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Aime tuberculosis
- 1. PULMONARY &EXTRAPULMONARY TUBERCULOSIS Prepared byAIME NSENGIYUMVA Doc III Student @ University of RWANDA
- 2. General Considerations Mycobacterium tuberculosisis a multisystemic disease with myriad presentations and manifestations,. It is caused by M.tuberculosis It was isolated by Robert Koch in 1882 It is confined to the lungs but may spread to part of the body The prevalence of drug-resistant TB is also increasing worldwide
- 3. microbiology the genus Mycobacterium •M. tuberculosis complex • M. Tuberculosis complex consists of: M. tuberculosis, M. bovis, M. africanum, M. microti, M. canetti M. tuberculosis • rod-shaped, • non-spore-forming, • thin aerobic bacterium • measuring 0.5 μm by 3 μm • slow-growing • facultative intracellular parasite
- 4. Pulmonary tuberculosis • Introduction •Epidemiology • Transmission and pathogenesis • Risk factors • Clinical presentation • Investigations • Diagnosis • Treatment • Drug resistance • Take home message
- 5. Pulmonary tuberculosis • Thelungs are the most common site for the development of TB; 85% of patients with TB present with pulmonary complaints. • Extrapulmonary TB can occur as part of a primary or late, generalized infection common sites LN,BONE, BRAIN, PLEURA,PERITONEUM, …
- 6. Epidemiology • GLOBAL BURDEN more than 2 billion people are estimated to be infected with TB 1.4 million people died from TB in 2019 including 208 000 people with HIV In 2019, 10 million people fell ill TB worldwide. MDR-TB remains a public health crisis and a health security threat.
- 7. EPIDEMIOLOGY • RWANDA TB incidencerates in Rwanda (86 incident TB cases -new and relapse- per 100,000 habitants in Rwanda in 2012 it is decreasing since 2006 • 557 MDR cases were diagnosed between 2005 and 2012 CDC Country profile 2017 Incidence 57/10000 Mortality 4,9/100000 Treatment success 80% in 2016 TB patients known with HIV 22%
- 9. Transmission • M. tuberculosisis carried in airborne particles, • called droplet nuclei, • 1– 5 microns in diameter. They are generated when persons who have pulmonary or laryngeal TB disease cough, sneeze, shout, or sing • M. tuberculosis is transmitted through the air, not by surface • can remain suspended in the air for several hours,
- 10. Factors that Determinethe Probability of M.tuberculosis Transmission • Infectiousness of the TB patient • Environment in which the exposure occurred • Frequency and duration of the exposure • immune status of the exposed individual
- 11. Not everyone infectedwith TB bacteria becomes sick. As a result, two TB-related conditions exist:
- 12. Pathophysiology 1. Droplet nucleicontaining tubercle bacilli are inhaled, enter the lungs, and travel to the alveoli. 2. Tubercle bacilli multiply in the alveoli
- 13. 3. A smallnumber of tubercle bacilli enter the bloodstream and spread throughout the body 4. Within 2 to 8 weeks, macrophages ingest and surround the tubercle bacilli The cells form a barrier shell, called a granuloma, that keeps the bacilli contained and under control (LTBI)
- 14. Pathophysiology • If theimmune system cannot keep the tubercle bacilli under control, the bacilli begin to multiply rapidly (TB disease). • This process can occur in different areas in the body, such as the lungs, kidneys, brain, or bone
- 15. Diagnosis Medical History Symptoms ofdisease: cough ≥3 weeks, chest Pain hemoptysis ,Tachypnea, lymphadenopathy Systemic sx; night sweats ,fever, weight loss, anorexia, History of TB exposure, infection, Past TB treatment Demographic risk factors for Tb Medical conditions that increase risk for TB disease: HIV ,CRF,DM, Alcoholics, Malnourished, Malignancy
- 16. Screening with TST(MANTOUX) • A reaction of less than 5 mm is considered negative • 5-9 mm is considered positive (+) • 10-19 mm is considered positive (++) • more than 20 mm is considered positive (+++) • A positive tuberculin skin test indicates tuberculous infection, with or without disease
- 17. Imaging &Lab workup •CXR : hilar/mediastinal LN, Infiltrate or consolidation ,Cavitations, nodules, effusion, pleural effusion, • A Tuberculin skin test (TST) • acid-fast bacilli (AFB) smear: sputum, 3x, 8hrs apart ,1 in mrng • nucleic acid amplification (NAA) testing • FBC, HIV test, plasma Liver enzymes, urea and creatinine
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- 20. TB LYMPHADENITIS • Commonestextrapulmonary site • Children & young adults • Cervical LN involvement- commonest • Firm discrete or matted lymph nodes • Occasionally abscess or sinus • Dx- FNAC or biopsy • Rx 2RHZE + 4RH:6 months • Surgery- NOT required
- 21. Pleural-Pericardial-Peritoneal TB • PleuralTB causes pleural effusion • Pericardial TB causes pericardial effusion • Peritoneal TB causes ASCITES • SYMPTOMS • non-specific: fever, cough, chest pain, SOB, abdominal swelling • Signs • pleural effusion • pericardial tamponade/constrictive pericarditis • ascitis
- 22. Pleural-peritoneal-pericardial • Ix: X-ray, EKG • DX: Pleural-pericardio-paracentesis and send fluid for analysis, AFB Smear,culture, Fluid ADA: increased • abdominal ultrasound • Cardiac ultrasound Rx: 2HRZE + 4HR • Steroids in pericardial TB
- 23. Fluid analysis Tuberculous pleuraleffusion • Color : straw colored • cell count: lymphocyte predominance • Protein: >3.0 g/d • Glucose: between 60-100 mg/dl • pH <7.40 • (LDH): elevated • (AFB) smear • and culture Ascitic fluid analysis • straw-colored • SAAG <1.1 g/dL • leukocyte count of 150 to 4000 cells/mm3, • with a relative lymphocytic pleocytosis • Protein >3.0 g/dl • The cell count is 150 to 4000 cells,predominantly lymphocytes
- 24. CNS Tuberculosis Pathogenesis andclinical presentation • Tuberculous meningitis (TBM) • May produce damage to vessels, infarction of brain, edema, fibrosis • Predilection: base of brain • In AIDS: cerebral abscess or tuberculomas • Space-occupying sign: headache, seizure, paralysis, personality change, CN defects, neck stiffness, papilledema • Symptoms- headache, fever, seizures, altered sensorium, III/VII/VIII nerve palsy • Signs: Neck stiffness with Kernig’s/Brudzinski sign +ve
- 25. CNS Tuberculosis Diagnosisand Treatment • CSF: clear or slightly opalescent; elevated protein and low glucose (virus: high) • AFB and culture: limited • Meningeal biopsy • CT and MRI: helpful TUBERCULOMA Thick ring-enhancing lesion ± cavitation on CT • Tx: Tuberculosis Meningitis 2 (RHZe) / 10(RH) • surgery
- 26. SKELETAL TB • Pott’sspine- • Lower thoracic/lumbar spine commonly involved • May involve contiguous vertebrae with disc involvement • Cold abscess is usually bilateral • Can lead to vertebral collapse with spinal instability, gibbous deformity & spinal cord compression • Arthritis- • Mostly monoarticular • Hip joint most commonly involved • Slowly progressive destruction of joint • Osteomyelitis- cold abscess of any bone
- 27. SKELETAL TB • Dx-X-ray, MRI, microscopy & culture of infected material • Rx- ATT. - osteo-articular TB: 2 (RHZe) / 10 (RH) • Surgery- • Diagnostic • Abscess drainage • Debridement of infected material • Decompression & stabilization of spinal cord • Follow-up- best clinically- pain, constitutional symptoms, mobility, neurologic improvement
- 28. MILIARY TB • Hematogenouslydisseminated • More common in immunocompromised • Symptoms- non-specific • Sign- choroidal tubercle on retinal exam • Dx- CxR- miliary tubercles • Rx- standard ATT
- 29. MDR TB • resistanceto at least Rifampicin and Isoniazid confirmed by drug sensitivity test (DST) • causes • Non adherence/poor compliance • when is MDR to be suspected? every failure of treatment despite a regular, correct and supervised treatment TB case diagnosed among the contacts of a know MDR-TB patient any re-treatment Investigations: Sputum culture with sensitivity test Bronchoalveolar lavage • Tx : 6(Km-Z-Lfx-Pto-Cs) 14(Km-Z-Lfx-Pto-Cs) duration: 20 months
- 30. Management • First-treatment (adultsfrom 15 years) • 2 RHZE / 4 RH (total duration: 6 months) • Indications: New cases. •
- 31. • Retreatment • 2SRHZe / 1 RHZE / 5 RHE (total duration: 8 months) • Indications: relapses, failures to first treatment, patients who return to treatment after default, « other» cases previously treated.
- 32. TYPE OF TBREGIMEN DURATION PULMONARY TB 2 RHZE / 4 RH 6 Months Retreatment 2 SRHZe / 1 RHZE / 5 RHE 8Months TB MENINGITIS 2 (RHZe) / 10(RH) 12months osteo-articular TB 2 (RHZe) / 10(RH) 12 Months Pleural & peritoneal 2 RHZE / 4 RH 6 Months Tb adenitis 2RHZE/4RH 6Months MDR TB 6(Km-Z-Lfx-Pto-Cs) 14(Km-Z-Lfx-Pto-Cs) 20 MONTHS
- 33. Clinical monitoring • Clinicalmonitoring — Patient education regarding symptoms of hepatitis and other possible drug toxicities • Patients should be instructed to report signs or symptoms of toxicity • During treatment of pulmonary tuberculosis, sputum should be obtained for AFB smear and culture at monthly intervals until two consecutive cultures are negative • Completion of therapy — Completion of the duration of therapy and the total number of doses administered • Interrupted therapy — In some cases, the specified number of doses cannot be administered within the targeted time period
- 34. TAKE HOME MESSAGE •TB IS A GLOBAL BURDEN • IT PRESENTS IN DIFFERENT PATTERNS DEPENDING TO AFFECTED SYSTEM • SUSPICION IS A KEY TO DIAGNOSIS AND MANAGEMENT • PATIENT EDUCATION IS A KEY O SUCCESSFUL TREATMENT • PREVENTION IS POSSIBLE • TB RESISTANCE IS A GLOBAL THREAT THAT NEEDS TO BE PREVENTED
- 35. References • Uptodate • Medscape •WWW.CDC.GOV /COUNTRY PROFILE • WHO Guidelines on tuberculosis 2019 • Handbook of TB, HIV-TB in Rwanda (RBC) • HARRISON’S PRINCIPLE OF INTERNAL MEDICINE 19TH EDITION • World Health Organization. Global Tuberculosis Report 2017. Available at: http://www.who.int/tb/publications/global_report/en/ (Accessed on November 03, 2017). • Tuli SM. Tuberculosis of the Skeletal System, Jaypee Brothers Medical Publishers, New Delhi 2016. • Centers for Disease Control and Prevention. Regional Training and Medical Consultation Centers (RTMCCs). Available at: http://www.cdc.gov/tb/education/rtmc/default.htm (Accessed on May 21, 2010). • Internal medicine guidelines 2012(RBC)