MBBS Lecture

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5. 5

6. 6

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

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

9. TB Key Facts:TB Key Facts: 30% world population infected!30% world population infected!
22ndnd
only to AIDS as the greatest killer as single infx.only to AIDS as the greatest killer as single infx.
 2015:2015: 10.4million cases (10.4million cases (3 million "missed“)3 million "missed“)
– 1.8million (450k children) death1.8million (450k children) death
– 480k had MDR-TB480k had MDR-TB
 11 of top 10 killers worldwideof top 10 killers worldwide
 >95% cases & deaths occur in DCs>95% cases & deaths occur in DCs
 1 of top 5 killers of women 15-44y1 of top 5 killers of women 15-44y
 HIV is x30 at riskHIV is x30 at risk
– 35% of HIV deaths35% of HIV deaths (0.4 million)(0.4 million)
multidrug resistant TB (MDR-TB). DCs: developing countriesmultidrug resistant TB (MDR-TB). DCs: developing countries

10.  6 countries have 60% of load:6 countries have 60% of load: India leading,India leading, f/byf/by
Indonesia, China, Nigeria, Pakistan & S. AfricaIndonesia, China, Nigeria, Pakistan & S. Africa
Bangladesh 7Bangladesh 7thth
 49million were saved by Dx & Rx between 2000-1549million were saved by Dx & Rx between 2000-15
 We met MDG6 !: to reduce MR 50% by 2015We met MDG6 !: to reduce MR 50% by 2015
 Incidence has fallen 1.5%/y since 2000: if 4–5%: reachIncidence has fallen 1.5%/y since 2000: if 4–5%: reach
2020 milestones of2020 milestones of "End TB Strategy“."End TB Strategy“. Ending TBEnding TB
epidemic by 2030 is target of SDGepidemic by 2030 is target of SDG
TB Key Facts ...TB Key Facts ...

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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%

13.  TB can mimic any SS;TB can mimic any SS; speaks every language.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, TB must be excludedIn suspected BA, TB must be excluded
 It isIt is ""a global health emergencya global health emergency””
 MDR-TB: is x100 expensive (Rx x2y), often fatalMDR-TB: is x100 expensive (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 ...

14.  90% infected do not get disease90% infected do not get disease
 SS may be mild for many mo, & can infect 10-15/y.SS may be mild for many mo, & can infect 10-15/y.
Immunodeficiency: most at risk of active TB & dying.Immunodeficiency: most at risk of active TB & dying. TheThe
majority can be cured. It is vital that courses ofmajority can be cured. It is vital that courses of Rx areRx are
completed to eradicate/reduce AB resistancecompleted to eradicate/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
TB Key Facts ...TB Key Facts ...

15. Bangladesh ScenarioBangladesh Scenario
 TB is a major PH problemTB is a major PH problem
 77thth
among 22 high TB burden (80%) countriesamong 22 high TB burden (80%) countries
 60% population infected;60% population infected; 7 million diseased7 million diseased
 >300k new cases/y>300k new cases/y (1/every 2min)(1/every 2min)
 70k die/y70k die/y (1/every 8 min)(1/every 8 min)
 No estimate on childhood TBNo estimate on childhood TB:: grossly underdiagnosedgrossly underdiagnosed
 MDR TB: 2.2%,MDR TB: 2.2%, but among previously Rx cases: 15%but among previously Rx cases: 15%
PH: public healthPH: public health

16.  TB CARE IITB CARE II (USAID):(USAID): helps DOT, Rx of MDR-TB; works withhelps DOT, Rx of MDR-TB; works with
NTP in line ofNTP in line of Stop TBStop TB StrategyStrategy.. Its achievements:Its achievements:
– improved access to quality servicesimproved access to quality services
– lab. quality assurancelab. quality assurance
– social support for MDR TB pts.social support for MDR TB pts.
– effective delivery of TB services at all levelseffective delivery of TB services at all levels
DOT: directly observed therapy. MDR: multi-drug resistantDOT: directly observed therapy. MDR: multi-drug resistant
NTP: national TB control programNTP: national TB control program
Bangladesh Scenario …Bangladesh Scenario …

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Prevalence In Our ChildrenPrevalence In Our Children
Not knownNot known
 Globally:Globally: 450k die/y450k die/y
 One ofOne of 1010 top U-5 killerstop U-5 killers
 Recurrent infx., Mn., & TB go h& in handRecurrent infx., Mn., & TB go h& in hand
 Often under-diagnosedOften under-diagnosed
Mn: MalnutritionMn: Malnutrition
10 child killers:10 child killers: ARI, D, Mn, malaria, AIDs, TB, LBW, B. Asphyxia,ARI, D, Mn, malaria, AIDs, TB, LBW, B. Asphyxia,
drowning, accidentsdrowning, accidents

18. Progress in BangladeshProgress in Bangladesh
MDG6: met already!
 Case detection up to 72%Case detection up to 72%
 Rx success 93%Rx success 93%
 NGO participationNGO participation
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

19. 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

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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

21. EtiologyEtiology
 M tuberculosis (commonest)M tuberculosis (commonest)
 M bovisM bovis
 M africanusM africanus
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

22. 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.

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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)

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

25. 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
 Mn.Mn.
 PollutionPollution
 Raw milkRaw milk
 Dm,Dm, HIV,HIV, immunodeficiency, chemo-immunodeficiency, chemo-
 Family TB, illicit drugsFamily TB, illicit drugs

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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. PTB commonest: subpleural site, more in RULAny organ. PTB commonest: subpleural site, more in RUL
Basic lesion:Basic lesion: tubercle (central caseation); spread bytubercle (central caseation); spread by
lymphohematogenous route: LN, other organslymphohematogenous route: LN, other organs
2 reactions:2 reactions: exudative (effusion) &exudative (effusion) &
granulomatous (tubercle)granulomatous (tubercle)
Mn: malnutrition. RUL Right upper lobe

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Tubercle

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Tubercle

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Usual Susceptible OrgansUsual Susceptible Organs

30. Reactivated/unmasked TBReactivated/unmasked TB
 DMDM
 CorticosteroidsCorticosteroids
 Malignancy, cytotoxicsMalignancy, cytotoxics
 MalnutritionMalnutrition
 Whooping cough, measles, KA, HIVWhooping cough, measles, KA, HIV
 Overwhelming inf.Overwhelming inf.
 Immunodeficient statesImmunodeficient states

31. Clinical typesClinical types
 Pulmonary (85%) & extrapulmonaryPulmonary (85%) & extrapulmonary
 OpenOpen (PTB: smear positive: 70%)(PTB: smear positive: 70%)
 ClosedClosed (no spread)(no spread)
 Primary & reinfectionPrimary & reinfection
 New & retreatmentNew & retreatment
Smear negativeSmear negative: when 2 sputum samples are negative: when 2 sputum samples are negative

33. 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

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PTBPTB (85%)(85%)
 Primary focusPrimary focus ((Usually 1;Usually 1; 25% >1); mostly RUL25% >1); mostly RUL
subpleuralsubpleural
 Regional lymphangiitisRegional lymphangiitis
 Regional LAPRegional LAP
=Together:=Together:
Primary ComplexPrimary Complex

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36. LymphangiitisLymphangiitis
Tubercle in LUL withTubercle in LUL with
fine lines offine lines of
drainage todrainage to
enlarged HLN. DD:enlarged HLN. DD:
bronchial Cabronchial Ca

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Primary & Post-1y TBPrimary & Post-1y 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 by calcificationHeals by calcification
 Less cavitationLess cavitation
Post-primaryPost-primary (adults)(adults)
 Reactivation/re-infectionReactivation/re-infection
 OpenOpen
 Parenchyma moreParenchyma more
 LessLess
 MoreMore
 UncommonUncommon
 FibrosisFibrosis
 CommonCommon

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BigBig
tuberculomatuberculoma

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airwayairway
calcificationcalcification
Hilar LN compress/erode into BVHilar LN compress/erode into BV
Hilar LN in TB compress/erode into BV (upper arrow)/airways (A).Hilar LN in TB compress/erode into BV (upper arrow)/airways (A).
These LN were part of an incompletely treated, chr. parenchymal inf.These LN were part of an incompletely treated, chr. parenchymal inf.

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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

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

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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)

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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

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Fate of Primary ComplexFate of Primary Complex
Best described in PTBBest described in PTB
 Primary focus: mostlyPrimary focus: mostly healsheals (70%; calcified). If(70%; calcified). If
progressprogress ⇒⇒ cavity, bronchiectasis, bleedcavity, bronchiectasis, bleed
 DiseaseDisease from focus & LNfrom focus & LN
 DisseminationDissemination within 6mowithin 6mo
 ComplicationsComplications:: LAP & 1y focusLAP & 1y focus

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PTB with large cavitationPTB with large cavitation

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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)

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PressurePressure by enlarged LNby enlarged LN
 Stridor, wheeze, hoarsenessStridor, wheeze, hoarseness
 DysphagiaDysphagia
 Bronchiectasis, collapse, emphysemaBronchiectasis, collapse, emphysema
DischargeDischarge of Caseous Materialsof 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, pneumothoraxFistula, pl. effusion, pneumothorax
 Severe hgeSevere hge
Complications: LNComplications: LN
Caseation LN (matted)Caseation LN (matted)

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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

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Gross emphysema

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

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PTBPTB
pneumothoraxpneumothorax

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PTB with fibrosisPTB with fibrosis
& emphysema& emphysema

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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

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

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

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

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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

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Extensive pleural effusionExtensive pleural effusion

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Clinical Features TBClinical Features TB
 Predisposing factorsPredisposing factors
 Age U-5, 15-45Age U-5, 15-45
 General features:General features:
 Organ specific features:Organ specific features:

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GeneralGeneral
 Evening F, night sweatsEvening F, night sweats
 ANV, wt. loss, fatigue, lassitude,ANV, wt. loss, fatigue, 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: L. vulgarisL. vulgaris
 Renal TB:Renal TB: hematuria, etchematuria, etc
 TBM:TBM: slow onset of meningitisslow onset of meningitis

61. 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

62. Spina ventosa

63. TB of hip jointTB of hip joint

64. 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

65. 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.

66. Phlyctenular
Keratoconjunctivitis

67. 67
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 juice, aspirate (70%)AFB culture: sputum, gastric juice, 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

68. 68

69. 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

70. 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

71. 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)

72. 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

73. 73

74. 74

75. 75
Other testsOther tests
 Gastric aspirateGastric aspirate
 ICTICT
 Inflammatory fluidInflammatory fluid
 PCRPCR
 FNACFNAC
 BiopsyBiopsy
ALSALS

76. 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

77. 77
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

78. 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

79. 79
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

81. 81

82. 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

83. 83
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

84. 84
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

85. 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 no Rx1 mo no 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

86. 86
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%

87. 87
Supportive RxSupportive Rx
 Treatment of symptomsTreatment of symptoms
 Correction of malnutritionCorrection of malnutrition
 Balanced foodBalanced food
 Adequate exerciseAdequate exercise
 RehabilitationRehabilitation

88. 88
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

89. 89
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

90. 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

91. 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

93. 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

94. 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

95. 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

96. 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

97. 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

98. 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

99. 99
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.

100. 100
 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 …

101. 101
 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 …

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

103. scrofulascrofula

105. Phlyctenular conjunctivitisPhlyctenular conjunctivitis

108. 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?

109. 109

110. 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

111. MCQMCQ
 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
 Commonest c/of pseudo-negative MT is faultyCommonest c/of pseudo-negative MT is faulty
techniquetechnique
 TB is an important c/of female infertilityTB is an important c/of female infertility

112. 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
 Most TB infx. leads to diseaseMost TB infx. leads to disease

116. Next Lec.Next Lec.
SALMONELLASALMONELLA

117. 117THANK YOU