TB, miliary TB </li></ul>2 months HRZ + E or S ffd by 10 months HR ± E/S given once daily or as DOT 3x weekly Same regimen as pulmonary disease <ul><li>Extrapulmonary </li></ul><ul><li>Severe, life-threatening disease: disseminated/ miliary, meningitis, bone/joint disease </li></ul><ul><li>Other extrapulmonary sites </li></ul>
  32. 32. Initial Empiric Therapy of Tuberculosis in Infants, Children and Adolescents In the presence of primary INH resistance, use Rifampicin 9 months INH 9 months INH 9 months INH <ul><li>Class II TB infection </li></ul><ul><li>PPD conversion within past 1-2 years, (-) CXR </li></ul><ul><li>PPD (+) not due to BCG,(-)CXR, (-) previous treatment </li></ul><ul><li>PPD (+) with stable/ healed lesion, (-) previous treatment </li></ul>
  33. 33. Initial Empiric Therapy of Tuberculosis in Infants, Children and Adolescents 1-2 mos For the duration of immunosup-pression 12 Months INH <ul><li>Class II TB infection </li></ul><ul><li>PPD (+) with stable / healed lesion, (+) previous treatment, at risk of reactivation due to: </li></ul><ul><li>Measles, pertussis, etc </li></ul><ul><li>Conditions/drugs inducing immunosuppression (IDDM leukemia chronicdialysis) </li></ul><ul><li>HIV infection/ persons at risk for infection but HIV status unknown </li></ul>
  34. 34. Initial Empiric Therapy of Tuberculosis in Infants, Children and Adolescents <ul><li>Streptomycin preferred in children < 6 years of age, where visual acuity/color perception cannot be monitored reliably </li></ul><ul><li>In immunocompromised patients, continuation phase extended to 7 months (total duration of therapy:9 months) or for at least 6 months after sputum conversion (if applicable) whichever is longer. If susceptibility results anavailable, continue E/S for the entire duration of therapy </li></ul>2 months HRZ once daily, ffd by 4 months HR given once daily or as DOT 3x weekly 2 months HRZ plus E or S once daily, ffd by 4 months HR ± E/S given once daily or as DOT 3x weekly <ul><li>Class IIIB TB Disease </li></ul><ul><li>Pulmonary </li></ul><ul><li>Fully susceptible: based on culture results of index case, </li></ul><ul><li>(-) previous treatment, <10% local prevalence of primary INH resistance </li></ul><ul><li>(b) Susceptibility unknown or initial drug resistance suspected because of big bacillary population, previous treatment (1 month), close contact with resistant source case, residence in area with >10% primary INH resistance </li></ul>
  35. 35. Algorithm for Preventive Therapy of Childhood Tuberculosis <ul><li>TB Exposure </li></ul><ul><li>Class I </li></ul><ul><li>yes </li></ul><ul><li><5years old Start INH for 3 months </li></ul><ul><li> No </li></ul><ul><li>Repeat Mantoux test Yes Radiologic findings Yes TB Disease </li></ul><ul><li>After 3 months(+) and /or, signs/symptoms (Class III) </li></ul><ul><li> No No suggestive of TB Multiple drug tx </li></ul><ul><li>If no Discontinue INH No </li></ul><ul><li>BCG scar, If no BCG scar, TB Infection </li></ul><ul><li>Give BCG give BCG (Class II) </li></ul><ul><li>Continue  6 INH </li></ul>