Dr .Sinboona Ararsa MD

1. Abdulselam Jemal
Feb 1,2012
1

2. OUT LINE
 Introduction
 Epidemiology
 Microbiology
 Pathogenesis
 Clinical manifestation
 Rx outline
 Cx of tbc

3. INTRODUCYION
 Mycobacterium tuberculosis
 Can affect any organ
 Commonest cause death among infectious disease
 E-merged 1980s ….AIDS
 Current main problem …drug resistance

4. EPIDEMIOLOGY
 Affects 1/3rd of world popn
 Cmn among HIV infected ,low socioeconomic status
 9 mill cases - annually world wide
 2 mill deaths annually
 >90% of cases /deaths were from developing countries

5. IN ETHIOPIA
 100,000 cases occur annually
 Death 3000 annually
 MDR -TB
 180 pt enrolled on Rx
 200 on waiting list

6. MICROBIOLOGY OF MTB
 Rod shaped , thin , non spore forming , non motile
,aerobic bacterium
 Neutral on Gm stain
 Once stained cant be decolorized by acid /alcohol
o Classification as AFB
due to CW structures
mycolic acid >60% of cell wall

7. contd
 Grow slowly
 solid media 3-8wks
 doubling time 18hrs

8. Pathogenesis
 1st 0-3 weeks
Inhaled droplet nuclei[<10%]
Alveolar macrophage
Unchecked proliferation ]

9. Contd
o After 3 weeks
 Two host response will develop
 Macrophage activating CMI
 Tissue damaging DTH
 Balance b/n the 2 –determine the form of Tbc
 Granulomatous lesions (tubercles)Formation
 In the majority of cases
 Cavitiery lesions

10. The bacilli have 4 potential fates:
o may be killed by immune system.
o may multiply and cause primary Tb.
o may become dormant and remain asymptomatic
o may proliferate after a latency period.

11. Clinical Manifestation
Pulmonary Tuberculosis
 Classified as primary & post primary [secondary]
 Primary Disease
 Occur soon after initial infn
 Middle & lower lung zones
 Usually peripheral
 Accompanied >1/2 by hilar & paratracheal LAP

12. contd
 Majority of lesion heal spontaneously
 Evident by small calcified nodule-Ghon complex
 10 tbc progress to clinical illness - In children & Imm
compromised
Initial lesion inc in size & evolve in d/t ways
 Pleural effusion [2/3rd]

13. contd
Cavitation
LAP –compress bronchi –obs - segmental/lobar collapse
 Partial obs –obstructive emphysema ,& bronchiectasis
may develop
Hematogenous diss [cmn & often asymp]
 May result in sever form in imm.comp.
 Milliary / meningitis

14. Post primary/Adult
type/Reactivation/Secondary Tbc
 From endogenous reactivation
 Localized
 Apical / post segment of upper lobe
 Superior segm. Of lower lobe
 Extent varies - from small infiltrates to extensive
cavitary disease

15. contd
Sign & symptom
- Early - : nonspecific
 Sym. Complex
 Later –cough
 Hemoptysis
 Pleuritic pain
 Dyspnea -extensive disease

16. Extrapulmonary Tuberculosis
 Is seen more commonly in HIV-infected
individuals
 all organ systems may be affected
 Common site L/N ,Pleura , GUS , Bones & joints

17. Pleural Tuberculosis
 accounts for ~ 20% of extrapulmonary cases
 Is common in primary tuberculosis
 may result from
 contiguous spread of parenchymal inflammation
 Actual penetration by tubercle bacilli in to the
pleural space
 the effusion may be small , and resolve
spontaneously
 Or may be sufficiently large
 Cx –trapped lung , bacterial contamination

18. Investigations
 CXR -effusion & parenchymal lesion
 Pleural fluid analysis
 Cell count
 Biochemical ( PH , glucose , LDH , protein)
 Bacteriological ( AFB ,Culture )
Pleural Bx = 80%
Adenosine deaminase (ADA) is a useful screening test:
tuberculosis is virtually excluded if the value is very low

19. Tb of upper airways
 Usually a Complication of advanced cavitary PTb
 May involve larynx , pharynx and epiglottis
 Sym - hoarseness,
 dysphonia, and
 dysphagia , chronic productive cough
Ulceration - may be seen on laryngoscopy
Ca of larynx - may have similar feature.
Dx - AFB , biopsy

20. HIV-Associated Tuberculosis
 Most common disease
 Can occur at any stage
 High CD4 – typical presentation
 Low CD4 – 10 tbc like pattern ,
milliary / diffuse infiltrate ,
little / no cavitation
 Overall sputum smear yield is low
 Dx is difficult [atypical CXR , sputum low yield]

21. Diagnosis of Tuberculosis
 AFB microscopy [sensitivity =40-60%]
a) Light microscopy
• Ziel- Neelson basic fuchsin dyes
• Kinyoun dyes
b) Fluorescence microscopy
• Auromine-rhodomine staining

22. Culture :-gold standard!
Drug susceptibility testing
Nucleic acid amplification
Tuberculin skin testing (Monteux
test)

23.  Chest radiograph:
 A patchy nodular infiltrate
 Pleural effusion
 Cavitations
 Round infiltrates-may confuse with lung Ca
 Homogenously calcified nodule-usually 5-
20mm are tuberculomas.
 Milliary infiltrates - numerous small nodular
lesions
 CT scanning:
. Vague CXR findings

24. contd

25. Rx out line
Medical Rx
 Drug sensitive Tbc almost all can be Rxd with
standard short course regimen !!!
 4 drug regimen [2 mon] [ H , R , Z ,E ]
 2 drug regimen [4 mon] [ H , R ]
Surgical Rx
 Is indicated only for complication !!!

26. Complication of Tbc
 Failure of medical therapy
 Progressive disease ,lung destruction ,drug resistance
 Massive hemoptysis
 Empyema
 Bronchiectasis
 Fibro thorax
 Broncho stenosis
 cavernoma
 Bronchopleural fistula
 Tracheo or bronchoesophageal fistula
 Lung cancer
 Middle lobe syndrome

27. contd
1. Drug resistance –arise by spontaneous point
mutation
 MDR-TB
 Resistance for at least H & R
 XDR-TB(extensively )
 Resistant to at least the fluoroquinolones
and one or more of the injectable drugs
amikacin, kanamycin, or capreomycin
 Higher incidence in HIV infected individual

28. contd
 Indication for surgery
 Same as drug sensitive
 Also for -persistence cavietery disease , destroyed
lobe or lung
 It should be localized & pt should tolerate surgery
 Pre & post op chemotherapy –
 Prior medical Rx of 3-6 mon is indicated
 Post operatively average - 8mon

29. contd
2 . Hemoptysis
massive >600ml/24hr
 causes
 Active tbc
 Aspergillosis
 Bronchiectasis
 Lung ca arising from tbc scar

30. contd
a) Active Tbc
 Majority-from erosion of bronchial artery which
become abundant around infected site
 Also from RASMUSSENS ANEURYSM [when TB extends
into the adventitia and media of bronchial arteries,
resulting in inflammation and thinning of the vessel wall;
this aneurysm subsequently ruptures into the cavity]
 Occasionally from small branches of pulm vessels,
acute tuberculouse ulceration of bronchial mucosa

31. contd
b)Aspergillosis
 A. fumigatus
 Aspergillus is considered an opportunistic pathogen
 Requiring : cavieties , asthma / CF , or imm
compromization
 The disease has 4 forms

33. contd
Aspergilloma [fungus ball]
 Aspergilloma characterized by a mass of fungal
mycelia, inflammatory cells, mucus and tissue
debris, all within a preformed lung cavity
 The fungus ball is mobile within the cavity and usually
does not completely fill the space

34. contd
 The true incidence of aspergilloma is unknown
 Most aspergillomas are asymptomatic

35. contd
 Hemoptysis is the most common presenting symptom
 Hemoptysis is -due to chronic irritation
 When hemoptysis is present, it is generally mild, but it
can be severe and life-threatening
 chronic cough and weight loss can also occur

36. Investigations
 On CXR:
-revel mass in a preexisting
cavity
- crescent sign, Monad’s sign
 On CT:
- provide better definition of mass within
the cavity.
- May demonstrate multiple Asprergillomas.

37. contd
 Bronchoscopy - to localize hemoptysis
 Serology(Ig E, Ig G) - Most patients have
serum +ve Ab
 sputum cultures +ve 50% of the time

38. Treatement
 Medical care:
- antifungal agents( Itraconazol)
-not effective
 Surgical care:
 Indication:
 Massive and recurrent hemoptysis
 If the lesion is close to main vessel
.

39. 3. Bronchiectasis
 Feature
 Cylindrical type
 Upper lobe (Dry bronchiectasis )
 May be asymptomatic or have dry cough , Hemoptysis
4. Empyema
 Usually result of ruptured cavieties in to pleural space
 BPF - ruptured cavieties in to pleural space
- erosion of empyema in to lung parenchyma
 Extensive fibrosis with gross thickened pleura

40. 5. Lung cancer
 Linkage –2 d/t ways
1. Tbc can be reactivated by bronchogenic car
 Localy by erosion of encapsulated caseous foci
 Systematically-debilitation
2. Dvt of malignancy in areas of scar
 So both disease can co-exist
 Histo Type – undifferentiated carcinoma ,
adenocarcinoma
 SCC - More peripherally based Ca will develop
 CXR - findings that suggest concomitant Ca :
 Progression of one area while the remainder of the lesion is
regressing.
 A large >3cm mass lesion admixed with infiltrative disease

41. 6. Middle Lobe Syndrome
 Isolated atelectasis of the middle lobe
 Also can involve the lingula
 Is due to extrinsic nodal compression of the bronchus
which results in post obstructive atelectasis and
chronic pneumonitis
 The predominant symptoms are
 recurrent infection and
 atelectatic middle lobe on chest radiograph, with or
without hilar LAP

42. contd
 Bronchoscopy often shows a tight stenosis of the
middle lobe bronchus
 it is important to rule out endobronchial obstruction
by a malignant neoplasm
 symptomatic patients fit for surgery should undergo
pulmonary resection.

43. 7. FIBROTHORAX
 results from fibrosis of the visceral pleura
 two mechanisms for formation of fibrothorax
 Most often, may develops from pleural inflammation in
patients with pleural effusions
 e.g. - incompletely evacuated hemothorax, tbc effusion, or
chronic empyema
 Less frequently, results from pulmonary parenchymal
disease
 e.g. inadequately treated tbc, bronchiectasis, or lung abscess

44. contd
 Any of above process lead to pleural scarring &
dvt of fibrous tissue that replaces & obliterate
pleural cavity.
 In severe cases the fibrotic process can invade the
chest wall, destroy the intercostals structures, replace
the endothoracic fascia , cause thickening of
periosteum of ribs, ultimately the ribs can fuse and
calcification of collagen can occur-resulting in a
limitation of resp. excursion and may lead to
development of scoliosis.
 The fibrotic process does not traverse the diaphragm.

45. contd
 Rx
 Best - to make appropriate interventions in patients
with complicated pleural effusions
 Decortication – definitive Rx

46. References
 Harrison's principles of internal medicine ,17th
ed
 Robbins basic pathology 8th ed
 Oxford Textbook of Surgery, 2nd ed.
 Thoracic surgery 2nd ed[pearson]
 Sabiston 7th ed ;cardiothoracic
 Schwartzs principle of surgery 9th ed
 Up to date 19.1
 General Thoracic surgery ,7th ed

47. Thank you!!