This document summarizes information about pulmonary tuberculosis. It begins with definitions of tuberculosis and discusses it being a global public health emergency. It then covers the causes, signs and symptoms, transmission routes, risk factors, stages of infection, and diagnostic steps for tuberculosis. The diagnostic steps include history and clinical examination, radiographic features, and bacteriological evaluation including smear, culture, and new diagnostic methods like MGIT and nucleic acid amplification.

1. Al-Balqa' Applied University
Department of Allied
Medical Science
Pulmonary Supervised By :
tuberculosi Dr. Waleed Al-Momani
s Presented By :
Ala’a Al-Dlahmeh

2. Pulmonary
Tuberculosis

3. Definitions
Tuberculosis or TB (tubercles bacillus)
is :
a contagious bacterial infection
that attacks the lungs can also
transmitted to other parts of the body.
A Global public health Emergency :
is the number one single
infectious disease killer, taking nearly 3
million lives per year .
Ref(4)

4. Causes
Mycobacterium tuberculosis
Mycobacterium africanum
Mycobacterium microti
Mycobacterium Bovis
all cause tuberculosis (TB) and are
members of the tuberculosis species
complex but the main cause is
Mycobacterium tuberculosis .
Ref(4)

5. Sings & Symptoms
Cough (that lasts 3 weeks
or longer, and can bring up
with blood) .
Chest pain .
Fever .
Fatigue .
Loss of appetite .
 weight loss .
Chills and night sweats .
Ref(4)

6. Transmission
Respiratory route
M.Tuberculosis
Inhalation of air droplet
that contain tubercle
bacillus
Intestinal route
M. bovis drinking or
eating
contaminated, unpasteuri
zed (raw) milk or milk
products.
(uncommon)
Ref(4)

7. Respiratory Rout
•Infection requires of inhalation particles small
enough to traverse the upper respiratory defenses
and deposit deep in the lung (alveoli).
• Large droplets tend to lodge in the more
proximal airways and typically do not result in
infection.
•when a person who is sick with active disease
coughs, sneezes, or laughs.
•To become infected with TB, a person usually
needs to share air space with someone sick with
TB disease.
Ref(1)

8. Risk factors
A healthy immune system can often successfully
fight TB bacteria, but your body can't mount an
effective defense if your resistance is low. diseases
and medications can weaken your immune
system, including :
•HIV/AIDS
•Diabetes
•Chemotherapy
•Malnutrition
•Advanced age
•Immunosuppressive medications
•for people who live in or travel to
countries that have high rates of tuberculosis
such as (Sub-Saharan Africa, India, China, Mexico, Southeast
Asia)
Ref(1)

10. Tb Infection
90% 50%
of those 10% death rate for
infected with chance that a
M. tuberculosis these active TB
latent infection cases
have
will progress to if untreated.
asymptomatic,
latent TB TB disease.
infection (LTBI)

11. Stage 1
TB infection begins when the mycobacteria
reach the pulmonary alveoli, where they invade
and replicate within the endosomes of alveolar
macrophages.
tubercle bacilli
Ref(1)

12. Stage2
Lymphocytes and fibroblasts are among the cells
that aggregate to form granulomas surrounding
the infected macrophages To prevents
dissemination of the mycobacteria & provides a
local environment for interaction of cells of the
immune system. Ref(1)
granulomas

13. Stage 3
Bacteria inside the granuloma can become
dormant, resulting in a latent infection. Another
feature of the granulomas of human tuberculosis is
the development of abnormal cell death (necrosis)
in the center of tubercles. To the naked eye this has
the texture of soft white cheese and is termed
caseous necrosis.
Ref(1)

14. The caseous centers of the tubercles
liquefy, and the organism begins to rapidly
multiply extracellularly. After time, the large
antigen load causes the walls of nearby
bronchi to become necrotic and rupture.
This results in cavity formation. Ghon
complex. Typically, the Ghon complex is
readily visible upon chest X-ray.
caseous
necrosis.
Ref(1)

15. Stage 4
Milliary or extrapulmonary stage :
is the hematogenous spread of MTB .
“Milliary" is derived from the fact that
metastasizing tubercles are about the same size
“millet seed”.
Two types of lesions caused by milliary TB:
I. Exudative lesions result from the
accumulation of PMN's around MTB.
Here the bacteria replicate with virtually
no resistance. formation of a "soft
tubercle".
II. Productive “granulomatous” lesions
occur when the host becomes
hypersensitive to tuberculoprotein.
formation of a "hard tubercle".
Ref(4)

16. Reactivation Of
Tuberculosis
Only persons with latent infection have high
risk of Tuberculosis Reactivation.
cased by tubercle bacilli that have survived
in the primary lesion.
Reactivation infection characterized by
chronic tissue lesions, formation of tubercle
caseation and fibrosis.
The reactivation type almost always begins at
the apex of the lung, where the oxygen
tension (PO2) is highest.
Ref(1)

17. Tubercle bacilli
Characteristics
Gram resistance (acid fast bacilli)
Obligate aerobe & Mesophile
Non-spore-forming & Non-motile rod
Slow generation time:15-18 hours
Lipid rich cell wall contains:
Mycolic acids 50% of cell wall dry weight.
Cord Factor responsible for the serpentine
cording, toxic to mammalian cells ,an inhibitor of PMN
migration & resistance to detergents, antibacterial.
Ref(1)

18. Diagnostic steps
History and clinical examination
Radiographic features
Bacteriologic evaluation

19. 1
History and clinical
examination
“The first rule of TB diagnosis: is to think of TB….”
The physician Include TB in his differential
diagnosis when history & symptoms are
consistent with TB diagnosis THEN he will
recomendrd appropriate diagnostic tests to
prove the infection.

20. 2
Radiographic features
Chest X-ray
Tuberculosis creates cavities visible in x-rays like
this one in the patient's right upper lobe.
Abnormalities on chest radiographs may be
suggestive of, but are never diagnostic of TB.
However, chest radiographs may be used to rule
out the possibility of pulmonary TB in a person
who has a positive reaction to the tuberculin skin
test and no symptoms of disease.
Ref(2) Chest X-ray

21. 3
Bacteriologic evaluation
Conventional diagnostic methods
{smear, culture}
New diagnostic methods
{NNA, BACTEC, MGIT}

22. Specimens :
Fresh sputum ,gastric washing , urin,
pleural fluid , cerebrospinal fluid , biopsy
material , blood.
Decontamination & concentration of specimens
:
sputum Specimens (nonsteril) should be :
•Liquefied with N-acetyl-L-cysteine
•Decontaminated with NaOH
•Neutralized with buffer
• concentrated by centrifugation.
Specimens processed in this way can be used for
acid fast stains and for culture.
Ref(4)

23. Acid Fast Bacilli
“AFB” Smear
Specimen examined for acid fast bacilli by staining:
Ziehl-neelson Acid Fast Auramine-rhodamine
Staining Staining
Ref(4)

24. Acid Fast Bacilli “AFB”
I. Solid media culture
1. Löwenstein-Jensen (egg and also contain
high concentrations of malachite green to
overcome contamination with other bacteria).
2. Middlebrook 7H10 & 7H11 are ( containe
defined vitamins, salts, catalase, glycerol, olic
asid and albumin to neutrelize toxic effect of fatty
acids).
II. liquid media*
1. BACTEC TB-460
*(new diagnostic methods)
2. MGIT960 systems

25. Acid fast bacilli (AFB) smear microscopy
and culture are still the “gold standards”
for the diagnosis of active TB but this
conventional methods for culture required
(6-8) weeks for isolation from media.
Ref(4)

26. Immunologic diagnosis
γ-Interferon release assays (GIRA)
Tuberculin Skin Test

27. γ-Interferon release assays
(GIRA)
Test rely on the fact that T-lymphocytes will
release γ-interferon when exposed to
specific antigens. These tests are mostly
developed for the field of tuberculosis
diagnosis, but in theory, may be used in the
diagnosis of other diseases which rely on
cell-mediated immunity.
Ref(2)

28. Tuberculin kin Test
Purified Protein Derivative (PPD) :
is a concentrated filter of broth in which
tubercle bacilli have grown for 6 weeks(old).
•A dose of 0.1 ml of 5-TU PPD injected.
• measuring the size of induration 48-72 hours.
• positive if ≥ 10 mm induration size.
•Standard method for screening & measuring of a
person’s cellular response.
1 2

29. Positive Reaction
person infected in the past or latent TB
infection
After BCG vaccination, but this may last
for only 3-7 years .
Persons are retested 2 weeks later; their
PPD skin test “boosted” by the recent
antigen injection.
High risk of (endogenous infection)
Ref(4)

30. Negative Reaction
 persons who have NEVER been
infected, they are not subject to that
risk, though they may become infected from
an external source (exogenous infection)

31. New Diagnostic
Methods
Mycobacteria Growth Indicator Tube
(MGIT).
BACTEC TB-460.
Nucleic Acid Amplification Method
(NAA).

32. Mycobacteria Growth Indicator
Tube (MGIT)
Is an automated system that exploits the
fluorescence of an oxygen sensor to detect
growth of mycobacteria in culture.
The instrument scans the MGIT every 60 minutes
for increased fluorescence. Analysis of the
fluorescence is used to determine if the tube is
Positive contains approximately 105 to 106
(CFU/mL).
Negative tubes remain for a minimum of 42 days
(up to 56 days)
Ref(2)

33. The BACTEC TB-460
Is an automated radiometric culture
method used for the rapid growth of
mycobacteria.
The methodology uses a liquid Middlebrook
7H12 medium that contains radiometric
palmitic acid labeled with radioactive (14 C).
Production of 14 CO2 by the metabolizing
organisms provides a growth index for the
mycobacteria. Growth is generally detected
within 9-16 days
Ref(2)

34. Nucleic Acid Amplification Method
polymerase chain reaction [PCR] allows
the direct identification of M.tuberculosis
in clinical specimens.
Contamination of samples by products of
previous amplification and the presence of
inhibitors in the sample may lead to false-
positive or false-negative results

35. Treatment
Latent infection
A person with a positive skin test, a normal
chest X-ray, no symptoms and is not
contagious. treatment with an antibiotic may be
recommended for this person to prevent the TB
from turning into an active infection. The
antibiotic used for this purpose is called
isoniazid (INH). If taken for six to 12
months, it will prevent the TB from becoming
active in the future.
Ref(4)

36. Treatment
Active infection
Active TB is treated with a combination of
isoniazid along with Rifampin, ethambutol
and pyrazinamide are the drugs commonly
used to treat active TB. Four drugs are often
taken for the first two months of therapy to
help kill any potentially resistant strains of
bacteria. Then the number is usually reduced to
two drugs for the remainder of the treatment
based on drug-sensitivity testing.
Ref(4)

37. Multi Drug Resistance Tuberculosis
(MDR –TB)
between one in 10^6 and one in 10^8 tubercle
bacilli are spontaneous mutants resistance to first-
line antituberculosis drugs. When the drugs are used
singly, the resistant tubercle bacilli emerge rapidly
and multiply. Treatment of MDR-TB must be done
on the basis of sensitivity testing. It is impossible
to treat such patients without this information.
patient should be started on SHREZ
(Streptomycin+isonicotinyl Hydrazine +Rifampicin
+Ethambutol+pyraZinamide)
Ref(4)

38. Prevention & Control
 prompt and effective treatment of patients with
active tuberculosis and carefully follow-up of their
contacts with tuberculin tests and x-rays .
Drug treatment of asymptomatic tuberculin-
positive persons .
Immunization: BCG (bacillus calmette-guerin)
used to induce a certain amount of resistance in
those heavily exposed to infection
The eradication of tuberculosis in cattles and the
pasteurization of milk have greatly reduced
M.bovis infections.
Ref(3)

39. Precaution Tips
Prevent latent TB from becoming active
prevent TB by TB vaccine (BCG)
Prevent inject illegal drugs.
Do not spend long periods of time in
stuffy, enclosed rooms with anyone who has
active TB until that person has been treated for at
least 2 weeks.
Use protective measures, such as face masks, if
you work in a facility that cares for people who
have untreated TB.
Ref(3)

40. TB control in Jordan
Jordanian Anti TB Association is providing support
to the national TB programme through financial aid
to TB patients & health education. Jordan also made
good progress in the TB Elimination Initiative by
lowering the incidence rate of smear positive new
cases to 6 per 100,000 populations.
At 2010 there's 336 case of TB in Jordan Ref(4)

41. DOTS
The WHO-recommended Directly Observed
Treatment, Short Course (DOTS) strategy was
launched formally as Revised National TB Control
programme in India in 1997. Since then DOTS has
been widely advocated and successfully applied.
DOTS is the most effective strategy available for
controlling TB.
Ref(3)

42. Ref(1)Tuberculosis, NICE Clinical Guideline (March 2011);
Clinical diagnosis and management of tuberculosis, and
measures for its prevention and control.
Ref(2) Landau,
Elaine. Tuberculosis. New York: F. Watts, 1995
http://www.healthofchildren.com/T/Tuberculosis.
Ref(3) TheStop TB Strategy: building on and enhancing DOTS
to meet the TB-related Millennium Development Goals
WHO. Geneva, World Health Organization, 2006b
(WHO/HTM/STB/2006.37).
Ref(4) G.Brooks
, K.Carrroll , J.Butel , S.Melnicks (Medical
Microbiology 24th Edition ) Jawetz , Melnicks Dahlberg's .

43. Thank You
For Your
Attention
!