This document discusses various anaerobic organisms and infections they can cause in the head and neck region. It describes key anaerobes like Bacteroides, Prevotella, Peptostreptococcus, Fusobacterium, Clostridium, Actinomyces and infections associated with them such as peritonsillar abscess, actinomycosis, acute necrotizing ulcerative gingivitis. It also discusses complications of anaerobic head and neck infections that can spread locally or hematogenously. The approach to patients involves considering proximity of infection to colonized mucosal sites and polymicrobial nature of infections that often involve both aerobic and anaerobic organisms.

1. ANAEROBIC ORGANISMS,ANAEROBIC ORGANISMS,
DIPHTHERIA, MYCOBACTERIADIPHTHERIA, MYCOBACTERIA
& TREPONEMA IN ENT& TREPONEMA IN ENT
Dr. Ramesh Parajuli, MSDr. Ramesh Parajuli, MS
Otorhinolaryngology, Head & Neck Surgery
Chitwan Medical College Teaching Hospital, Bharatpur-10, Chitwan, Nepal

2. Corynebacterium DiphtheriaeCorynebacterium Diphtheriae
Aerobic, Gram-positive rod,Aerobic, Gram-positive rod,
non spore forming, non motilenon spore forming, non motile
Club shaped, palisades (v or lClub shaped, palisades (v or l
shaped) or “shaped) or “Chinese letter”-Chinese letter”-
tellurite medium(D)tellurite medium(D)
Granules-loeffler’s medium(SGranules-loeffler’s medium(S))

3. 2 phenotypes- toxigenic(tox+ ve) and non2 phenotypes- toxigenic(tox+ ve) and non
toxigenic(tox-ve)toxigenic(tox-ve)
Diphtheria-nasopharyngeal & skin infection causedDiphtheria-nasopharyngeal & skin infection caused
by c.diphtheriaeby c.diphtheriae
Toxigenic:pharyngeal diphtheriaToxigenic:pharyngeal diphtheria
Non-toxigenic:cutaneous diphtheriaNon-toxigenic:cutaneous diphtheria
Lysogenic conversion by bacteriophage ‘tox’ geneLysogenic conversion by bacteriophage ‘tox’ gene

4. 3 strains: Gravis ,3 strains: Gravis ,
Intermedius & MitisIntermedius & Mitis
Gravis and intermediusGravis and intermedius
types-higher mortalitytypes-higher mortality
CornebacteriumCornebacterium
ulcerans:- infected byulcerans:- infected by
bacteriophagebacteriophage
diphtheria likediphtheria like
presentationpresentation

5. Mechanism of action of DiphtheriaMechanism of action of Diphtheria
ToxinToxin

6. PathologyPathology
Tonsil Necrosis - initialTonsil Necrosis - initial
lesionlesion
CharactersticCharacterstic
pseudomembranepseudomembrane
formation: (necrotic tissue +formation: (necrotic tissue +
bacteria+ fibrinous exudate)bacteria+ fibrinous exudate)
Early removal - Bleeding,Early removal - Bleeding,
easy separation latereasy separation later
Bull neck: Cellulitis &Bull neck: Cellulitis &
Cervical lymphadenopathyCervical lymphadenopathy

7. Bull-neck
appearance

8. Transmission:Transmission:
aerosol(resp.droplet)aerosol(resp.droplet)
Incubation period:3-4 daysIncubation period:3-4 days
ToxemiaToxemia
Mechanical complications:Mechanical complications:
pseudomembranepseudomembrane
Systemic effects:Systemic effects:
toxintoxin

9. Clinical FeaturesClinical Features
Age : Rare over 10 yearsAge : Rare over 10 years
Malaise ,Sore throat andMalaise ,Sore throat and
PyrexiaPyrexia
Membrane over theMembrane over the
Faucial pillarsFaucial pillars
Progressive DysphagiaProgressive Dysphagia
and Toxemiaand Toxemia
Inspiratory Stridor andInspiratory Stridor and
Barking coughBarking cough
Cough – Paroxysmal andCough – Paroxysmal and
ExhaustingExhausting

11. DeathDeath
-Acute airway obstruction-Acute airway obstruction
-circulatory failure-circulatory failure
Acute Toxic MyocarditisAcute Toxic Myocarditiscardiaccardiac
dysfunctiondysfunction
-2-2ndnd
weekweek
Peripheral NeuropathyPeripheral Neuropathy
--Recurrent laryngeal nerve palsyRecurrent laryngeal nerve palsy
-Palatal Paralysis most common-Palatal Paralysis most common
-Presents with nasal regurgitation-Presents with nasal regurgitation
& hyper nasal speech& hyper nasal speech

13. Differential DiagnosisDifferential Diagnosis
Foreign bodyForeign body
Infectious MononucleosisInfectious Mononucleosis
Peritonsillar AbscessPeritonsillar Abscess
Retropharyngeal AbscessRetropharyngeal Abscess

14. Differential DiagnosisDifferential Diagnosis cont.cont.
StreptococcalStreptococcal
pharyngitispharyngitis
Vincent’s anginaVincent’s angina
ThrushThrush
Post-tonsillectomyPost-tonsillectomy
faucial membranesfaucial membranes
Leukemia andLeukemia and
agranulocytosisagranulocytosis

15. ManagementManagement
Airway :Airway :
-Removal of Laryngeal-Removal of Laryngeal
MembraneMembrane
-Humidification-Humidification
-0xygen therapy-0xygen therapy
- ET intubation or- ET intubation or
TracheostomyTracheostomy
-Systemic Steroids : Reduce need-Systemic Steroids : Reduce need
for airway interventionfor airway intervention

16. ManagementManagement
Benzyl Penicillin :Benzyl Penicillin :
600mgx i.v.x 6 hourly600mgx i.v.x 6 hourly
Diptheria AntitoxinDiptheria Antitoxin
10,000-1,00,000 units10,000-1,00,000 units
(Depending upon(Depending upon
severity)severity)

17. Bed rest – 2 toBed rest – 2 to
4 weeks until4 weeks until
danger ofdanger of
myocarditis ismyocarditis is
overover
Vaccination:Vaccination:
DPTDPT

18. Diptheroids (Coryneforms)Diptheroids (Coryneforms)
Nondiphtherial corynebacteriaNondiphtherial corynebacteria
Colonisers or contaminants –invasiveColonisers or contaminants –invasive
disease in immunocompromiseddisease in immunocompromised
C.pseudodipthericum –pharynx ,skinC.pseudodipthericum –pharynx ,skin
-C.xerosis – skin ,nasopharynx & conjunctiva-C.xerosis – skin ,nasopharynx & conjunctiva
C.Auris – EAC, C.striatum – ant.Nares ,skinC.Auris – EAC, C.striatum – ant.Nares ,skin

19. Anaerobic OrganismsAnaerobic Organisms
Most are commensals-Most are commensals-
harmlessharmless
eg saliva,gingival scrappingeg saliva,gingival scrapping
Sites- skin, mouth,Sites- skin, mouth,
nasopharynx, uppernasopharynx, upper
respiratory tractrespiratory tract
Conditions favored-Conditions favored-
Decreased oxidation-Decreased oxidation-
reduction potential eg.reduction potential eg.
Trauma, Tissue destruction,Trauma, Tissue destruction,
foreign body, malnutrition.foreign body, malnutrition.

20. ClassificationClassification
Gram-negative rods:Gram-negative rods: BacteroidesBacteroides [e.g.[e.g. B.B.
fragilisfragilis],],Fusobacterium, prevotella,Fusobacterium, prevotella,
porphyromonasporphyromonas
Gram-positive rods:Gram-positive rods:
ActinomycesActinomyces,clostridium,,clostridium,EubacteriumEubacterium,,
BifidobacteriumBifidobacterium,,PropionibacteriumPropionibacterium
Gram-positive cocci:Gram-positive cocci: PeptostreptococcusPeptostreptococcus
andand PeptococcusPeptococcus
Gram-negative cocci:Gram-negative cocci: VeillonellaVeillonella

21. IMPORTANT ANAEROBESIMPORTANT ANAEROBES
Bacteroides-Bacteroides-
B. fragilis- most frequently isolatedB. fragilis- most frequently isolated
Resistant to beta lactamsResistant to beta lactams
Prevotella: newly named & previously BacteroidesPrevotella: newly named & previously Bacteroides
B. melaninogenicus (Recently PrevotellaB. melaninogenicus (Recently Prevotella
melaninogenicus )- black, brown colonies Majormelaninogenicus )- black, brown colonies Major
group in oral flora.group in oral flora.
Peptostreptococcus-Peptostreptococcus-
-Normal flora of skin ,mucus membrane-Normal flora of skin ,mucus membrane
Species- P. micros, P. anaerobius P. magnusSpecies- P. micros, P. anaerobius P. magnus
(abscess)(abscess)

22. PeptococcusPeptococcus
FusobacteriumFusobacterium
Clostridium - spore formingClostridium - spore forming
Gas gangrene, food poisoning, tetanus, colitisGas gangrene, food poisoning, tetanus, colitis
Cl. Perfringens- Toxin- hemolytic- dermonecrotic,Cl. Perfringens- Toxin- hemolytic- dermonecrotic,
Phospholipase c, LecithinasePhospholipase c, Lecithinase
Wound contamination- cellulitis- myositisWound contamination- cellulitis- myositis gasgas
gangrene.gangrene.

23. Infection due to anaerobes- mostly polymicrobialInfection due to anaerobes- mostly polymicrobial
Abscess cavity or necrotic tissueAbscess cavity or necrotic tissue
Failure of abscess to yield organism on routineFailure of abscess to yield organism on routine
cultureculture clue for anaerobic organismclue for anaerobic organism
Abscess in deeper body tissueAbscess in deeper body tissue
Putrid smelling infection site or dischargePutrid smelling infection site or discharge

24. Acute Necrotizing UlcerativeAcute Necrotizing Ulcerative
Gingivitis(ANUG)/ Trench Mouth/Vincent’sGingivitis(ANUG)/ Trench Mouth/Vincent’s
StomatitisStomatitis
-Etiology. :Fusobacterium-Etiology. :Fusobacterium
Nucleatum, BorreliaNucleatum, Borrelia
VincentiVincenti
- Tender bleeding gums,- Tender bleeding gums,
foul breathe &bad tastefoul breathe &bad taste
-Gingival mucosa esp.-Gingival mucosa esp.
papilla-ulcerated&papilla-ulcerated&
covered with greycovered with grey
exudateexudate
-Fever, Cervical-Fever, Cervical
lymphadenopathy &lymphadenopathy &
leucocytosisleucocytosis

25. Acute Necrotizing UlcerativeAcute Necrotizing Ulcerative
Mucositis / Noma/Cancrum OrisMucositis / Noma/Cancrum Oris
Usually a/w ulcerativeUsually a/w ulcerative
gingivitisgingivitis
Anaerobes esp.Anaerobes esp.
B.porphyromonasB.porphyromonas
Rapid tissueRapid tissue
destructiondestructionteeth fallteeth fall
outoutbone/wholebone/whole
mandible sloughmandible slough
Heal leaving disfiguringHeal leaving disfiguring
defectdefect

26. Acute Necrotizing infection of PharynxAcute Necrotizing infection of Pharynx
Usu.a/w ulcerativeUsu.a/w ulcerative
gingivitisgingivitis
C/F:fever,sore throat,foulC/F:fever,sore throat,foul
breath,badbreath,bad
taste,sensation of chokingtaste,sensation of choking
O/E: Greyish membraneO/E: Greyish membrane
over Tonsillar pillars thatover Tonsillar pillars that
peel easilypeel easily
Lymphadenopathy &Lymphadenopathy &
LeucocytosisLeucocytosis
May spread to larynxMay spread to larynx

27. PeriPharyngeal spacePeriPharyngeal space
infectioninfection
Peritonsillar abscessPeritonsillar abscess
- Complication of Tonsillitis orComplication of Tonsillitis or
De novoDe novo
- Mixed flora containing bothMixed flora containing both
Anaerobes & GABHSAnaerobes & GABHS
- Association betweenAssociation between
Periodontal disease (sourcePeriodontal disease (source
of anaerobic organism) andof anaerobic organism) and
PTA.PTA.
- Ludwig’s AnginaLudwig’s Angina

28. ActinomycosisActinomycosis
Member of normal oral flora-Member of normal oral flora-
gingival crevicesgingival crevices
G+ve, anaerobic,branchingG+ve, anaerobic,branching
rodsrods
A.israelii-most common.A.israelii-most common.
A.naeslundii,A.naeslundii,
A.odontolyticus,A.viscous etcA.odontolyticus,A.viscous etc

29. Disruption of mucosalDisruption of mucosal
barrierbarrierlocal infectionlocal infectionslowlyslowly
progressiveprogressivechronic phasechronic phase
with single or multiple induratedwith single or multiple indurated
lesionslesions
Trauma, F.B. poor oral hygieneTrauma, F.B. poor oral hygiene
Chronic granulomatousChronic granulomatous
infectioninfection

30. Firm indurated mass- central necrosis withFirm indurated mass- central necrosis with
fibrotic ‘wooden wall’(neutrophils & sulfurfibrotic ‘wooden wall’(neutrophils & sulfur
granules)granules)
Multiple sinus tract which discharge pusMultiple sinus tract which discharge pus
Usu. angle of jaw involvedUsu. angle of jaw involved

32. Sulphur granules-characteristicSulphur granules-characteristic
D/D- Malignancy or GranulomatousD/D- Malignancy or Granulomatous
diseasedisease
Any mass lesion or relapsing infection inAny mass lesion or relapsing infection in
head & neck regionhead & neck regionrule outrule out
actinomycosisactinomycosis

33. Sinusitis &OtitisSinusitis &Otitis
Anaerobes implicated in (0-88)% of CRSAnaerobes implicated in (0-88)% of CRS
(Doyle, Ramadan, Brook)(Doyle, Ramadan, Brook)
anaerobes in CRS (0 to 52%)(Harrison 17anaerobes in CRS (0 to 52%)(Harrison 17thth
edn.)edn.)
Peptostreptococcus, Fusobacterium & P.Peptostreptococcus, Fusobacterium & P.
acnesacnes
COMCOM
- Anaerobes in Upto 50% casesAnaerobes in Upto 50% cases
- B.fragilis in upto 28% cases of COMB.fragilis in upto 28% cases of COM

34. Complications of AnaerobicComplications of Anaerobic
Head & Neck InfectionHead & Neck Infection
Continuous spreadContinuous spread
- Craniad: Osteomyelitis of skull /mandible orCraniad: Osteomyelitis of skull /mandible or
intracranial complications(brainintracranial complications(brain
abscess,subdural empyema)abscess,subdural empyema)
- Caudal :Mediastinitis or PleuropulmonaryCaudal :Mediastinitis or Pleuropulmonary
infectioninfection
- Hematogenous disseminationHematogenous dissemination
- Lemierre’s Syndrome-Lemierre’s Syndrome- Fusobacterium necrophorumFusobacterium necrophorum

35. Approach to the patientsApproach to the patients
Harmless commensals, disease proximityHarmless commensals, disease proximity
to mucosal site colonisedto mucosal site colonised
Site of lower oxidation-reduction potentialSite of lower oxidation-reduction potential
Polymicrobial naturePolymicrobial nature
Negative cultureNegative culture ‘clue’‘clue’
Foul or putrid infection site or dischargeFoul or putrid infection site or discharge
diagnosticdiagnostic

36. DiagnosisDiagnosis
3 critical steps3 critical steps
1.1. Proper specimenProper specimen
collectioncollection
2.2. Rapid transportRapid transport
preferably in anaerobicpreferably in anaerobic
mediamedia
3.3. Proper handling ofProper handling of
specimen by the labspecimen by the lab

37. Specimen collectionSpecimen collection
Sterile body fluid – blood,Sterile body fluid – blood,
pleural, peritoneal fluid,CSFpleural, peritoneal fluid,CSF
and aspirates or biopsies fromand aspirates or biopsies from
normally sterile sitesnormally sterile sites
Specimen unacceptable:Specimen unacceptable:
expectorated sputum ,nasalexpectorated sputum ,nasal
tracheal suction, bronchoscopytracheal suction, bronchoscopy
specimen,voided urine &specimen,voided urine &
faecesfaeces

38. Ways of eliminating oxygen gasWays of eliminating oxygen gas
Gas pac jarGas pac jar : -: - Contains aContains a
packet of sodiumpacket of sodium
borohydride, sodiumborohydride, sodium
bicarbonate & citric acid.bicarbonate & citric acid.
- Addition of water causes- Addition of water causes
production of H2, CO2 gas &production of H2, CO2 gas &
displaces air (and thusdisplaces air (and thus
oxygen).oxygen).

39. Gas exchange jar : Air in theGas exchange jar : Air in the
jar is replaced with O2-freejar is replaced with O2-free
gas (from a tank).gas (from a tank).
Glove box:Glove box: Box is filled withBox is filled with
anaerobic (O2-free) gasanaerobic (O2-free) gas
,usually a mixture of H2 and,usually a mixture of H2 and
CO2.CO2.
-Positive pressure-Positive pressure
keeps O2 outkeeps O2 out

41. TreatmentTreatment
Surgical drainage (mostSurgical drainage (most
circumstances) + antimicrobialscircumstances) + antimicrobials
DOC: Penicillin GDOC: Penicillin G
For Beta –lactamase producingFor Beta –lactamase producing
Bacteroides and PrevotellaBacteroides and Prevotella
-Clindamycin (DOC infections above-Clindamycin (DOC infections above
diaphragm) & Metronidazolediaphragm) & Metronidazole

42. Mycobacterium TuberculosisMycobacterium Tuberculosis
Rod shaped, obligateRod shaped, obligate
aerobes ,slow growingaerobes ,slow growing
Acid-fast – high contentAcid-fast – high content
of mycolic acidof mycolic acid
Low cell wallLow cell wall
permeability topermeability to
antibioticsantibiotics

43. No exotoxin norNo exotoxin nor
endotoxinendotoxin
Damage done byDamage done by
immune system (CMI)immune system (CMI)
Tuberculin(surfaceTuberculin(surface
protein) along withprotein) along with
mycolic acidmycolic aciddelayeddelayed
type hypersensitivity &type hypersensitivity &
CMICMI

44. Nasal TuberculosisNasal Tuberculosis
ROUTES OFROUTES OF
SPREADSPREAD
- Direct inoculation:- Direct inoculation:
Nose Pricking orNose Pricking or
Finger nail TraumaFinger nail Trauma
- Droplet Spread:- Droplet Spread:
Coughing, SneezingCoughing, Sneezing
- Haematogenous- Haematogenous
disseminationdissemination

45. 3 FORMS3 FORMS
1. Nodular1. Nodular
2.Ulcerative2.Ulcerative
3.Sinus Granuloma3.Sinus Granuloma

46. 1.Nodular1.Nodular
Begins in VestibuleBegins in Vestibule
APPLE JELLY NODULEAPPLE JELLY NODULE
Untreated-scar and deformityUntreated-scar and deformity
2.Ulcerative form2.Ulcerative form
Usually cartilaginous septum or inferior TurbinateUsually cartilaginous septum or inferior Turbinate
Septal PerforationSeptal Perforation
3.Sinus granuloma3.Sinus granuloma
Isolated sinus involvement without any sign and symptomsIsolated sinus involvement without any sign and symptoms
in the nose.in the nose.
Unilateral , Maxillary Sinus- usuallyUnilateral , Maxillary Sinus- usually

47. Tuberculous Otitis MediaTuberculous Otitis Media
Incidence < 1% COMIncidence < 1% COM
Spread: Insuffalation via E.tube,Spread: Insuffalation via E.tube,
Hematogenous, contiguousHematogenous, contiguous
Presentation:Presentation:
-Chronic Otorrhoea-Chronic Otorrhoea
-Hearing loss (moderate to severe-Hearing loss (moderate to severe
CHL, mixed)CHL, mixed)
-Dizziness-Dizziness

48. O/EO/E
Multiple perforations (hall mark)-Multiple perforations (hall mark)-
later coalesce into a single largelater coalesce into a single large
perforationperforation
AbundantAbundant pale granulationpale granulation
tissue - characteristictissue - characteristic
Handle of Malleus- denudedHandle of Malleus- denuded
Middle ear mucosa- paleMiddle ear mucosa- pale
Complications:Complications:
-Profound SNHL-Profound SNHL
-Facial n. palsy-Facial n. palsy

49. Diagnosis-HPEDiagnosis-HPE
- ME Mucosal biopsy & Aural polpectomy- ME Mucosal biopsy & Aural polpectomy
specimen positive in 30% & 35%specimen positive in 30% & 35%
respectivelyrespectively
- Management:Management:
- ATT- ATT
- Mastoidectomy- Mastoidectomy

50. Tuberculous Cervical AdenitisTuberculous Cervical Adenitis
Most common Cause of LNMost common Cause of LN
swelling in neckswelling in neck
Children & young adultsChildren & young adults
Primary foci – usually tonsilsPrimary foci – usually tonsils
90% single LN group usually90% single LN group usually
Deep Jugular chainDeep Jugular chain
Stages:Stages:
Stage of LymphadenitisStage of Lymphadenitis
Stage of Periadenitis includingStage of Periadenitis including
“collar stud”“collar stud” abscessabscess
Stage of sinus formationStage of sinus formation

51. Differential diagnosisDifferential diagnosis
1.Persistent Generalised Lymphadenopathy(PGL)1.Persistent Generalised Lymphadenopathy(PGL)
2.Lymphoma2.Lymphoma
3.Kaposi’s Sarcoma3.Kaposi’s Sarcoma
4.Carcinomatious Metastasis4.Carcinomatious Metastasis
5.Sarcoidosis5.Sarcoidosis
6.Drug Reaction(eg.Phenytoin)6.Drug Reaction(eg.Phenytoin)

52. Diagnosis:Diagnosis:
- Tuberculin skin test,Tuberculin skin test,
- FNAC-70%sensitivityFNAC-70%sensitivity
- LN excisional biopsy-LN excisional biopsy-
80% sensitivity80% sensitivity
- Treatment: ATT+Treatment: ATT+
excision of LNexcision of LN

53. Oropharyngeal TuberculosisOropharyngeal Tuberculosis
Secondary to coughingSecondary to coughing
heavily of infected sputumheavily of infected sputum
Oral lesion – not commonOral lesion – not common
-Ulceration :dorsum of tongue-Ulceration :dorsum of tongue
-Painless , irregular-Painless , irregular
,granulating floor,granulating floor
Pharynx-not commonPharynx-not common
- Site of primary infectionSite of primary infection
(Tonsils, Adenoids)(Tonsils, Adenoids)

54. Mycobacterial infection of theMycobacterial infection of the
Salivary glandsSalivary glands
Etiology.: atypical or NTMEtiology.: atypical or NTM
Parotid, submandibular glandsParotid, submandibular glands
Presentation :Presentation :
-Children age group 3 – 4 years-Children age group 3 – 4 years
-Painless mass in neck or face-Painless mass in neck or face
-Skin breakdown &sinus-Skin breakdown &sinus
formationformation

55. TB Esophagitis:TB Esophagitis:
-swallowed sputum or direct-swallowed sputum or direct
spread from adjacent LNspread from adjacent LN
-stricture,fistula, mucosal-stricture,fistula, mucosal
irregularitiesirregularities
GranulomatousGranulomatous
cheilitis-cheilitis- rarerare

56. TB LarynxTB Larynx
Nearly always aNearly always a
complication of advancecomplication of advance
cavitatory PTBcavitatory PTB
C/F:C/F:
-Dysphonia-Dysphonia
-Pain on swallowing &-Pain on swallowing &
speakingspeaking
-Otalgia-Otalgia

57. O/EO/E
-Predominantly posterior-Predominantly posterior
1/31/3rdrd
of glottisof glottis
-Diffuse redness &-Diffuse redness &
edemaedema
-Ulcerations-Ulcerations
Diagnosis:Diagnosis:
-Biopsy of laryngeal-Biopsy of laryngeal
tissuetissue

58. TreatmentTreatment
-Securing airway-Securing airway
-ATT-ATT
ComplicationsComplications
- Stenosis- Stenosis
- Vocal cord fixation- Vocal cord fixation

59. DIAGNOSISDIAGNOSIS
SpecimenSpecimen
1.1.Sputum- 3 early morning specimenSputum- 3 early morning specimen
2.2.Swab- larynx / gastric aspirateSwab- larynx / gastric aspirate
3.3.Tissue biopsy :Tissue biopsy :
AFB Microscopy: -Low sensitivity (40 -60)%AFB Microscopy: -Low sensitivity (40 -60)%
Culture- definite diagnosisCulture- definite diagnosis
- Lowenstein- Jensen medium: 4 to 8- Lowenstein- Jensen medium: 4 to 8
weeksweeks
BACTEC media –growth 2 weeksBACTEC media –growth 2 weeks
DNA amplification/ PCR : allows diagnosis inDNA amplification/ PCR : allows diagnosis in
several hoursseveral hours

60. RadiologyRadiology
Tuberculin skin test-Tuberculin skin test-
Mantoux test, zone of induration after 48- 72 hrMantoux test, zone of induration after 48- 72 hr

61. TB Skin TestTB Skin Test

63. Mycobacterium tuberculosisMycobacterium tuberculosis bacteria usingbacteria using
acid-fastacid-fast Ziehl-Neelsen stainZiehl-Neelsen stain..

64. Colonies ofColonies of M. tuberculosisM. tuberculosis
growing on mediagrowing on media

65. Histopathologic appearanceHistopathologic appearance

66. TB on AFB smearTB on AFB smear

67. TREATMENT & PREVENTIONTREATMENT & PREVENTION
BCG vaccinationBCG vaccination
ChemotherapyChemotherapy

68. 11STST
Line TreatmentLine Treatment
Rifampicin – Dose- 10mg/kg body wt.Rifampicin – Dose- 10mg/kg body wt.
Isoniazid – Dose-5mg/kg,Administer vitamin B6Isoniazid – Dose-5mg/kg,Administer vitamin B6
Pyrazinamide –25mg/kgPyrazinamide –25mg/kg
Ethambutol – 15mg/kgEthambutol – 15mg/kg
Streptomycin -15mg/kgStreptomycin -15mg/kg

69. 22NDND
LINE TREATMENT OR NEWER DRUGSLINE TREATMENT OR NEWER DRUGS
AMINOGLYCOSIDES: Capreomycin,amikacin,kanamicinAMINOGLYCOSIDES: Capreomycin,amikacin,kanamicin
THIOAMIDES: Ethionamide,prothionamideTHIOAMIDES: Ethionamide,prothionamide
PAS(Para-Aminosalicyclic acid)PAS(Para-Aminosalicyclic acid)
CYCLOSERINE (or trizidone)CYCLOSERINE (or trizidone)
FLUOROQUINOLONES-FLUOROQUINOLONES-
ofloxacin,ciprofloxacin,sparfloxacinofloxacin,ciprofloxacin,sparfloxacin
&Gatifloxacin,Sparfloxacin-latest(improved activity)&Gatifloxacin,Sparfloxacin-latest(improved activity)
Rifabutin, RifamycinRifabutin, Rifamycin
ThiocetazoneThiocetazone
Rifapentine- latest one 600mg/weeklyRifapentine- latest one 600mg/weekly
Macrolide- clarithromycin.Macrolide- clarithromycin.
Linezolide :Oxazolidinone antibioticLinezolide :Oxazolidinone antibiotic

70. MDR-MDR- TBTB
MDR suspected :MDR suspected :
-History of irregular multi-drug therapy and sputum-History of irregular multi-drug therapy and sputum
remaining positiveremaining positive
-No good response in a smear positive case put-No good response in a smear positive case put
on standard re-treatment regimen.on standard re-treatment regimen.
- Sputum- Sputum
C/S testC/S test
Causes:Causes:
- inappropriate regimen ,non compliance,interruption of drug- inappropriate regimen ,non compliance,interruption of drug
supply,lack of diagnosis and free treatmentsupply,lack of diagnosis and free treatment

71. XDR-TBXDR-TB
Extensively drug resistant TB:TB that has developedExtensively drug resistant TB:TB that has developed
resistance to at least rifampicin & isoniazid as well as toresistance to at least rifampicin & isoniazid as well as to
any member of the quinolone family & at least one of theany member of the quinolone family & at least one of the
following 2following 2ndnd
line anti-TB injectable drugs:line anti-TB injectable drugs:
kanamycin,capreomycin or amikacinkanamycin,capreomycin or amikacin
(Global Task Force on XDR-(Global Task Force on XDR-
TB,WHO,2006)TB,WHO,2006)
11STST
line drug misused, mismanagedline drug misused, mismanaged MDR- TBMDR- TB
22NDND
line drug misused, mismanagedline drug misused, mismanaged XDR-TBXDR-TB

72. POTENTIAL NEWER THERAPIES FORPOTENTIAL NEWER THERAPIES FOR
TUBERCULOSISTUBERCULOSIS
Protein kinase inhibitors: pyridomycin, RifadineProtein kinase inhibitors: pyridomycin, Rifadine
Pyridine analogues like NAD (NicotinamidePyridine analogues like NAD (Nicotinamide
adenine dinucleotide) and Streptolydigin whichadenine dinucleotide) and Streptolydigin which
inhibits initiation of RNA synthesis.inhibits initiation of RNA synthesis.
Cytokine Immunotherapy: IL-2- subcutaneous lowCytokine Immunotherapy: IL-2- subcutaneous low
dose for patients with active tuberculosis todose for patients with active tuberculosis to
augment the immune cell response.augment the immune cell response.
IFN Gammatherapy by aerosol toIFN Gammatherapy by aerosol to
accelerateaccelerate M.tuberculosisM.tuberculosis killing.killing.
Interleukin-12: for restoring impaired cellularInterleukin-12: for restoring impaired cellular
immune function in AIDS and tuberculosis.immune function in AIDS and tuberculosis.

73. Recent Advances in theRecent Advances in the
Diagnosis & Management ofDiagnosis & Management of
Tuberculosis:Tuberculosis:
1.BACTEC TM 460-liquid culture method1.BACTEC TM 460-liquid culture methoddetectsdetects
radiolabeled CO2 releasedradiolabeled CO2 released
2.MGIT(mycobacterial growth indicator tube)2.MGIT(mycobacterial growth indicator tube)
3.PCR3.PCR
4.PA-824 :a nitroimidazopyran compound related to4.PA-824 :a nitroimidazopyran compound related to
metronidazole activity against both slow &rapidlymetronidazole activity against both slow &rapidly
dividing mycobact.dividing mycobact.may enter human testingmay enter human testing
soonsoon

74. 5.Rifacinna5.Rifacinna
6.Benzofuro(2,3-b) quinolone derivative6.Benzofuro(2,3-b) quinolone derivative
7.Interferon gamma release assay(IGRAs)-mtb-7.Interferon gamma release assay(IGRAs)-mtb-
specific antigens,ESAT-6 & CFP-10specific antigens,ESAT-6 & CFP-10
8.Dipiperidines8.Dipiperidines
9.Multiplex SNaphot technique-identification of9.Multiplex SNaphot technique-identification of
diff.species of mycobacteriadiff.species of mycobacteria
10.R207910(TMC207)-a lead compound10.R207910(TMC207)-a lead compound

75. Atypical MycobacteriaAtypical Mycobacteria
Mycobacteria other than M.tuberculosis & M.bovisMycobacteria other than M.tuberculosis & M.bovis
Mycobacteria Other Than Tuberculosis(MOTTS)=NonMycobacteria Other Than Tuberculosis(MOTTS)=Non
Tuberculous MycobacteriaTuberculous Mycobacteria
Oppurtunistic infection in human beingsOppurtunistic infection in human beings
Non contagiousNon contagious
4 groups-based on pigment production & rate of growth4 groups-based on pigment production & rate of growth
1.1. Photochromogens – yellow orange colonies in lightPhotochromogens – yellow orange colonies in light
eg.M.kansasii , M. marinumeg.M.kansasii , M. marinum
2. Scotochromogens –pigment in dark eg. M scrofulaceum2. Scotochromogens –pigment in dark eg. M scrofulaceum
3. Nonchromogens –no pigments,eg.MAC3. Nonchromogens –no pigments,eg.MAC
4. Rapid growers –eg M.Fortuitum ,M. chelonei4. Rapid growers –eg M.Fortuitum ,M. chelonei

76. Mycobacterium LepraeMycobacterium Leprae
Hansen (1868)-first bacterial pathogen ofHansen (1868)-first bacterial pathogen of
humans to be describedhumans to be described
Acid fast rodAcid fast rod
Obligate intracellular-can’t be cultured inObligate intracellular-can’t be cultured in
vitro, but in mouse footpadvitro, but in mouse footpad
Optimum temp.growth-less than bodyOptimum temp.growth-less than body
temptemp preference for skin, mucosa &preference for skin, mucosa &
superficial nervesuperficial nerve

77. Transmission- nasal dischargeTransmission- nasal discharge
Both Humoral & cellularBoth Humoral & cellular
immune responseimmune response
Clinically- ChronicClinically- Chronic
granulomatous diseasegranulomatous diseaseskin,skin,
peripheral nerve & nasalperipheral nerve & nasal
mucosamucosa

79. ENT PRESENTATIONENT PRESENTATION
Early involvement of nasal mucosaEarly involvement of nasal mucosa
Nasal obstruction ,crust formation & blood stainedNasal obstruction ,crust formation & blood stained
discharge.discharge.
Atrophic rhinitis, Cartilaginous perforation & DorsalAtrophic rhinitis, Cartilaginous perforation & Dorsal
saddling –latesaddling –late
Nasopharynx to oropharynx- Granulomatous lesion,Nasopharynx to oropharynx- Granulomatous lesion,
ulcers, healing with fibrosisulcers, healing with fibrosis
Larynx- lesion like TB & SyphilisLarynx- lesion like TB & Syphilis
- Supraglottic- mainly epiglottis, aryepiglottic folds- Supraglottic- mainly epiglottis, aryepiglottic folds
-Epiglottis : hollow rod, mucosa studded with tiny-Epiglottis : hollow rod, mucosa studded with tiny
nodules- laryngeal stenosis & airway obstructionnodules- laryngeal stenosis & airway obstruction..

80. TuberculoidTuberculoid LepromatousLepromatous
Cell mediatedCell mediated
immuneimmune
systemsystem
Strong CMIStrong CMI Weak CMIWeak CMI
LepromineLepromine
skin testskin test
++ __
No. ofNo. of
organismorganism
LowLow HighHigh
No. of lesion &No. of lesion &
symptomssymptoms
Fewer lesions,Fewer lesions,
Macular, nerveMacular, nerve
enlargement,enlargement,
paresthesiaparesthesia
Numerous lesions- nodular,Numerous lesions- nodular,
loss of eyebrows,loss of eyebrows,
destruction of nasal septum,destruction of nasal septum,
parasthesia, Leonine faciesparasthesia, Leonine facies

81. Diagnosis:Diagnosis:
Punch biopsy,Punch biopsy,
nasal scrapings,nasal scrapings,
skin lesionsskin lesions
& ear lobules& ear lobules

82. FormForm
ofof
LeprosLepros
yy
WHO Recommended RegimenWHO Recommended Regimen
(1982)(1982)
TubercTuberc
uloiduloid
(paucib(paucib
acillary)acillary)
Dapsone-100 mg/d,Dapsone-100 mg/d,
unsupervised)unsupervised) ++
Rifampin-600 mg/month,Rifampin-600 mg/month,
supervised for 6 monthssupervised for 6 months
LepromLeprom
atousatous
(multiba(multiba
cillary)cillary)
Dapsone-100 mg/d+Dapsone-100 mg/d+
clofazimine -50mg/d, unsupervised;clofazimine -50mg/d, unsupervised;
rifampin-rifampin-600 mg +600 mg + clofazimine-clofazimine-300300
mg monthly (supervised)mg monthly (supervised)
for 1–2 yearsfor 1–2 years

83. TREPONEMATREPONEMA
trepos=turn, nema= threadtrepos=turn, nema= thread
Spiral, round or pointed endsSpiral, round or pointed ends
Member of genera SpirochetesMember of genera Spirochetes
subspecies:subspecies:
1.Pallidum- venereal Syphilis1.Pallidum- venereal Syphilis
2.Endemicum - endemic Syphilis2.Endemicum - endemic Syphilis
(bejel)(bejel)
3.Pertenue- Yaws3.Pertenue- Yaws
4.Carateum-4.Carateum- PintaPinta

84. Treponema PallidumTreponema Pallidum
Thin walled spiral organismThin walled spiral organism
Motile : endoflagella(axialMotile : endoflagella(axial
filaments)filaments)
Thin not reliably seen in gramThin not reliably seen in gram
stain,stain,
darkfield microscopy ordarkfield microscopy or
immunofluorescenceimmunofluorescence
Not grown on bacteriologic mediaNot grown on bacteriologic media
or cell cultureor cell culture

85. Stages of syphilisStages of syphilis

86. Nasal SyphilisNasal Syphilis
Primary SyphilisPrimary Syphilis
- External nose or Vestibule- External nose or Vestibule
-chancre-rare-chancre-rare
-Self limiting disappears in-Self limiting disappears in
6-10 weeks6-10 weeks
-contagious-contagious

87. Secondary SyphilisSecondary Syphilis
Most infectiousMost infectious
MUCOUS PATCHES ON THE
TONGUE OF A PATIENT WITH
SECONDARY SYPHILIS

88. Tertiary SyphilisTertiary Syphilis
Most common stage ofMost common stage of
nasal syphilisnasal syphilis
Bony portion of NasalBony portion of Nasal
SeptumSeptum
Gumma –pathognomicGumma –pathognomic
punched out ulcerpunched out ulcer

90. Congenital SyphilisCongenital Syphilis
EARLY:EARLY:
first 3mos of life,manifestfirst 3mos of life,manifest
as snufflesas snufflesnasalnasal
discharge purulentdischarge purulent
LATE:manifest at pubertyLATE:manifest at puberty
gummatous lesiongummatous lesion
destroys nasal structure,destroys nasal structure,
Keratitis,deafness,hutchisoKeratitis,deafness,hutchiso
n’s teethn’s teeth

91. Syphilitic PharyngitisSyphilitic Pharyngitis
May be congenital or acquired by sexualMay be congenital or acquired by sexual
intercourseintercourse
Secondary stage most likelySecondary stage most likely
incidence rising– Mainly in HIV positiveincidence rising– Mainly in HIV positive

92. Primary SyphilisPrimary Syphilis
Extragenital sites : lips,Extragenital sites : lips,
tongue, buccal mucosatongue, buccal mucosa
and tonsilsand tonsils
Begins as a Papule,Begins as a Papule,
breaks down to form abreaks down to form a
painless ulcer withpainless ulcer with
indurated marginindurated margin
(chancre)(chancre)
Non tender cervicalNon tender cervical
lymphadenopathylymphadenopathy
Spontaneous healingSpontaneous healing

93. Secondary SyphilisSecondary Syphilis
-is infectious-is infectious
Hyperemia and inflammation ofHyperemia and inflammation of
pharynx and soft palatepharynx and soft palate
Snail Track ulcer :-OralSnail Track ulcer :-Oral
cavity and oropharnyxcavity and oropharnyx
-Ulcerated leison covered with-Ulcerated leison covered with
greyish white membranegreyish white membrane
which when scraped haswhich when scraped has
pink basepink base
with no bleeding.with no bleeding.

94. Tertiary SyphilisTertiary Syphilis
Typically painless .Typically painless .
No lymphadenopathy unless secondaryNo lymphadenopathy unless secondary
infection.infection.
GUMMA are characterstic.GUMMA are characterstic.
- Seen in Hard palate, Nasal septum- Seen in Hard palate, Nasal septum
,Tonsil ,PPW or larynx.,Tonsil ,PPW or larynx.
VDRL may be negativeVDRL may be negative

95. EAREAR- TM perforation, granular- TM perforation, granular
middle ear, COM- if super infection.middle ear, COM- if super infection.
-Infection mimic TB.-Infection mimic TB.
-Inner ear: Hennebert’s sign ,-Inner ear: Hennebert’s sign ,
Tullio’signTullio’sign
-SNHL, Vertigo, Endolymphatic-SNHL, Vertigo, Endolymphatic
hydrops- Fibrous adhesion bet.hydrops- Fibrous adhesion bet.
Stapes foot-plate & Labyrinth.Stapes foot-plate & Labyrinth.

96. Syphilis LarynxSyphilis Larynx
Rarely involvedRarely involved
Secondary & Tertiary more commonSecondary & Tertiary more common
Hoarseness & Dysphagia – commonHoarseness & Dysphagia – common
O/EO/E
- Epiglottis & Aryepiglottic folds- Epiglottis & Aryepiglottic folds
principally involvedprincipally involved

97. DiagnosisDiagnosis
1.Immunoflurorescence or dark field microscopy1.Immunoflurorescence or dark field microscopy
2. Biopsy:2. Biopsy:
3.Serology:3.Serology:
Non-treponemal antibody tests:VDRL,RPR,ARTNon-treponemal antibody tests:VDRL,RPR,ART
For screening and treatment follow upFor screening and treatment follow up
Treponema specific antibody tests:forTreponema specific antibody tests:for
confirmation,usu.remains positive for life,confirmation,usu.remains positive for life,
FTA-ABS test,TPHAFTA-ABS test,TPHA

98. Stage of SyphilisStage of Syphilis TreatmentTreatment
Primary, secondary, or earlyPrimary, secondary, or early
latentlatent
Penicillin G benzathine (singlePenicillin G benzathine (single
dose of 2.4 mU IM)dose of 2.4 mU IM)
Late latent (or latent ofLate latent (or latent of
uncertainuncertain
duration), cardiovascular, orduration), cardiovascular, or
benign tertiarybenign tertiary
benzathine Penicillin Gbenzathine Penicillin G
(2.4 mU IM weekly for 3 weeks)(2.4 mU IM weekly for 3 weeks)
Procain penicillin- 1.2mu for 20Procain penicillin- 1.2mu for 20
days.days.
Alternative drugsAlternative drugs Doxycycline- 100mg bd/ 15 daysDoxycycline- 100mg bd/ 15 days
Erythromycin- 500mg qid for 15Erythromycin- 500mg qid for 15
days.days.
Ceftriaxone1gm/ im/ 7-15 daysCeftriaxone1gm/ im/ 7-15 days

99. THANK YOUTHANK YOU