Lecture for MBBS

4. 4

5. 5

6. 6
Miliary mottlingMiliary mottling

7. 7
What is the diagnosis?What is the diagnosis?

8. CHILDHOODCHILDHOOD
Dr Mohammad Nurul HuqDr Mohammad Nurul HuqWORLD TB DAY 24 MARCH

9. 9
DefinitionDefinition
It is a chr.It is a chr. granulomatousgranulomatous IDID c/by certain strains ofc/by certain strains of
Mycobacteria mainly affecting the lungsMycobacteria mainly affecting the lungs
 Commonly children <5 y of age are affectedCommonly children <5 y of age are affected
 Less common 5-15yLess common 5-15y

10. EtiologyEtiology
 M tuberculosis (commonest)M tuberculosis (commonest)
 M bovisM bovis
 M africanuM africanumm
 M canetti & M. microti (all togetherM canetti & M. microti (all together MTB complex)MTB complex)
Non-Tb. & non-leprous mycobacteria (Non-Tb. & non-leprous mycobacteria (environmentalenvironmental-- oror
atypical -)atypical -) causecause
non-Tb mycobacterial diseasenon-Tb mycobacterial disease
M bovis:M bovis: TB in cattle. Humans affected by milk; causes moreTB in cattle. Humans affected by milk; causes more
extrapulmonary TBextrapulmonary TB.. Typically resistant to PZATypically resistant to PZA

11. TB Key Facts:TB Key Facts: 30% world population infected!30% world population infected!
22ndnd
only to AIDS as great killer as single infectiononly to AIDS as great killer as single infection
2016:2016: 10.4million (1mln. children) cases (10.4million (1mln. children) cases (3mln. "missed“)3mln. "missed“)
– 1.7million1.7million (250,000 children) death(250,000 children) death.. 0.4 million among HIV0.4 million among HIV..
>95% cases & deaths occur in L&MICs>95% cases & deaths occur in L&MICs
– 480,000 had MDR-TB480,000 had MDR-TB
 11 of top 10 killers worldwideof top 10 killers worldwide
 1 of top 5 killers of women 15-44y1 of top 5 killers of women 15-44y
 A leading killer in HIV (x30 at risk)A leading killer in HIV (x30 at risk)
– 40% of HIV deaths40% of HIV deaths

12.  7 countries7 countries: 64%: 64% load:load: India leadingIndia leading ⇒⇒ Indonesia,Indonesia,
China, Philippines, Pakistan, Nigeria, & S. AfricaChina, Philippines, Pakistan, Nigeria, & S. Africa
Bangladesh 8Bangladesh 8thth
 53million were saved by Rx between 2000-1653million were saved by Rx between 2000-16
 We met MDG6 !: to reduce MR 50% by 2015We met MDG6 !: to reduce MR 50% by 2015
 Incidence is falling 2%/y: if 4–5%Incidence is falling 2%/y: if 4–5% ⇒⇒reach 2020 target ofreach 2020 target of
"End TB Strategy“."End TB Strategy“. Ending TB epidemic by 2030 isEnding TB epidemic by 2030 is
target of SDGtarget of SDG
TB Key Facts ...TB Key Facts ...

13.  TB can mimic any SS; speaks every languageTB can mimic any SS; speaks every language
 Tb occursTb occurs everywhere, in every race, gender, ageeverywhere, in every race, gender, age
 Malnutrition & TB go hand & in handMalnutrition & TB go hand & in hand
 In suspected BA, COPD, bronchitis, TB must be excludedIn suspected BA, COPD, bronchitis, TB must be excluded
 It isIt is ""a global health emergencya global health emergency””
 MDR-TB: is x100 expensive to RxMDR-TB: is x100 expensive to Rx (Rx x2y), often fatal(Rx x2y), often fatal
 Let no one die from PUO without trial by ATDsLet no one die from PUO without trial by ATDs
ATD: anti TB drugs. SS: symptoms & signs. MDR: multi-drug resistanceATD: anti TB drugs. SS: symptoms & signs. MDR: multi-drug resistance
TB Key Facts ...TB Key Facts ...

15. 15
SEAR: 95% in India, Indonesia, BD, Thailand, & BurmaSEAR: 95% in India, Indonesia, BD, Thailand, & Burma
2
-
S.E. Asia has 38% of all TB cases
WPR
25%
AFR
18%
EMR
8%
EUR
6%
AMR
5%
SEAR
38%

16.  90% infected do not get disease90% infected do not get disease
 SS may be mild for months, & can infect 10-15 pax/y.SS may be mild for months, & can infect 10-15 pax/y.
Immunodeficiency: most at risk of active TB & dying.Immunodeficiency: most at risk of active TB & dying. TheThe
majority can be cured. Rx must be completed tomajority can be cured. Rx must be completed to
eradicate/reduce AB resistanceeradicate/reduce AB resistance
 Most fatal in 1Most fatal in 1stst
y of lifey of life
 +ve MT indicates infx., not necessarily the disease+ve MT indicates infx., not necessarily the disease
 BCGBCG has a high efficacy against TBM & MTB, but variablehas a high efficacy against TBM & MTB, but variable
efficacy against adult PTBefficacy against adult PTB
Broadly 2 forms:Broadly 2 forms: pulmonary (90%) & extra-pulmonarypulmonary (90%) & extra-pulmonary
TBM: TB meningitis, MTB: miliary TB, PTB: pulmonary TBTBM: TB meningitis, MTB: miliary TB, PTB: pulmonary TB
TB Key Facts ...TB Key Facts ...

17. Bangladesh ScenarioBangladesh Scenario
 TB is a major Public Health problemTB is a major Public Health problem
 88thth
among 22 high TB burden countries (80%)among 22 high TB burden countries (80%)
 60% population infected;60% population infected; 7 million diseased7 million diseased
 >300,000 new cases/y>300,000 new cases/y (1/every 2min)(1/every 2min)
 70,000 die/y70,000 die/y (1/every 8 min)(1/every 8 min)
 MDR TB: 2.2%,MDR TB: 2.2%, but among previously Rx cases: 15%but among previously Rx cases: 15%
DOT:DOT: works with NTP in line ofworks with NTP in line of Stop TBStop TB StrategyStrategy
PH: public health.PH: public health. DOT: directly observed therapy. MDR: multi-drug resistant, NTP: nationalDOT: directly observed therapy. MDR: multi-drug resistant, NTP: national
TB control programTB control program

18. The end TB strategy:The end TB strategy:
Aims:Aims:
toto endend globalglobal TBTB epidemicepidemic
to reduceto reduce TBTB deaths by 95%deaths by 95%
to cut down incidence of new cases by 90%to cut down incidence of new cases by 90%
between 2015 & 2035between 2015 & 2035
to ensure no family is burdened with catastrophicto ensure no family is burdened with catastrophic
expenses due toexpenses due to TBTB
It sets interim milestones for 2020, 2025, and 2030It sets interim milestones for 2020, 2025, and 2030

19. 19
Prevalence In Our ChildrenPrevalence In Our Children
Not known:Not known: grossly underdiagnosedgrossly underdiagnosed
 Globally: 250,00 die/yGlobally: 250,00 die/y
 One ofOne of 1010 top U-5 killerstop U-5 killers
 Recurrent infx., Mn., & TB go hand in handRecurrent infx., Mn., & TB go hand in hand
Mn: MalnutritionMn: Malnutrition
10 top child killers:10 top child killers: Pneumonia, Diarrhea, Mn, Malaria, AIDs, TB,Pneumonia, Diarrhea, Mn, Malaria, AIDs, TB,
LBW, B. Asphyxia, Drowning, AccidentsLBW, B. Asphyxia, Drowning, Accidents

20. Progress in BangladeshProgress in Bangladesh
MDG6 (To combat HIV/AIDS, malaria, & other diseases)o combat HIV/AIDS, malaria, & other diseases):
met already!
 Case detection up to 72%Case detection up to 72%
 Rx success 93%Rx success 93%
 NGO participationNGO participation
 Previously 5Previously 5thth
now 8now 8thth
in burden of TB pts.in burden of TB pts.
TB is declining but v. slowly:TB is declining but v. slowly: incidence fell 1.5%/yincidence fell 1.5%/y
since 2000)since 2000)
MM: morbidity & mortality

21. MillenniumMillennium
DevelopmentDevelopment
Goals: 2015Goals: 2015

22. HIV plus TB:HIV plus TB: Expensive & fatal !Expensive & fatal !
 1/31/3rdrd
HIV have TBHIV have TB
 Untreated:Untreated: 90% die in months90% die in months
 More in young peopleMore in young people
 More primary infx., more reactivationMore primary infx., more reactivation
 More MDR-TBMore MDR-TB
 Rapid progressionRapid progression
HIV cases should be treated freeHIV cases should be treated free

23. Synonyms/KeywordsSynonyms/Keywords
 Tuberculosis, TB, consumption, phthisisTuberculosis, TB, consumption, phthisis
 Mycobacterial infx., primary TB, reactivation/adult TB,Mycobacterial infx., primary TB, reactivation/adult TB,
unmasked TBunmasked TB
 Miliary TB, MTB, TB meningitis, TBM, MDR-TB, XDR-TBMiliary TB, MTB, TB meningitis, TBM, MDR-TB, XDR-TB
 Pulmonary TB, endobronchial TB, extrapulmonary TBPulmonary TB, endobronchial TB, extrapulmonary TB
 TB lymphadenopathy,TB lymphadenopathy, scrofulascrofula, vertebral TB, vertebral TB
 Pott disease, TB spondylitis, bone TB, joint TB, skeletalPott disease, TB spondylitis, bone TB, joint TB, skeletal
TB, congenital TB, etc.TB, congenital TB, etc.

24. 24
TerminologyTerminology
Primary TBPrimary TB:: First-time inf.First-time inf.
Mainly children. Characterized byMainly children. Characterized by Primary ComplexPrimary Complex
Post-primary/reactivatedPost-primary/reactivated or Adult-onset/or Adult-onset/
Unmasked TBUnmasked TB
Reactivation of dormant inf. Mainly adults. CharacterizedReactivation of dormant inf. Mainly adults. Characterized
byby parenchymal damageparenchymal damage
Positive TST/MT
Likely infection. 2-12w after primary (~3-4 wk)

25. 25
Exposed person
Recent contact with open PTB but negative TST, normal PE
& CXR
Source case
who transmits M tuberculosis
TB Disease
CF and/or X-Ray signs of TB
Latent TB Infx (LTBI)
positive MT but normal PE, CXR or healed focus
(calcification in lung, LN, or both)

26. Predisposing factorsPredisposing factors
 Smoking:Smoking: >20% of TB are attributable to smoking>20% of TB are attributable to smoking
 PovertyPoverty, poor housing, - hygiene, - sanitation, poor housing, - hygiene, - sanitation
 Overcrowding, illiteracyOvercrowding, illiteracy
 MalnutritionMalnutrition
 PollutionPollution
 Raw milkRaw milk
 Dm,Dm, HIV,HIV, immunodeficiency, chemotherapyimmunodeficiency, chemotherapy
 Family TB, illicit drugsFamily TB, illicit drugs

27. 27
PathogenesisPathogenesis
Spread:Spread: aerosol, infected milk. Rarely verticalaerosol, infected milk. Rarely vertical
 Lag period/IP: 2-12w (MT positive)Lag period/IP: 2-12w (MT positive)
 Mostly heal (90%)Mostly heal (90%)
 Any organ:Any organ: PTB commonest: subpleural site, more in RUL.PTB commonest: subpleural site, more in RUL.
Thyroid & heart are least affectedThyroid & heart are least affected
Basic lesion:Basic lesion: tubercle; spread bytubercle; spread by lymphohematogenous routelymphohematogenous route
2 reactions:2 reactions: granulomatous (tubercle)granulomatous (tubercle)
exudative (effusion)exudative (effusion)
Mn: malnutrition. RUL Right upper lobe

28. 28
Tubercle

29. 29
Tubercle

30. 30
Usual Susceptible OrgansUsual Susceptible Organs

31. Reactivated/unmasked TBReactivated/unmasked TB (of dormant(of dormant
M. tuberculosis)M. tuberculosis)
 DMDM
 CorticosteroidsCorticosteroids
 MalignancyMalignancy
 CytotoxicsCytotoxics
 MalnutritionMalnutrition
 Whooping cough, measles, Kala Azar, HIVWhooping cough, measles, Kala Azar, HIV
 Overwhelming inf.Overwhelming inf.
 Immunodeficient statesImmunodeficient states

32. Clinical typesClinical types
Pulmonary (85%)Pulmonary (85%)
 OpenOpen ((smear positive only in 70%. Post-primary)smear positive only in 70%. Post-primary)
 ClosedClosed (no spread)(no spread)
 Primary & reinfectionPrimary & reinfection
 New & retreatmentNew & retreatment
Extrapulmonary (15%)Extrapulmonary (15%)
Smear negativeSmear negative: when 2 sputum samples are negative: when 2 sputum samples are negative

34. Severe & less severe extra-PTB
Severe
TM Meningitis (TBM)
Less Severe
Lymph nodes (gl& TB)
Miliary TB (MTB)
TB Pericarditis Bone (excluding spine)
Bilateral/extensive
TB pleural effusion
Spinal TB
Intestinal TB
Pleural effusion (unilateral)
Peripheral joint

35. P.TBP.TB
 Primary focus (tubercle)Primary focus (tubercle) ((Usually 1;Usually 1; 25% >1);25% >1);
mostly RUL; subpleuralmostly RUL; subpleural
 Regional lymphangiitisRegional lymphangiitis
 Regional LAPRegional LAP
=Together:=Together:
Primary ComplexPrimary Complex

36. 36

37. LymphangiitisLymphangiitis
Tubercle in LUL withTubercle in LUL with
fine lines offine lines of
drainage todrainage to
enlarged HLNenlarged HLN

38. Intrathoracic lymphadenopathyIntrathoracic lymphadenopathy
Paratracheal LAPParatracheal LAP
Hilar LAPHilar LAP
Subcarinal LAPSubcarinal LAP

39. 39
Primary & Post-1y TBPrimary & Post-1y TB (classical in P.TB)(classical in P.TB)
PrimaryPrimary (children)(children)
 First time exposureFirst time exposure
 Mostly closedMostly closed
 LNs more affectedLNs more affected
 More caseationMore caseation
 Less fibrosisLess fibrosis
 Dissemination commonDissemination common
 Heals byHeals by calcificationcalcification
 Less cavitationLess cavitation
Post-primaryPost-primary (adults)(adults)
 Reactivation/re-infectionReactivation/re-infection
 OpenOpen
 Parenchyma moreParenchyma more
 LessLess
 MoreMore
 UncommonUncommon
 FibrosisFibrosis
 CommonCommon

40. Left sided Hilar LAPLeft sided Hilar LAP

41. Rt. Paratracheal LAPRt. Paratracheal LAP Lt. Paratracheal LAPLt. Paratracheal LAP

42. Hilar LNHilar LN

43. Complicated LN diseaseComplicated LN disease
LN eroded bronchus:LN eroded bronchus:
BronchopneumoniaBronchopneumonia
LN obstructing bronchus:
Upper lobe collapse

44. Complicated LN disease …Complicated LN disease …
Hilar LN obstructed bronchi:Hilar LN obstructed bronchi:
Rt middle lobe collapseRt middle lobe collapse
Bronchiectasis RtBronchiectasis Rt
middle and lower lobemiddle and lower lobe

45. Complicated Primary TBComplicated Primary TB
1.1. Over-inflation of Rt. ULOver-inflation of Rt. UL
(ball-valve effect)(ball-valve effect)
2.2. Compressed middle andCompressed middle and
lower zonelower zone

46. Pericardial EffusionPericardial Effusion

47. Pericardial EffusionPericardial Effusion

48. Cavitary diseaseCavitary disease

49. Miliary mottling, LAP,Miliary mottling, LAP,
CavityCavity
LAP: lymphadenopathyLAP: lymphadenopathy

50. Miliary TB in spleenMiliary TB in spleen

51. Spinal TBSpinal TB

52. Spinal TB & Paravertebral AbscessSpinal TB & Paravertebral Abscess
10
9
1
1
1
2
8

53. 53
Big tuberculomaBig tuberculoma

54. 54
Follow-up of PTBFollow-up of PTB
1978:1978: no active d.no active d. 5/1989:5/1989: a mix of exudation & cavities in RUL & a biga mix of exudation & cavities in RUL & a big
exudative lesion in LUL.exudative lesion in LUL. 8/1989:8/1989: lesions in RUL decreased due tolesions in RUL decreased due to
healing; exudative mass on L has necrosed & eroded a bronchus.healing; exudative mass on L has necrosed & eroded a bronchus.
Necrosis is emptied to form cavityNecrosis is emptied to form cavity
10/1989:10/1989: residuum on R are fine linear opacities. L cavity shrunk & theresiduum on R are fine linear opacities. L cavity shrunk & the
surrounding consolidations have resolvedsurrounding consolidations have resolved

55. 55
““Tree in` bud"Tree in` bud"
CT: ill-defined small nodules adjacent to peripheral bronchi:CT: ill-defined small nodules adjacent to peripheral bronchi:
calledcalled tree in budtree in bud

56. 56
CXR & CT of a cavityCXR & CT of a cavity in the apical segment of RUL (K). The drainingin the apical segment of RUL (K). The draining
bronchus is visible (arrow). CT (2mm slice)bronchus is visible (arrow). CT (2mm slice)

57. 57
Immunity in TBImmunity in TB
Immunity is complex &Immunity is complex & incompleteincomplete::
 CMICMI
 Humoral:Humoral: many antibodiesmany antibodies
 MO may stay viable inside healed LN for decades;MO may stay viable inside healed LN for decades;
unmasks when immunity fallsunmasks when immunity falls

58. 58
Fate of Primary ComplexFate of Primary Complex
Best described in PTBBest described in PTB
 Primary focus:Primary focus: mostlymostly healsheals (70%; calcified). If(70%; calcified). If
progressprogress ⇒⇒ symptoms, cavity, bronchiectasis, bleedsymptoms, cavity, bronchiectasis, bleed
 LAP:LAP:
 DisseminationDissemination within 6mowithin 6mo
 ComplicationsComplications:: LAP & primary focusLAP & primary focus

59. 59
CXR & CT of productive TB with multiple nodules (nodules ofCXR & CT of productive TB with multiple nodules (nodules of
MTB are smaller)MTB are smaller)

60. 60
PressurePressure by enlarged LNby enlarged LN
 Stridor, wheeze, hoarsenessStridor, wheeze, hoarseness
 DysphagiaDysphagia
 Bronchiectasis, collapse, emphysemaBronchiectasis, collapse, emphysema
DischargeDischarge of caseous materials:of caseous materials:
 Into BV, lymphatics:Into BV, lymphatics: disseminated TBdisseminated TB
 Into bronchus:Into bronchus: TB Br.Pn. (endobronchial TB)TB Br.Pn. (endobronchial TB)
 Fistula, pl. effusion, pyothorax, pneumothorax; mixFistula, pl. effusion, pyothorax, pneumothorax; mix
 Severe hgeSevere hge
Complications: LAPComplications: LAP
Caseation LN (matted)Caseation LN (matted)

61. 61
Endobronchial spreadEndobronchial spread:: eroding a bronchus: caseated material iseroding a bronchus: caseated material is
aspirated (TB Br.Pn). Lesions are bigger & not well defined as in MTBaspirated (TB Br.Pn). Lesions are bigger & not well defined as in MTB

62. 62
Gross emphysema

63. Complications: 1y FocusComplications: 1y Focus
 CavitationCavitation
 Pl. effusionPl. effusion
 PneumothoraxPneumothorax
 PyothoraxPyothorax
 CollapseCollapse
 ConsolidationConsolidation
 BronchiectasisBronchiectasis
 FibrosisFibrosis
 HgeHge

64. 64

65. 65
Disseminated TBDisseminated TB
 Within 2-6mo of 1y inf.Within 2-6mo of 1y inf.
 Commonly venous; occasionally arterialCommonly venous; occasionally arterial ((local MTB)local MTB)
 Endobronchial:Endobronchial: ac. TB Br.Pnac. TB Br.Pn
 May be asymptomatic:May be asymptomatic: balance of inf.balance of inf.~~defencedefence
 2 gravest forms: ac. MTB & TBM2 gravest forms: ac. MTB & TBM
 Multi-organMulti-organ features. Mfeatures. Mainly liver, kidneys, other partsainly liver, kidneys, other parts
of lungs, skin, LN, brain, etc.of lungs, skin, LN, brain, etc.
Bone, uro-genital involvement very latelyBone, uro-genital involvement very lately

66. 66
Newborn with MTB (mother had active TB)Newborn with MTB (mother had active TB)

67. MTB:MTB: diffuse small pulmonary nodules in a random (haemotogenous) distributiondiffuse small pulmonary nodules in a random (haemotogenous) distribution

68. 68
MTB of lungsMTB of lungs
Spleen in MTBSpleen in MTB
MTB seedling of peritoneum

69. 69
TB Pleural EffusionTB Pleural Effusion (exudative)(exudative)
 Localized PE is part of primary TBLocalized PE is part of primary TB
 Huge exudation may occurHuge exudation may occur
 Ac. onset, fever, chest pain, SoBAc. onset, fever, chest pain, SoB
 Diminished chest movement & B. SoundDiminished chest movement & B. Sound
 Stony dull percussion noteStony dull percussion note
SoB: short of breathingSoB: short of breathing

70. 70
Extensive pleural effusionExtensive pleural effusion

71. 71
Clinical Features TBClinical Features TB
Predisposing factors,Predisposing factors, age U-5, 15-45age U-5, 15-45
General features:General features:
Organ specific features:Organ specific features:

72. 72
GeneralGeneral
 Evening Fever, night sweatsEvening Fever, night sweats
 ANV,ANV, wt. loss, fatiguewt. loss, fatigue, lassitude,, lassitude, loss of initiativeloss of initiative
 HA, irritability, chr. ill health, GLAP, etc.HA, irritability, chr. ill health, GLAP, etc.
Organ specificOrgan specific
 PTB:PTB: chr. cough, hemoptysischr. cough, hemoptysis
 Abdo. TB:Abdo. TB: RAP, distension, diarrhea, constipationRAP, distension, diarrhea, constipation
 Bone TB:Bone TB: arthritis, gibbousarthritis, gibbous
 CNS TB:CNS TB: HA, epilepsy.HA, epilepsy. Skin:Skin: Lupus vulgarisLupus vulgaris
 Renal TB:Renal TB: hematuria, etchematuria, etc
 TBM:TBM: slow onset of meningitisslow onset of meningitis

73. TBM: opacity ofTBM: opacity of
leptomeninges coveringleptomeninges covering
interpeduncular cistern.interpeduncular cistern.
Pus tends to accumulatePus tends to accumulate
along the base of brainalong the base of brain

74. Gibbous: Pott disease:Gibbous: Pott disease: Pre-op. & post-op. pix. of a child withPre-op. & post-op. pix. of a child with
kyphosis corrected by osteotomykyphosis corrected by osteotomy

75. Spina ventosa

76. TB of hip jointTB of hip joint
2 types of lesions of bone TB. 1. caseating exudative type: caseating2 types of lesions of bone TB. 1. caseating exudative type: caseating
necrosis & cold abscess 2. proliferating type: cellular prolif. withnecrosis & cold abscess 2. proliferating type: cellular prolif. with
minimal caseation (granuloma). Type depends on how body reactsminimal caseation (granuloma). Type depends on how body reacts

77. Skin TB: lupus vulgarisSkin TB: lupus vulgaris
TB of Skin (verrucosa cutis)TB of Skin (verrucosa cutis)
Scrofuloderma: chr. effect of skin overlyingScrofuloderma: chr. effect of skin overlying
a TB process, typically LAP, osteoarticular d.a TB process, typically LAP, osteoarticular d.
or epididymitis. Subcut. TB leads to coldor epididymitis. Subcut. TB leads to cold
abscessabscess

78. Suspect TB in a childSuspect TB in a child
MayMay mimic any S/Smimic any S/S
ClassicalClassical
Cough >3w (persistent cough)Cough >3w (persistent cough)
RRTIRRTI
FTTFTT
MalnutritionMalnutrition
Rec. asymmetric wheezesRec. asymmetric wheezes
Rec. FRec. F
PUOPUO
 RAP with positive MTRAP with positive MT
 Chr./rec. diarrheaChr./rec. diarrhea
 Cx LAPCx LAP
 Phlyctenular conj.Phlyctenular conj.

79. PhlyctenularPhlyctenular
KeratoconjunctivitisKeratoconjunctivitis

80. 80
Diagnosis (PTB)Diagnosis (PTB)
 2 sputum (1 spot, 1 early morning).2 sputum (1 spot, 1 early morning). 50% sensitivity50% sensitivity
 CXR PA & Lateral view, CT, MRICXR PA & Lateral view, CT, MRI
 Pleural fluid, pleural biopsy, USGPleural fluid, pleural biopsy, USG
 AFB culture: sputum, gastric aspirate (70%)AFB culture: sputum, gastric aspirate (70%)
 MT (v. imp. in children)MT (v. imp. in children)
 GeneXpert testGeneXpert test (PCR. Dx & drug sensitivity)(PCR. Dx & drug sensitivity)
High index of suspicion is essential. CBC do not confirm orHigh index of suspicion is essential. CBC do not confirm or
exclude. CXR is non-specificexclude. CXR is non-specific

81. 81

82. Tuberculin Skin Testing (TST)/Mantoux TST (MT)Tuberculin Skin Testing (TST)/Mantoux TST (MT)
Standard method to know inf. withStandard method to know inf. with M tbM tb
V. imp. in children. Stronger MT: more active TBV. imp. in children. Stronger MT: more active TB
0.1 ml PPD i.d.:0.1 ml PPD i.d.: needle bevel facing upneedle bevel facing up (pale wheal 6-10mm)(pale wheal 6-10mm)
Read 48-72h later. If pt. does not return: repeatRead 48-72h later. If pt. does not return: repeat
Measure induration,Measure induration, not erythema in mm. in long axisnot erythema in mm. in long axis
CI:CI: severe reaction (necrosis, blistering, anaphylaxis, orsevere reaction (necrosis, blistering, anaphylaxis, or
ulcerations) to a previous TSTulcerations) to a previous TST
BCG:BCG: reacts up to 3yreacts up to 3y

83. IndurationInduration
≥≥5mm5mm is positive:is positive:
- HIV- HIV
- A recent contactA recent contact
- changes on CXRchanges on CXR
- with transplantswith transplants
-i-immunosuppressedmmunosuppressed
≥≥10mm10mm is positiveis positive
-Recent immigrantsRecent immigrants
- (<5y) from endemic(<5y) from endemic
countriescountries
- IDU- IDU
- Residents &- Residents &
employees of high-riskemployees of high-risk
congregate settingscongregate settings
- lab personnel- lab personnel
- Infants, children, &- Infants, children, &
adolescents exposed toadolescents exposed to
adults in high-riskadults in high-risk
categoriescategories
≥≥15mm15mm is positiveis positive
-in any person-in any person
-including persons-including persons
without riskwithout risk
factorsfactors

84. False-Positive ReactionsFalse-Positive Reactions
Non-TB mycobacteriaNon-TB mycobacteria
BCG vaccinationBCG vaccination
Incorrect method, - interpretation, - antigenIncorrect method, - interpretation, - antigen
False-Negative ReactionsFalse-Negative Reactions
Faulty tech.(Faulty tech.(commonest),commonest), anergy, malnutrition,anergy, malnutrition,
 First 6–10w of inf.First 6–10w of inf.
Severe sys. d., immunosuppressionSevere sys. d., immunosuppression
V. old TB inf. (many years)V. old TB inf. (many years)
<6mo age; overwhelming d<6mo age; overwhelming disseminated TBisseminated TB
Recent live-virus vax (measles & smallpox)Recent live-virus vax (measles & smallpox)
Some viral illnesses (measles & chicken pox)Some viral illnesses (measles & chicken pox)

85. How Often Can TSTs Be Repeated?How Often Can TSTs Be Repeated? NNo risk to repeato risk to repeat
What is a Boosted Reaction?What is a Boosted Reaction?
Reaction to PPD may wane over time (false-negative). But,Reaction to PPD may wane over time (false-negative). But,
TST may stimulate the immune sys, causing a boostedTST may stimulate the immune sys, causing a boosted
reaction later (2-step testing)reaction later (2-step testing)
It is useful for HCW/nursing home residentsIt is useful for HCW/nursing home residents
Can TSTs Be Given To Persons Receiving Vax?Can TSTs Be Given To Persons Receiving Vax?
Vax–live-viruses may interfere with TSTVax–live-viruses may interfere with TST
Do it either on the same day of vax or 4-6w laterDo it either on the same day of vax or 4-6w later
Do it at least 1mo after smallpox vaxDo it at least 1mo after smallpox vax

86. 86

87. 87

88. 88
Other testsOther tests
 Gastric aspirateGastric aspirate
 ICTICT
 Inflammatory fluidInflammatory fluid
 PCRPCR
 FNACFNAC
 BiopsyBiopsy
ALSALS

89. ALSALS (Antibodies in lymphocyte secretion)(Antibodies in lymphocyte secretion)
AdvantagesAdvantages
 Sensitivity >93 %; correlate clinically; an early biomarkerSensitivity >93 %; correlate clinically; an early biomarker
of active infectionof active infection
 Rapid detection of active TBRapid detection of active TB
 Diseased specimen not requiredDiseased specimen not required
 May be preserved for long timeMay be preserved for long time
DisadvantagesDisadvantages
 Cannot be applied if MT done within 40dCannot be applied if MT done within 40d
 It is a complementary test to other testsIt is a complementary test to other tests
 Rx is not given if only ALS is positiveRx is not given if only ALS is positive

90. 90
TreatmentTreatment
AIMSAIMS
 To cure, prevent disabilityTo cure, prevent disability
 To prevent relapse, drug resistance & toxicityTo prevent relapse, drug resistance & toxicity
 To prevent transmissionTo prevent transmission
 RehabilitationRehabilitation
RxRx
 SpecificSpecific
 SupportiveSupportive
 Rx of complicationsRx of complications
MDR Rx costs x100MDR Rx costs x100.. Right dosage, duration & combination of drugsRight dosage, duration & combination of drugs
are essentialare essential

91. Case classification by Rx historyCase classification by Rx history
 New:New: received no Rx or treated for <1moreceived no Rx or treated for <1mo
 Relapse:Relapse: treated previously (completed & cured)treated previously (completed & cured)
 Rx failure:Rx failure: smear is still positive after 5mo Rxsmear is still positive after 5mo Rx
 Rx after default:Rx after default: Rx after incomplete RxRx after incomplete Rx
 MDR-TB:MDR-TB: resistant to INH & RFMresistant to INH & RFM
 XDR-TB:XDR-TB: resistant to 2resistant to 2ndnd
line drugs: 1line drugs: 1
fluroquinolones plus any of amikacin,fluroquinolones plus any of amikacin,
capreomycin, kanamycincapreomycin, kanamycin

92. 92
Directly Observed Therapy (DOT)Directly Observed Therapy (DOT)
 ATD are given directly to the pt. by HWATD are given directly to the pt. by HW (not friend)(not friend) &&
documented. Prevent DR & spreaddocumented. Prevent DR & spread
 Non-cooperation isNon-cooperation is rarerare & illegal (PH law)& illegal (PH law)
 Coverage in Bangladesh 99%Coverage in Bangladesh 99%
5-point package:5-point package:
– political commitment, fundpolitical commitment, fund
– case detectioncase detection
– standard Rx with supervision & supportstandard Rx with supervision & support
– effective drug supplyeffective drug supply
– monitoringmonitoring

94. 94

95. ATDATD
 First line:First line: Rifampicin, INH, streptomycinRifampicin, INH, streptomycin
 22ndnd
line:line: Thiacetazone, PZA, ethambutolThiacetazone, PZA, ethambutol
Reserved:Reserved: ethionamide, PAS, amikacin, prothionamide,ethionamide, PAS, amikacin, prothionamide,
cycloserine, ciprofloxacin, ofloxacin, capreomycincycloserine, ciprofloxacin, ofloxacin, capreomycin
They are safe & well tolerated; SE are uncommon in children;They are safe & well tolerated; SE are uncommon in children;
no routine LFT, no routine B6no routine LFT, no routine B6
PZA: pyrazinamide. PAS:PZA: pyrazinamide. PAS: p-p-aminosalicylic acidaminosalicylic acid

96. 96
Side EffectsSide Effects
Seek helpSeek help in renal-, hepatic-, & pregnancy TBin renal-, hepatic-, & pregnancy TB
RFM:RFM: cholestatsis, inactivate OCP, ‘flu’-like syn.cholestatsis, inactivate OCP, ‘flu’-like syn.
INH:INH: hepatitishepatitis,, neuropathy, agranulocytosis, B6 defi.,neuropathy, agranulocytosis, B6 defi.,
Ethambutol:Ethambutol: optic neuritisoptic neuritis
PZA:PZA: arthralgia, hepatitis (arthralgia, hepatitis (gout is a CIgout is a CI))
Streptomycin:Streptomycin: ototoxicity, nephrotoxicityototoxicity, nephrotoxicity

97. 97
Standard ATD TherapyStandard ATD Therapy
A. Initial/intensive PhaseA. Initial/intensive Phase
3-4 drugs (2mo)3-4 drugs (2mo)
RifampicinRifampicin
INH, PZAINH, PZA
EthambutolEthambutol
StreptomycinStreptomycin
B. Continuation PhaseB. Continuation Phase
2 drugs (4mo):2 drugs (4mo):
RifampicinRifampicin
INHINH
Standard drug regimen: earlier bacterial clearance (non-infectious: 2Standard drug regimen: earlier bacterial clearance (non-infectious: 2
weeks), less resistance, better monitoring, low costweeks), less resistance, better monitoring, low cost

98. Categories of Standard RxCategories of Standard Rx
CategoriesCategories Pt. categoriesPt. categories InitialInitial
phasephase
Cont.Cont.
phasephase
Cat. ICat. I New smear +veNew smear +ve
New ,, -veNew ,, -ve
New extra-PTBNew extra-PTB
New HIV-TBNew HIV-TB
2mo (HRZE)2mo (HRZE) HR: 4moHR: 4mo
Cat. IICat. II Smear +ve despite RxSmear +ve despite Rx
≥≥1 mo without Rx1 mo without Rx
RelapseRelapse
Rx failure Cat. IRx failure Cat. I
Rx after defaultRx after default
OthersOthers
2 mo:2 mo:
(HRZES) &(HRZES) &
1mo: (HRZE)1mo: (HRZE)
=3mo=3mo
HRE: 6moHRE: 6mo

99. 99
Drug Resistance in BDDrug Resistance in BD
 StreptomycinStreptomycin 59.3%59.3%
 INHINH 17.4%17.4%
 RFMRFM 3.5%3.5%
 EthambutolEthambutol 3.5%3.5%
 INH+RFMINH+RFM 3.5%3.5%

100. 100
Supportive RxSupportive Rx
 Treatment of symptomsTreatment of symptoms
 Correction of malnutritionCorrection of malnutrition
 Balanced foodBalanced food
 Adequate exerciseAdequate exercise
 RehabilitationRehabilitation

101. 101
Treatment FailureTreatment Failure
 Commonest:Commonest: noncompliancenoncompliance
 MDR/XDR-TBMDR/XDR-TB
 Inadequate number/dose/duration of drugsInadequate number/dose/duration of drugs
 Incorrect DxIncorrect Dx

102. 102
Coricosteroids in TBCoricosteroids in TB
Indications:Indications: P. Effusion, TBM, pericarditis, HIV-TB,P. Effusion, TBM, pericarditis, HIV-TB,
endobronchial TB, TB adrenal atrophy, MTB,endobronchial TB, TB adrenal atrophy, MTB,
compressing TB lymphadenitiscompressing TB lymphadenitis
Prednisolone is the DoCPrednisolone is the DoC
Does not shorten duration of RxDoes not shorten duration of Rx
1-2 mg/kg/d. 6w in TBM1-2 mg/kg/d. 6w in TBM
4-6w with tapering4-6w with tapering
Advantages:Advantages: TBM:TBM: ⇓⇓ MM.MM. MTB:MTB: improves GCimproves GC dramatically.dramatically.
Pericardial E.:Pericardial E.: prevents constriction.prevents constriction. Pl. effusion:Pl. effusion: early relief.early relief.
Endobronchial TB:Endobronchial TB: relieves distressrelieves distress

103. Congenital TBCongenital TB
 RareRare
 Primary complex usually lies in the liverPrimary complex usually lies in the liver
 Dx can beDx can be difficultdifficult
 50% die within 3-4 w50% die within 3-4 w
 CXR may shows MTB or primary TBCXR may shows MTB or primary TB
 May be born with primary skin TBMay be born with primary skin TB
 Mother may have no evidenceMother may have no evidence

104. PreventionPrevention
 Contact tracing & Rx are primary goals (13% un-identified)Contact tracing & Rx are primary goals (13% un-identified)
 BCG vaccinationBCG vaccination
 Raising living standard, nutrition & healthRaising living standard, nutrition & health
educationeducation
 Cough etiquette & hand washingCough etiquette & hand washing

106. WHO responseWHO response toto control TB.control TB. Stop TB StrategyStop TB Strategy
 Global leadershipGlobal leadership
 Policies, strategies, standards for Px, Rx, care & control.Policies, strategies, standards for Px, Rx, care & control.
Monitor theseMonitor these
 FinancingFinancing
 Provide technical supportProvide technical support
 Research & dissemination of knowledgeResearch & dissemination of knowledge
 Facilitate & engage in partnerships for TBFacilitate & engage in partnerships for TB

107. Stop TB (WHO)
 Vision:Vision: A TB-FREE WORLDA TB-FREE WORLD
 Goal:Goal: to dramatically reduce TB by ‘15 (MDG6)to dramatically reduce TB by ‘15 (MDG6)
 Objectives:Objectives: universal access to HQ care for alluniversal access to HQ care for all
– Reduce suffering & SE burden of TBReduce suffering & SE burden of TB
– Protect vulnerable popn. from TB, TB-HIV, MDR-TBProtect vulnerable popn. from TB, TB-HIV, MDR-TB
 Targets:Targets:
– by 2015: reduce cases & deaths by 50%by 2015: reduce cases & deaths by 50%
– by 2050: eliminate TB as a PH problemby 2050: eliminate TB as a PH problem

108. Components of the Stop TB strategyComponents of the Stop TB strategy
1. DOT1. DOT expansion:expansion: political will, detection & Dx,political will, detection & Dx,
standard Rx & support, drug supply,standard Rx & support, drug supply, monitoring &monitoring &
evaluationevaluation
2. TB-HIV, MDR-TB,2. TB-HIV, MDR-TB, & the needs of poor popn.:& the needs of poor popn.:
sscale-up collaborative TB/HIV activities, scale-cale-up collaborative TB/HIV activities, scale- upup
prevention & management of MDR-TB,prevention & management of MDR-TB, addressaddress
TB contacts, & needs of poor &TB contacts, & needs of poor & vulnerablevulnerable
peoplepeople

109. 3. Strengthening primary HC:3. Strengthening primary HC: improve policies,improve policies,
develop HW, effective running; infx. control,develop HW, effective running; infx. control,
lab networkslab networks
4. Engage all care providers:4. Engage all care providers: involve all; promoteinvolve all; promote
International Standards for TB CareInternational Standards for TB Care
5. Empower people about TB5. Empower people about TB:: communication &communication &
social mobilization; community participationsocial mobilization; community participation
6. Research:6. Research: operational research; research tooperational research; research to
develop Dx, drugs, Vaxdevelop Dx, drugs, Vax

110. MDR-TBMDR-TB
do not respond to INH & rifampicin (2 most powerful)do not respond to INH & rifampicin (2 most powerful)
 The primary cause is inappropriate RxThe primary cause is inappropriate Rx
 2013: globally 480k had MDR-TB: >50% in India, China,2013: globally 480k had MDR-TB: >50% in India, China,
Russia. 9% MDR-TB are XDR-TBRussia. 9% MDR-TB are XDR-TB
 Curable by 2Curable by 2ndnd
-line drugs x2y: are limited, not plenty & v-line drugs x2y: are limited, not plenty & v
expensive: ~severe SEexpensive: ~severe SE
 XDR-TB: responds to fewer drugsXDR-TB: responds to fewer drugs

111. SummarySummary
 TB occurs everywhereTB occurs everywhere
 Mostly PTBMostly PTB
 It is curable & preventableIt is curable & preventable
 Spreads by droplets; only a few bacteria can infectSpreads by droplets; only a few bacteria can infect
 1/31/3rdrd
world popn. infected:world popn. infected: 10% lifetime risk of active TB10% lifetime risk of active TB
 Immunocompromised has a much higher riskImmunocompromised has a much higher risk
 One can infect 15 close contacts/yOne can infect 15 close contacts/y
 Untreated: 2/3Untreated: 2/3rdrd
diedie

112. 112
Points to PonderPoints to Ponder
 TB may mimic any S/S; oTB may mimic any S/S; oftenften under-diagnosedunder-diagnosed
 Most primaries are asymptomaticMost primaries are asymptomatic
 More prevalent in AIDSMore prevalent in AIDS
 MDR-TB is almost aMDR-TB is almost a ‘death sentence’‘death sentence’
 Treating open cases controls spreadTreating open cases controls spread
Contd.Contd.

113. 113
 Infection necessarily is not a diseaseInfection necessarily is not a disease
 Adult PTB is mostly open, child PTB is closedAdult PTB is mostly open, child PTB is closed
 Normal CXR, CBC do not exclude PTBNormal CXR, CBC do not exclude PTB
 TB is an important c/of PUOTB is an important c/of PUO
 BCG does not prevent TBBCG does not prevent TB
Points to Ponder …Points to Ponder …

114. 114
 ComplianceCompliance is essential:is essential:
– prevents spreadprevents spread
– less drug resistanceless drug resistance
– full recoveryfull recovery
 Monitoring: DOT, urine colorMonitoring: DOT, urine color
 Vision check in ethambutol useVision check in ethambutol use
Points to Ponder …Points to Ponder …

115. Extra Pulmonary TB:
CNS
Disseminated TB
Lymphatics, pleura, bones & joints
Urogenital
Skin

116. scrofulascrofula

118. Phlyctenular conjunctivitisPhlyctenular conjunctivitis

121. OSPEOSPE
Look at the CXR of a child whose mother hasLook at the CXR of a child whose mother has
persistent cough, irregular F, & wt losspersistent cough, irregular F, & wt loss
1.1. What abnormalities you find?What abnormalities you find?
2.2. How do you confirm your Dx?How do you confirm your Dx?
3.3. What are the complications of the primary infx.?What are the complications of the primary infx.?
4.4. How do you treat?How do you treat?

122. 122

123. Answer KeysAnswer Keys
 Miliary mottling in both lung fieldsMiliary mottling in both lung fields
 MT, gastric/tracheal aspirate for CS, PCR, ALSMT, gastric/tracheal aspirate for CS, PCR, ALS
 Complications from primary focus …., enlarged LNComplications from primary focus …., enlarged LN
….. & from caseous material …..….. & from caseous material …..
 4 drug Rx for minimum 6mo4 drug Rx for minimum 6mo

124. MCQMCQ
 Most TB infx. leads to diseaseMost TB infx. leads to disease
 BCG vax. prevents TBBCG vax. prevents TB
 Childhood TB is mostly contagiousChildhood TB is mostly contagious
 Normal CXR excludes PTBNormal CXR excludes PTB
 Normal CBC excludes TBNormal CBC excludes TB

125. MCQMCQ
 TB can mimic any sign or any symptomTB can mimic any sign or any symptom
 Most primary infx. healsMost primary infx. heals
 Use of steroid reduces Rx durationUse of steroid reduces Rx duration
 Non-compliance is the commonest c/of Rx failureNon-compliance is the commonest c/of Rx failure
 inadequate Rx is the main c/of MDR-TBinadequate Rx is the main c/of MDR-TB

126. Thyroid is commonly affected by TB
 Commonest c/of pseudo-negative MT isCommonest c/of pseudo-negative MT is
faulty techniquefaulty technique
 TB is an important c/of female infertilityTB is an important c/of female infertility
MCQMCQ

131. RabiesRabies
Next Lec.Next Lec.

132. 132THANK YOU