INDIA IS HOME FOR TUBERCULOSIS,THIS PPT IS UPDATED A/P WHO AND RNTCP GUIDELINES

1. TUBERCULOSIS
DR MAHTAB
MBBS,DCH,DNB
HIMSR,NEW DELHI

2. INTRODUCTION
INDIA CONTRIBUTE 25% OF TOTAL WORLD TUBERCOLOSIS
40%INDIAN IS INFECTED,PEDIATRIC CASES IS 6-10%(ABOUT 5.5
LAKHOF NEW CASES,80000 DEATH ANNUALLY
CHILD TB OFTEN RAPID PROGRESSION,SHORTER INCUBATION
PERIOD,
EXTRAPULMONARY TB MORE COMMONLY OCCUR IN CHILDREN
25-30%OF CHILDHOOD TB

3. • PULMONARY PARENCHYMAL DISEASE AND INTRATHROCIC ADENOPATHY
60-80 %
• LYMPHADENOPATHY MC 67%EXTRAPULMONARY MANIFESTATION
F/B CNS 13%INVOLVEMENT,PLEURAL
6%,MILIARY/DISSEMINATED5%,SKELETAL4%
PROGRESSION OF DS DEPEND UPON AGE<3YR,HIV
COINFECTION,MALNUTRITION 3 IMP FACTOR

4. • CASE FINDING AND DIAGNOSIS: SYMPTOM BASED APPROACH
• PEDIATRIC PRESUMPTIVE TB: FEVER AND COUGH >2 WK,LOSS
OF WT/NOT GAINING WT,AND/OR EXPOSURE TO SMEAR
POSTIVE PT OR SIGNIFICANT SUPERFICIAL LYMPHADENOPATHY
• PRESUMPTIVE DR –TB PT WHO FAILED T/T WITH FIRST LINE
DRUGS,CONTACT WITH MDR TB,TB PT WITH HIV COINFECTION

5. SYMPTOM
•fever: persistent
>2wk,unexplained,>38*c,reported by
guardian/recorded atleast once
•Cough:persistent ,unremitting,not a/w cold
•Ftt or definite wt loss; no wt gain in last 3
month,unexplained wt loss >5% of highest wt
recorded in last 3 month

6. • Lymph node; max prevalence 5-9 yr
• mc site is neck ( jugular, posterior triangular,
supraclavicular )
• h/o contact; in symptomatic pt contact with any
form of active disease in past 2 yr, in
asymptomatic pt exposure to smear positive pt
•

7. DIAGNOSIS OF TB IN CHILDREN
• Smear microscopy for afb;
1) Zn (ziehl neelsen) stain
2) LED based fluorescent microscopy
Culture ;
1)Lj (Lowenstein –Jensen medium (solid)
bactec (liquid) Eg BACTEC 460TB,MGIT 960
liquid medium having 10% more yield,reduce time for result week to
days

8. ZN STAINING
(BRIGHT RED)

9. • CBNAAT; CARTRIDGE BASED NUCLEIC ACID AMPLIFICATION )
PCR BASED,DETECT MTB COMLEX,RIF AND INH RESISTENCE
BETTER THAN XPERT
• GENEXPERT (XPERT); DETECT TUBERCLE BACILLI AND RIF
RESISTENCE FROM SPUTUM AND SPECIMEN FROM
EXTRAPULMONARY SITE. CURRENTLY FIRST
LINEBACTERIOLOGICAL TEST RECOMMENDED IN RNTCP

10. SPECIMEN COLLECTION
• 2 SAMPLE FOR TEST ONE SAMPLE FOR GENEXPERT
• GASTRIC ASPIRATE(GA) EARLY MORNING,AFTER 4-6 HR
FASTING,TRANSPORT TO LAB IMMEDIATELY WITHIN 4 HR IF
DELAY ADD 1-2ML OF SODIUM BICARBONATE
• INDUCED SPUTUM; CAN DO IN AMBULATORY SETTING NO NEED
OF FASTING
• BAL (BRONCHIAL ALVEOLAR LAVAGE) ;USED TO EVALUATE
PERSISTENT PNEUMONIA YIELD IS LESSER THAN GA AND
INDUCED SPUTUM SO USED AS ADD ON TEST

11. CHEST RADIOGRAPHY
• ; HIGHLY SUGGESTIVE FINDING ARE MILIARY SHADOW,HILAR OR
MEDIASTINAL NODES AND FIBROCAVITORY
SHADOW,CONSOLIDATION,NON HOMOGENOUS
OPACITY,GROUND GLASS APPERANCE
• PA AND LATERAL VIEW CAN PICKED MISSED LESION HIDDEN
AREA LIKE LLL(BEHIND HEART),HILAR LOBE BY FRONTAL VIEW. A
LAT VIEW CAN PICK UPTO 12-19% OF LESION MISSED BY
FRONTAL VIEW

12. MILIARY SHADOW

13. HILAR LYMPHADENOPATHY

14. LUNG PATCHES

15. TB PNEUMONIA

16. • CONTRAST ENHANCED CT; R/O TB IN PUO,AND PERSISTENT PNEUMONIA,GIVE
BETTER ANATOMINAL DETAIL,NODE DESCRPTION AND HIDDEN
AREA,RECOMMENDED BY RNTCP IN SELECTED CASES
• TUBERCULIN SKIN TEST; CONTRIBUTORY TEST ALONG WITH H/SIGN
/SYMPTOM/RADIOLOGY
• CURRENT RECOMMENDATION IS TO USE 2 TU RT23 IF NOT AVAILABLE 5 TU IS
ACCEPTED,READ BETWEEN 48-72 HR
10MM INDURATION POSITIVE
5MM HIV POSITIVE
IF PT REPORT AFTER 72 HR CAN BE READ UPTO 7 DAYS IF + CONSIDER IT. IF
NEGATIVE REPEAT TEST, IF REPORTING AFTER 7 DAYS TEST IS REPEATED
IRRESPECTED OF INDURATION,IN OPPOSITE ARM
SEVERE FORM OF TB,HIV INFECTION,SEVERE MALNUTRITION , RECENT INFCTION
IMPORTANT CAUSE OF FALSE NEGATIVE RESULT

17. MT TEST

18. DIAGNOSIS OF LYMPH NODE TB
• EITHER FNAC/BIOPSY IS NEEDED. SAMPLE SEND FOR CYTOLOGY
( GRANULOMA),BACTERIOLOGICAL TEST AFB SMEAR/AFB
CULTURE AND XPERT.
• CXR SHOW FINDING IN 5-40% OF CASES,TST POSITIVITY >70%.

21. TREATMENT
• CASE DEFINITION; MICROBILOGICAL CONFIRM AND CLINICALLY
DIAGNOSED ABSENCE OF POSITIVE BACTERIOLOGICAL TEST
• NEW CASE; CASES NOT TAKEN T/T,TAKEN T/T <1 MONTH
• PREVIOUSLY TREATED CASES;
RELAPSE CASE;PREVIOUSLY SUCCESSFUL TREATED CASE AGAIN
DEVELOP BACTERIOLOGICAL CONFIRMED TB
TREATMENT FAILURE;PATIENT DECLARED FAILURE AT THE END OF
TREATMENT
DEFAULTER TOOK ATLEAST ONE MONTH T/T LATER COME WITH
BACTERIOLOGICAL CONFIRMED TB

22. DEPENDING UPON DRUG RESISTENCE
• MONO RESISTENT TB; RESISTENCE TO ANY ONE OF THE FIRST
LINE DRUG
• POLY RESISTENT TB; RST TO >1 DRUG(OTHER THAN INH,R)
• MDR TB ; RESISTENCE TO INH+RIF WITH OR WITHOUT
RESISTENCE TO OTHER FIRST LINE DRUGS
• XDR TB; MDR TB +RESISTENCE TO ANY FQ AND ATLEAST ONE
OF THE THREE SECOND LINE INJECTABLE DRUGS
(CAPREOMYCIN,KANAMYCIN,AMIKACIN)

23. DRUG FIRST LINE ATT
ISONIAZID 10 ( 7-15) 300
RIFAMPICIN 15 (10-20) 600
PYRAZINAMIDE 35 (30-40)
ETHAMBUTOL 2O (15-25)
STREPTOMYCIN 15 (12-18)
HRSEP,10,15,15,2O,35
HIGHER END OF INH IN CHILD AS CHILD GROW UP LOWER END OF
DOSING RANGE BECOME APPROPRIATE

24. IN 2010 WHO RECOMMENDED DAILY DAILY DOSE WHEREVER
FEASIBLE FOR NEW PT THROUGHOUT COURSE,ADD ETHAMBUTOL
BOTH INTENSIVE AND CONTINOUS PHASE, ALSO RECOMMENDED
FIXED DOSE COMBINATIONS (FDC)
TYPE OF PT INTENSIVE PHASE CONTINOUS PHASE
NEW 2HRZE 4 HRE
PREVIOUSLY T/T 2HRZES+1HRZE 5 HRE
IN SEVERE TB Eg CNS TB ,DISSEMINATED TB,SKELETAL TB
CONTINUATION PHASE IS EXTENDED 12-24 WK MORE (3-6 M)

25. • ETHAMBUTOL EARLIER NOT GIVEN <6YR BCZ IT MIGHT CAUSE OPTIC
NEURITIS,CHILDREN WILL NOT REPORT COULD LEAD TO
IRREVERSIABLE BLINDNESS.
• E IS BACTERIOSTATIC DRUG WHICH WILL LOWER RISK OF TREATMENT
FAILURE,SO GIVEN IN BOTH INTENSIVE AND CONTINOUS
PHASE,TOXICITY IS DOSE RELATED NEGLIGIBLE IF RECOMMENDED
DOSAGES ARE ADHERE TO.

26. FIXED DRUG COMBINATION
• REDUCE PILL BURDEN AND PRESCRIPTION ERROR
• NEWLY RECOMMENDED FDC HAVING INH:RIF 2:3 RATIO ,IT HAS
INH 50,RIF75,PZA 150 @10:15:30MG/KG

27. • WT CATEGORY NO OF TB
INTENSIVE PHASE CONTINOUS PHASE
HRZ E HRE
50/75/150 100 50 /75/100
• 4-7 1 1 1
• 8-11 2 2 2
• 12-15 3 3 3
• 16-24 4 4 4
• 25-29 3+1A * 3 3+1A*
• 30-39 2+2A* 2 2+2A*
• A* ADULT FDC FOR IP 75/150/400/275 A* ADULT FDC FR CP 75/150/275

28. AGJUVANT THERAPY IN TB
• STEROIDS; USED IN COMPLICATED FORM OF TB EG TBM,MILIARY
TB,TUBERCULOS PERICARDITIS,ENDOBRONCHIAL TB,AIRWAYS
OBSTRUCTION OF LYMPH NODE,PLEURAL EFFUSION WITH SEVERE
DISTRESS
• PREDNISOLONE 2MG/KG ( INCREASE TO 4MG/KG IN SERIOUS ILLNESS)
MAX 60MG/DAY FOR 4WK , TAPER OVER 1-2 WEEKS
• PYRIDOXINE; INH CAUSE NEUROPATHY IN CHILDREN WITH SEVERE
MALNUTRION AND RETRO INFECTION ON ART WHO
RECOMMENDED(5-10MG/DAY)

29. • TREATMENT RESPONSE AND FOLLOW-UP; IDEALLY ASSESSED 2
WK AFTER START OF T/T, AT THE END OF INTENSIVE PHASE
THAN EVERY 2 MONTHS UNTIL COMPLETION OF T/T
• NOT RESPONDING… DR TB,ANOTHER CAUSE,UNUSUAL
COMPLICATION OF PULMONARY DISEASE,PROBLEM WITH T/T
ADHERENCE

30. ATT INDUCED HEPATITIS
• TRANSIENT ELEVATION OF LIVER ENZYME UPTO 5 TIME IS NOT INDICATION TO STOP
TREATMENT
DRUG INDUCED LIVER INJURY DIAGNOSED WHEN
1. RISE OF ALT/AST >5 TIME OF UNL IN ASYMPTOMATIC CHILD
2. ALT RISE >3 TIME IN SYMPTOMATIC CHILD
3. S.BILIRUBIN >1.5
RED FLAG SIGN; N,V,J,ANOREXIA,NEW ONSET HEPATOMEGALY, unexplained fatigueness
,BLEEDING
IN SEVERELY ILL PT GIVE MODIFIED ATT (NON HEPATOTOXIC) REGIMN WITH S,E,AND A FQ
(SAFE)
IN NON SEVERELY ILL PT STOP ATT DO WEEKLY LIVER ENZYME TILL IT REACHES TWICE THE
NORMAL LEVEL RESTART WITH R (1ST) NEXT INH THAN PZA

31. PREVENTION OF TB
• INDICATION FOR CONTACT INVESTIGATION; HOUSEHOLD OR
CLOSE CONTACT ARE INVESTIGATED WHEN INDEX CASE
• SPUTUM SMEAR POSITIVE PULMONARY TB
• PROVEN OR SUSPECTED MDR OR XDR TB
• PERSON LIVING WITH HIV
• CHILDREN <5 YR OF AGE

32. ISONIAZID PREVENTION THERAP (IPT)
INDICATION OF PREVENTIVE THERAPY
1. CHILDREN <6YR WHO HAD EXPOSURE TO AN INFECTIOUS TB CASES
2. ALL HIV INFECTED CHILD WHO HAD EXPOSURE TO AN INFECTIOUS
TB CASES
3. ALL TST +(>5MM) WHO IS HIV + WITH NO EXPOSURE TO TB
4. ALL TST + CHILDREN WHO IS RECEIVING IMMUNOSUPPRESSIVE
THERAY EG NS,ACUTE LEUKEMIA
INH 10MG/KG MAX 300MG/DAY FOR 6M IS STARTED AFTER
EXCLUDING ACTIVE DS

33. CONGENITAL TB
• IN PREGNENCY ALL 1ST LINE EXCEPT S CN BE GIVEN(SAFE FR FETUS)
• MILIARY AND MENINGEAL TB ARE HIGH RISK FACTOR .VERTICAL TRANSMISSON
DOESN’T OCCUR IN PLEURAL EFFUSION AND LYMPH NODE TB,LESS CHANCE IF
MOTHER TOOK ATT 2 WK BEFORE DELIVERY OR COMPLITED COURSE BEFORE
DELIVERY
• PRESENT RECOMMENDATION GIVE INH PROPHYLAXIS 10MG/KG FOR 6 MONTHS
TO ALL BABIES BORN TO A MOTHER WHO IS DIAGNOSED TO HAVE ACTIVE TB
DURING PREGNANCY,AFTER DELIVERY OR EXPOSED TO ANY CASE OF ACTIVE DS
AFTER DELIVERY
• BCG VACCINATION ;2 WK AFTER COMPLETION OF INH
PROPHYLAXIS(WHO),RNTCP FOR PRACTICAL PURPOSE AT BIRTH EVEN
CHEMOPROPHYLAXIS IS PLANNED

35. BREAST FEEDING OF BABY
• ALL EFFORT SHOULD BE SOUGHT TO CONTINUE BF
ISOLATION OF BABY IS INDICATED ONLY IF MOTHER IS
1. MOTHER IS HAVING MDR TB
2. MOTHER IS SICK
3. NO ADHERENT TO THERAPY
4. RECEIVED ATT<2WK OR SUSPECTED TO HAVE DR TB
BARRIER NURSING ,USING FACE MASK AND APPROPRIATE COUGH HYGIENE ALL ADVISED TO
ALL MOTHER

36. THANK YOU HIMSR
• SOURCE; RNTCP TB GUIDELINE 2016
T/T OF TB GUIDELINE WHO 2010
AIIMS NEONATOLOGY BOOK