Pulmonary tb Nepal Guidelines

1. PULMONARY TUBERCULOSIS
Dr.Manoj Aryal
MBBS,MD(KU)
Physician/Internist
Department of Internal medicine
LMCTH Palpa

4. EPIDEMIOLOGY
• Globally,10 million population developed TB in 2017 and 1.3
million death.
• Overall 90% adults and 64% males,9% people living with HIV
• South east asia holds nearly 45% of global tb cases.
• WHO, In Nepal total of 32474 cases of TB notified and
registered.TB HIV co-infection rate in nepal 1.1%.
• Treatment success rates 90% for DS-TB,70% for DR TB.

6. Tuberculosis case Definition
• Bacteriologically confirmed TB case
• Clinically diagnosed TB case
• Confirmed bacteriologically or clinically before commencing
on TB treatment.
• No patient commenced on trial tb treatment.

7. High risk patient for routine screening
1. HIV positive patient
2. Patient on long steroid therapy
3. Diabetic
4. Cancer patient
5. Severe acute malnutrition.
6. Elderly
7. Symptomatic moderate acute malnutrition

8. Classification of TB
• Anatomical site of disease
• History of previous treatment
• Drug resistance
• HIV status

9. Tuberculosis case detection and diagnosis
• Presumptive TB: patient with symptoms or sign of TB.
• Signs and symptoms of tb:
1. Cough for 2 weeks or more
2. Coughing sputum with or without blood
3. Fever and night sweats
4. Loss of appetite and unintentional weight loss.
Household or other close contacts of bacteriologically
confirmed tb.
Chest x ray suggestive of any lung field abnormality.
9

10. Diagnosis of extrapulmonary TB
• Symptoms of EPTB:
-Fever (80% cases)
-Weight loss
-Night sweat
-Loss of appetite

11. 11

12. Symptoms
• Fever, Night sweats
• Cough
• Expectoration
• Hemoptysis
• Dyspnea
• Weight loss
White Army 12

13. Hemoptysis in TB
• Erosion of vessel in wall of cavity
• Bronchial mucosal erosions
• Bronchiectasis
• Rasmussen aneurysmal rupture
• Aspergilloma..
13

14. • Signs of path. process
14

15. 15

16. 16

17. Investigations
• ESR ↑
• Lymphocytosis
• Sputum – AFB
• ZN staining
• Auramine fluorescence technique
• Sputum – Culture - LJ Media
• Fluid analysis- exudate
• Skin tests- Heaf , Mantoux..
• ADA
• Biopsy
•Bronchoscopy – Lavage/ Bx
17

18. Sputum – Z-N staining
• Two morning sputum samples ( Purulent)
• Cheap , easy & rapid
• High predictive value > 90%
• Specificity of 98%
• Sputum with high load ~>5000 AFB/ ml
• Young children, elderly & HIV infected persons may not produce cavities & sputum
containing AFB.
18

19. Cultures on L-J media
• Lowenstein –Jensen medium is an egg based media with addition of
salts, 5 % glycerol, Malachite green & penicillin.
 Specificity ~ 99 %
 Very sensitive
 Can differentiate between TB complex & NTM using biochemical reactions
 Sensitivity tests for anti tuberculous drugs
 SLOW process ( up to 8 weeks )
19

20. Tuberculin Test
• A positive test = induration >10mm.
previous exposure and carriage of T.B.
 Tuberculin positive persons may develop reactivation
• False positive reactions ? Infection with NTM
• A negative tuberculin test excludes infection
 Negative persons are at risk of gaining new infection
• False negative reactions - Miliary T.B.; Hodgkin’s disease - Corticosteroid therapy;
Malnutrition; AIDS…
• Most useful in Children below 5 years
• >5 mm in HIV is POSITIVE
20

21. CXR in PTB
• Minimal
• Moderate
• Severe
21

22. 22

23. 23

24. White Army 24

25. White Army 25

26. 26

27. 27

28. 28

29. 29

30. Newer diagnostic methods
• Liquid culture – BACTEC
• PCR
• Nucleic acid amplification tests
• Sensitivity tests
• QuantiFERON / Interferon gamma assay
30

31. Newer Technique - BACTEC
• Rapid radiometric culture system
• specimens are cultured in a liquid medium
• Middle brook - broth base
• Growing mycobacteria utilize the acid, releasing radioactive CO2
which is measured as growth index (GI) in the BACTEC instrument.
• Quick
31

32. Newer Technique – PCR , NAAT
• DNA Probes
• Polymerase enzymes are used to amplify & many copies of specific
DNA or RNA sequences extracted from mycobacterial cells.
• Rapid procedure
• High sensitivity (1-10bacilli / ml sputum)
• 1-2 hours
32

33. QuantiFERON- TB Gold test
White Army 33

34. Type to enter a caption.

35. Fixed dose combination
Type to enter a caption.
Type to enter a caption.

36. White Army 36

37. INDICATION OF STEROID
• TB Meningitis:
• Dexamethasone at dose of 0.3-0.4mg/kg day for
2-4 wks,then tapper 0.1mg/kg/week until
0.1mg/kg then 4mg/day tapper by
1mg/week.total duration 12 weeks.
• TB Pericarditis:
• Prednisolone 2mg/kg daily increased to 4mg/kg
daily for 4 week,then tapper 0.5mg/kg every week
over 4 weeks for total of 2 week

38. 1st line drugs
• INH- 5mg / kg
• RIFAMPICIN – 10mg /kg
• Ethambutol – 15 mg/kg
• Pyrazinamide- 25 mg/kg
• Streptomycin – 0.75- 1gm inj
38

39. 2nd line drugs
• PAS - 15 gms 12 hrly PO
• Ethionamide - 0.75-1 gm PO
• Capreomycin - 0.75- 1 gm IM
• Cycloserine - 0.75-1 gm PO
• Ciprofloxacin - 750 mg bid

41. • Mono-resistance:
• Rifampicin resistance(RR)
• Poly-resistance: H/R+other FLD
• Multi drug resistant TB(MDR-TB):H+R+/- FLD
• Extensive drug resistance(XDR-TB)
• Isoniazide+rifampicin
• One fluoroquinolone(lev,moxi,gatifloxacin)
• One 2nd line injectable ATT(cap,amik,kanamycin)

42. DR/MDR-TB regimen in nepal
• Shorter standaradized treatment regimen:

43. Complications of Pul TB
• Massive hemoptysis
• Pneumothorax
• Aspergilloma
• Fibrosis
• Chr Resp failure
• Pericardial tamponade
• Addisons
• TBM
• Int estinal obstruction
• MDR- TB
• XDR- TB

45. PREVENTION
• BCG:- 70% immunity
• Contact tracing
• INH prophylaxis

46. REFERENCES
• Davidsons-Principles-and-Practice-of-Medicine-23rd-Edition
• Harrisons Principle of Internal Medicine 21th edition.