Pulmonary tuberculosis (PTB) is a major communicable disease caused by Mycobacterium tuberculosis, contributing significantly to global mortality. In Nepal, about 42,000 cases were reported in 2018, with higher incidence rates among men and links to several predisposing factors such as age, smoking, and immunosuppression. Diagnosis involves various investigations like sputum examinations and chest radiography, while treatment typically includes a combination of first- and second-line antibiotics, with emphasis on prevention strategies such as vaccination and regular check-ups.

1. PULMONARY
TUBERCULOSIS(PTB)
BY
Dr. Akhilesh Sah
MBBS(TU)

2. Introduction
 Tuberculosis (TB) is disease caused by infection with Mycobacterium
tuberculosis (MTB), which is part of a complex of organisms including M. bovis
(reservoir cattle) and M. africanum (reservoir humans).
 Tuberculosis (TB) is a communicable disease that is a major public health
problem and one of the top 10 causes of death worldwide as well as in
Nepal(2018/19)
 Globally, an estimated 10.0 million people fell ill with TB in 2018. Nepal
population contributed to 0.35% of the global population, but with regards to
TB, Nepal accounted for 0.45% of global TB cases
 In Nepal, an estimated 42000 fell ill with TB in 2018 (incidence rate of 151
per 100 000)
 According to the latest WHO Global TB report 2019, the tuberculosis mortality
rate was 20 per 100,000 populations in Nepal
 Among the reported cases, men are nearly 1.7 times as compared to women
cases (M:F = 1.7:1).

3. Pathology-physiology
 M. bovis infection arises mainly drinking non-sterilised milk from infected
cows. M. tuberculosis is spread by the inhalation of aerosolised droplet nuclei
from other infected patients
 Once inhaled, the organisms lodge in the alveoli and initiate the recruitment
of macrophages and lymphocytes which form tuberculous granuloma
 Numerous granulomas aggregate to form a primary lesion or ‘Ghon focus’
 Spread of organism to hilar lymph nodes is followed by a similar pathological
reaction, and combination of primary lesion and regional lymph node is known
as primary complex of ranke
 Reparative processes encase the primary complex in a fibrous capsule,
limiting the spread of bacilli
 Lymphatic or haematogenous spread may occur before immunity is
established, however, seeding secondary foci in other organs, including lymph
nodes, serous membranes, meninges, bones, liver, kidneys and lungs, which
may lie dormant for years

5. Predisposing factors
 Age (children > young adults < elderly)
 Close contacts of patients with smear-positive pulmonary TB
 Overcrowding (prisons, collective dormitories);
 Chest X-ray evidence of self-healed TB
 Primary infection < 1 year previously
 Smoking: cigarettes, bidis and cannabis
 Immunosuppression: HIV, anti-tumour necrosis factor (TNF) and other biologic
therapies, high-dose glucocorticoids, cytotoxic agents
 Malignancy (especially lymphoma and leukaemia)
 Diabetes mellitus
 Chronic kidney disease
 malnutrition ( Deficiency of vitamin D or A)
 Recent measles in children

6. Clinical features
 Cough productive/non productive, may/maynot contains blood(hemoptysis)
 Fever (evening rise/low grade)
 Loss of appetite
 Night sweats
 Anorexia
 Crackles on auscultation
 Feature of extrapulmonary spread
 UNRESOLVED pneumonia, pleural effusion, pneumothorax(CXR)

7. Systemic presentations
of extra PTB

8. Investigation
 Radiological : Chest x-ray and CT scan of chest
 Sputum examination: AFB stain At least two sputum samples (including at
least one obtained in the early morning)
 Sputum Culture
 Pleural fluid Examination: ADA(adenosine Deaminase)
 Xpert MTB/Rif (Nucleic acid amplification test NAAT)
 Bronchoscopy
 Tuberculin skin test :
 Baseline Blood tests: CBC, CRP, ESR, Urea, and electrolytes, LFT

11. Complications
 Massive hemoptysis
 Cor pulmonale
 Fibrosis/emphysema
 Lung/pleural calcification
 Obstructive lung disease
 Bronchiectasis
 Brocho-pleural fistula
 Extra-pulmonary Tb
 Pneumothorax

12. Classification of TB
TB cases whether bacteriologically confirmed or clinically diagnosed cases are
classified according to:
1. Anatomical site of disease : PTB, E-PTB, MILIARY TB
2. History of previous treatment
3. Drug resistance
4. HIV status : HIV +VE TB, HIV –VE TB, HIV STATUS UNKNOWN TB

15. Treatment

16. Cont.
Chemotherapy
First Line
 Rifampin(R)
 Isoniazid(H)
 Pyrazinamide(Z)
 Ethambutol (E)
 Streptomycin(S)

17. Second Line
 Kanamycin
 Streptomycin
 Capreomycin
 Amikacin
 Levofloxacin
 Moxifloxacin
 Gatifloxacin
 Ethionamide

18.  OTHERS USED DRUGS:
Glucocorticoids:
 Good nutrition
 REGULAR FOLLOW UP
 PROPER COUNSELLING

19. t

22. PREVENTION AND CONTROL
-DETECTION OF LATENT TB
-DOTs
 Regular tb check up for HIV, AND OTHER chronic disease patient
 Vaccines : BCG vaccine
 Proper disposal of sputum of PTB patients