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  1. 1. Tuberculosis Jiang Lihong Tianjin Medical University
  2. 2. Questions <ul><li>Pathogen of TB </li></ul><ul><li>what is primary complex? </li></ul><ul><li>Clinical manifestations especially tuberculous meningitis </li></ul><ul><li>When the patient has miliary tuberculosis, what is the typical chest x-ray manifestation? </li></ul>
  3. 3. Diagnostic tests and procedures the tuberculin test
  4. 4. The tuberculin test <ul><li>method </li></ul><ul><li>assessment </li></ul><ul><li>a negative reaction </li></ul><ul><li>studies indicated when the tuberculin test is positive </li></ul>
  5. 5. Who need to take the tuberculin test <ul><li>People who have had close day-to-day contact with someone who has active TB disease </li></ul><ul><li>people who has symptoms </li></ul><ul><li>people who have to be tested for a job or school </li></ul><ul><li>people who have lowered immunity </li></ul>
  6. 6. method <ul><li>OT: old tuberculin </li></ul><ul><li>PPD: purified protein derivative tuberculin </li></ul><ul><li>Standard dose of PPD tuberculin: 5 units 0.1ml of Tween stabilized solution </li></ul>
  7. 7. tuberculin test is done on children
  8. 8. Site:volar surface of the forearm
  9. 9. Size:diameter 6-10mm
  10. 11. Within 48 to 72 hours, a positive TB skin test is marked by an area of reddish induration greater than 10 mm. It is the induration (firm bump) that is gently palpated that determines the size, not the area of redness. This reaction is slightly larger than the average positive test 17 mm in size. The positive reaction shown here was obtained with a TB skin test performed 20 years after the initial infection
  11. 14. <ul><li>Figure A.   6 hours after administration of tuberculin, some reaction can be seen.  It is thought that this does not reflect a specific reaction. </li></ul><ul><li>Figure B.   After 24 hours a clear reaction is seen, but the demarcations are unclear. </li></ul><ul><li>Figure C.   After 48 hours a central induration is now clearly present. It is thought to be the result of release of cytokines by specified cells that activate the local macrophages, resulting in the typical induration. </li></ul><ul><li>Figure D.   After 72 hours the result can be read equally well.  The recommendation is to read the tuberculin test after 48 to 72 hours. </li></ul>
  12. 15. Assessment <ul><li>Site: volar surface of the forearm </li></ul><ul><li>time: 48 to 72 hours </li></ul><ul><li>assessment: </li></ul><ul><li>(1)erythema without induration and induration less than 5 mm—negative(-) </li></ul><ul><li>(3)induration greeter than 5 mm but less than 10 mm—doubtful(+) </li></ul><ul><li>(4)induration greater than to 10 mm but less than 20 mm—positive(++) </li></ul><ul><li>(5) induration greater than to 20 mm (+++) </li></ul><ul><li>(6)blister and necrosis—positive(++++) </li></ul>
  13. 23. A negative reaction <ul><li>A negative reaction to tuberculin testing usually means that the individual has never been infected with the tubercle bacillus. However, reaction may be falsely negative, and it is important to recognize the circumstance under which this may occur </li></ul>
  14. 24. A negative reaction <ul><li>(1)individual has never been infected with the tubercle bacillus </li></ul><ul><li>(2)intercurrent disease </li></ul><ul><li>(3)viral vaccines </li></ul><ul><li>(4)corticosteroids and immunosuppressive agents </li></ul><ul><li>(5)celluar immune deficiency disease </li></ul>
  15. 25. A negative reaction <ul><li>(6)Severe malnutrition </li></ul><ul><li>(7)overwhelming tuberculous infection </li></ul><ul><li>(8)testing too early </li></ul><ul><li>(9)important testing material </li></ul><ul><li>(10)faulty technique </li></ul>
  16. 26. Studies indicated when the tuberculin test is positive <ul><li>If a pulmonary infiltrative lesion is detected by radiography, gastric washing should be performed in an attempt to culture the tubercle bacillus. </li></ul><ul><li>members of the family and other close contacts should evaluated with a careful history, a physical examination, a chest radiograph, and /or a tuberculin test. </li></ul>
  17. 27. Identification of the tubercle bacillus by smear or culture <ul><li>Sputum </li></ul><ul><li>gastric washing </li></ul><ul><li>CSF </li></ul>
  18. 28. sputum <ul><li>If the child with pulmonary infections is producing sputum, this may be cultured. If not, an aerosol-induced sputum may prove useful in the child old enough to cooperate. </li></ul>
  19. 29. Gastric washings <ul><li>In a child of any age gastric washing can be obtained or examination. Before breakfast the stomach is lavaged with sterile water, the washing are aspirated and cultures are then performed. </li></ul>
  20. 30. CSF <ul><li>When the tuberculous meningitis is suspected, the centrifuged sediment of the cerebrospinal fluid should be examined for tubercle bacilli. T he cerebrospinal fluid should be cultured and treatment should be instituted immediately on clinical grounds. </li></ul>
  21. 31. Radiographic studies <ul><li>Radiographic studies may support the opinion that the child has pulmonary or osseous TB.However, similar radiographic findings are present in other diseases. Therefore caution should be exercised interpretation of X-ray studies, and the diagnosis should not be made on this evidence alone. </li></ul>
  22. 32. PCR <ul><li>Polymerase chain reaction allows detection of M. Tuberculosis DNA. This is generally performed on sputum samples. </li></ul>
  23. 33. What does having TB infection mean? <ul><li>Having TB infection means that the TB germs are in the body but they are in an inactive state. </li></ul>
  24. 34. Inactive TB germs can't hurt you now ...
  25. 35. What is TB disease? <ul><li>It is possible to get TB disease shortly after the germs enter the body if body defenses are weak. </li></ul><ul><li>It is possible that the inactive TB germs become active when body defenses are weakened. </li></ul>
  26. 36. ... when body defenses are weakened, inactive TB germs become active and break out
  27. 37. case
  28. 38. Tuberculin test
  29. 39. Tuberculosis from sputum
  30. 40. Chest x-ray
  31. 41. Chest x-ray
  32. 42. treatment <ul><li>General care </li></ul><ul><li>chemotherapy </li></ul><ul><li>immunization </li></ul>
  33. 43. General care <ul><li>Patients with asymptomatic initial infection can be managed as outpatients and require no restriction of activity. They should receive all immunizations, including rubeola vaccine. </li></ul><ul><li>Those with complications should be hospitalized until afebrile and until their condition has stabilized to the point where home care is possible. </li></ul><ul><li>The patients with chronic tuberculosis is contagious only so long as the sputum is positive for M. tuberculosis and significant coughing is present. </li></ul>
  34. 45. chemotherapy
  35. 46. Asymptomatic tuberculin-positive children and adolescents <ul><li>Isoniazid </li></ul><ul><li>period:12 momths </li></ul><ul><li>dosage: 10-20mg/kg/24hr(max300mg) </li></ul><ul><li>toxic effects: hepatotoxicity(rare in children), peripheral neuritis(reported only in association with accidental poisoning), toxic encephalopathy(rare and probably reversible with withdrawal of the drug) </li></ul>
  36. 47. Children and adolescents with symptomatic tuberculosis <ul><li>Combined therapy with isoniazid and rifampin </li></ul><ul><li>rifampin: 10-20mg/kg(max600mg); </li></ul><ul><li>toxic effects:transient abnormalities of liver function, nausea and vomiting, an orange-red color may be noted in secretions </li></ul>
  37. 48. Short-course chemotherapy <ul><li>Period: 6-9months </li></ul><ul><li>isoniazid and rifampin at usual daily doses for 1 month </li></ul><ul><li>isonizid and rifanpin twice weekly for 8 months </li></ul>
  38. 49. Other drugs <ul><li>Pyrazinamide: 15-30mg/kg/24hr(potentially hepatotoxic) </li></ul><ul><li>streptomycin: 20-40mg/kg(potentially nephrotoxic) </li></ul><ul><li>ethambutol, ethionamide, para-aminosalicylic acid, capreomycin, kanamycin, cycloserine </li></ul>
  39. 50. As same as INH po 10-15mg ETH Optic neuritis po 15-25mg EMB Hepatotoxic,hyperuricemia,arthralgia, po 20-30mg (≤750mg/d) PZA Nephrotoxic,hypersensitivity,fever im 20-30mg (≤750mg/d) SM Hepatotoxicity,nausea,vomit po 10mg(≤450mg/d) RFP Hepatotoxicity,peripheralneuritis,hypersensitivity,fever po (im, iv) 10mg(≤300mg/d) INH Main adverse reaction method Dosage(kg/d) drug
  40. 51. corticosteroid <ul><li>Actual or impeding cerebrospinal fluid block in tuberculous meningitis </li></ul><ul><li>respiratory distress in tuberculous endobronchitis </li></ul>
  41. 52. immunization <ul><li>BCG: bacille calmette guerin </li></ul><ul><li>Indicated only when contact with active tuberculosis cannot be avoided in the family or community. </li></ul><ul><li>Should not be given to individuals with comprised immune status caused by underlying disease or immunosuppressive drug therapy. </li></ul>
  42. 53. <ul><li>Two French scientists Albert Calmette and Camille Guerin developed a vaccine against tuberculosis from an attenuated form of the bovine bacillus in 1921. BCG stands for Bacillus-Calmette‑Guerin. It is the only vaccine we have for the prevention of TB. It should be given to children at birth. BCG protects children from meningial and milliary TB. </li></ul>
  43. 54. question <ul><li>How to assess tuberculin test </li></ul><ul><li>what dose a negative reaction mean? </li></ul><ul><li>Short-course treatment: drug; dosage </li></ul><ul><li>how to immunize? </li></ul>
  44. 55. thanks