Tuberculosis is caused by infection with Mycobacterium tuberculosis. It typically affects the lungs but can spread to other organs. Primary TB occurs after initial exposure and may result in an asymptomatic Ghon focus or spread to lymph nodes and other sites. Secondary TB occurs from reactivation of a dormant lesion, usually in the apices of the lungs. Diagnosis involves testing sputum, blood, or other fluids for acid-fast bacilli on smear or culture. Chest x-ray may show consolidations, cavities or fibrosis. Treatment involves a multi-drug regimen over 6-9 months to prevent resistance, with monitoring of side effects like hepatitis and optic neuritis. Contact tracing and screening of household members is
The Epstein–Barr virus (EBV), also called human herpesvirus 4 (HHV-4), is one of eight known human herpesvirus types in the herpes family, and is one of the most common viruses in humans.
The Epstein–Barr virus (EBV), also called human herpesvirus 4 (HHV-4), is one of eight known human herpesvirus types in the herpes family, and is one of the most common viruses in humans.
Optingin vs opting out - Malaysian Thoracic Society Dr Hirman Ismail
ABSTRACT
Lung transplant – opting in vs. opting out
Hirman Ismail MD (UKM) MPH (Nottingham)
Transplantation Unit, Medical Development Division
There are many strategies that have been widely discussed and implemented in many countries to increase donor pool and organ transplantation rate. These include among others strengthening central and local organisational structure, establish good transplant/ donor coordinator network, raising public awareness, addressing professional awareness and competencies, incentive (to donor, staff & medical institution), establish mechanism for potential deceased donor identification, ABO incompatible transplant, paired exchange programme, domino transplant, extended donor criteria and regional organ sharing. Legislation has been implicated to be as one of the many ways to improve organ and tissue donation rate in particular through the implementation of opting out system. Opting out system or also known as presumed consent is a system by which consent to donate organ and tissue is presumed unless a person has expressly indicated otherwise during his/her lifetime. Contrary to the opting out system, in opting in system however, consent to donate has to be explicit through verbal or written consent expressed by the donor when he/she was still alive. Legal and ethical barrier in implementing opting out system arises because of the fact that such system would exclude the next of kin from the decision making process when a donor passes away. In Malaysia, the law that governs the authorisation of removal of organ and tissue from a deceased is Human Tissues Act 1974 [Act 130]. Malaysia practices an opting in system as specified in subsection 2(1) of the Act 130 but the final decision to authorise the removal of organ and tissue of the deceased donor rest on the spouse or the next of kin, as specified in subsection 2(2). At the moment, the Ministry is in the process of drafting a new more comprehensive law on transplantation in which the option for possible implementation of opting out system was discussed. Even though it is thought that opting out system may increase donor pool as demonstrated in some countries, the challenges to its implementation is much more complex and shall be tailored to consider local sensitivity, level of awareness/ acceptance and also cultural/ religious values.
Prostate cancer for public awareness by DR RUBZDr. Rubz
A presentation prepared for Charity Dinner with Fun Charity. All the profits of the event will go to FReHA (a NGO which supports women's and reproductive health.)
Cavitary TB involves the upper lobes of the lung. The bacteria cause progressive lung destruction by forming cavities, or enlarged air spaces.
is a characteristic feature of "secondary" tuberculosis.
This type of TB occurs in reactivation disease.
The upper lobes of the lung are affected because they are highly oxygenated (an environment in which M. tuberculosis thrives). Cavitary TB can, rarely, occur soon after primary infection.
HIV discrimination among health providers in Malaysia by Dr RubzDr. Rubz
Although doctors took oath that they will treat everyone the best they can and without judging anyone but discrimination still exist especially in HIV affected people. Due to this issue, Pertubuhan Advokasi Masyarakat Terpinggir Malaysia has taken a step to engage with doctors at government sector and desensitize them and find the line to stand together.
Testicular cancer for public awareness by Dr RubzDr. Rubz
A presentation prepared for Charity Dinner with Fun Charity. All the profits of the event will go to FReHA (a NGO which supports women's and reproductive health.)
Breast Cancer for public awareness by Dr RubzDr. Rubz
A presentation prepared for Charity Dinner with Fun Charity. All the profits of the event will go to FReHA (a NGO which supports women's and reproductive health.)
This is the first phase (qualitative) of the current project we are working on with the supervision of University Malaya and Yale School of Medicine.It will be publish as IBBS 2013 by end of the year. This slide is just a rough picture of what we are doing at the moment. This is copyright protected!
1. Tuberculosis Signs
Crepitations ± Signs of fibrosis ± Signs of effusion
Signs of consolidation ± Signs of pneumothorax
Pathology
Infection → Type IV hypersensitivity rxn → Acute inflammatory response by neutrophils fail 2) Miliary TB
to deal with MTB → Chronic inflammatory response by macrophages → Granuloma Persistent cough Tachycardia Fever
formation. SOB Anaemia LOW
Primary TB: Crepitations Hepatosplenomegaly Night sweats
o First exposure, usually asymptomatic. Resulting in formation of Ghon focus in Choroidal tubercles on ophthalmoscopy Lympadenopathy
inferior upper lobe or superior lower lobe of lungs + spread to bronchial or hilar
LNs to form Ghon complex. 3) Extra-pulmonary TB
o If immune response is poor, primary TB may spread by various routes: 1. GI – Diarrhoea Peritoneal fluid for AFB
1. Progressive Pulmonary TB – direct spread. intestine or Malabsorption
2. Tuberculous pleurisy – rupture through visceral pleura / spread through peritoneum I/O
lymphatics. May result in pleural effusion or empyema. Ascites
3. Tuberculous pericarditis – spread through lymphatics 2. Pericardium Pericardial effusion or tamponade Requires steroids to
4. Bronchopneumonia – rupture through bronchial walls Constructive pericarditis due to post- reduce need for
5. Miliary TB – rupture through blood vessel walls. May cause TB infectious fibrosis pericardiectomy
meningitis. 3. GU Haematuria 3 early morning urine
6. Collapse - Large tuberculous mediastinal LN may compress lobar or Frequency for AFB
segmental bronchus. Dysuria Renal U/S
Secondary TB: Sterile pyuria IVU
o Source of infection: usually reactivation of dormant TB from healed primary lesion. Salpingitis
o Usually at apices of lungs Tubal abscess
o May heal by fibrosis resulting in tubercle formation, or may spread if immune Epididymal TB – swelling / sinus
response is poor. Route of spread as above. formation
o Complications: 4. CNS Headache CSF for AFB – fibrin
1. Pleurisy ± pleural effusion Meningism web, mononuclear
2. Pneumothorax – due to rupture of cavity into pleural space Altered mental state cells, cell count 10-
3. Empyema / Pyopneomothorax – rupture of tuberculous lesion into pleural Vomiting 1000, ↓glucose, N/↑
space Neurological deficits protein
4. Fungal colonization of cavities – eg aspergilloma formation 5. LN Usually cervical LN.
5. Respiratory failure & right heart failure – late stage cx due to extensive Swelling and sinus formation
pulmonary destruction and fibrosis 6. Bone / Joint Vertebral collapse X-ray
6. TB laryngitis Pyarthrosis MRI to determine
7. TB enteritis – swallowing of infected sputum. Osteomyelitis extent of involvement
8. Ischiorectal abscess Cold abscess formation Culture biopsies
9. Miliary TB Bone marrow: anaemia,
thrombocytopenia
Transmission & Infectious Period 7. Others Adrenal gland destruction → Addison’s
Airborne. disease
Smear + pul TB considered non-infectious after 2 wks of effective Rx Skin: lupus vulgaris, erythema nodosum
Smear negative and non-pul TB is generally not infectious. Eyes: Phlyctenular keratoconjunctivitis,
iritis, choroiditis
Clinical features
1) Pulmonary TB Other pertinent history:
Symptoms Contact history with anyone with similar symptoms
Fever Pleural pain Lethargy Comorbidities predisposing to TB – DM/ CRF/ HIV/ Steroids
Persistent cough Spontaneous pneumothorax LOW Previous TB
Hemoptysis Non-resolving pneumonia Night sweats
2. Investigations Continuation phase Rifampicin & As above
Microbiology Samples: sputum, induced sputum (using nebuliser), laryngeal swab and (4 mths on 2 drugs Isoniazid
direct smear, NG aspirate (pump in saline and withdraw in the morning), Ethambutol 15mg/kg/day PO For resistant TB
BAL, pleural fluid, pleura, urine, pus, ascites, CSF
ZN or auramine stain Common & Important ADRs
o + in 30% (up to 70%) Rifampicin Hepatitis Stop if bilirubin rises
o Indicates high bacterial population and infectiousness. Cholestasis
o Not specific for MTB. May be other mycobacterial spp. Orange discoloration of urine & tears
C/S Severe thrombocytopenia
o + in 66% Visual changes
o Specific for MTB Liver enzyme inducer Caution in concurrent use with
o Average 12-14 days for + result to return, another 1-2wks for OCP, warfarin, steroids, OHGA,
sensitivity results phenytoin & digoxin.
o Culture usually kept for up to 8 wks if negative Isoniazid Hepatitis
Radiology CXR: Neuropathy, encephalopathy Give pyridoxine (Vit B6) to prevent
o consolidation, cavitations, fibrosis, calcification / tuberculoma, collapse Pyridoxine deficit
o Post TB bronchiectasis (usu upper lobes) Agranulocytosis
o reticular-nodular opacities in miliary TB Pyrazinamide Hepatitis
Mantoux Tests skin sensitivity to tuberculoprotein. + = sensitivity, NOT active infxn Arthralgia, gout Contraindicated in gout
test (only 20% of infected individuals devt active infxn). May be + during Ethambutol Optic neuritis Test color vision before initiating Rx
dormant OR active infection. Gout
Inject 0.1ml of PPD intradermally Streptomycin Vestibular disturbance / ototoxicity Test for hearing before initiating Rx
Read at 2-4 days: + if induration >10mm (locally 15mm), − if <5mm Nephrotoxicity
False −: in sarcoidosis, malnutrition, Hodgkin’s dz, immunosuppression and
overwhelming active TB Second line drugs:
False +: atypical mycobacterial infections o Aminosalicylic acid
Main use for contact tracing, to treat for latent TB infection o Cycloserine
Serology o Ethionamide
γ-interferon Eg Quantiferron, Elispot o Ofloxacin / Ciprofloxacin
assays More sensitive c.f Mantoux test, but expensive. Not routinely done yet. Meningeal, ureteric and pericardial disease: consider adding steroids to reduce risks of Cx
from scarring
Monitoring of Rx efficacy – AFB smear & culture @ 2mths of Rx and after completing Rx,
Management plus CXR after completing Rx.
1) Isolation
For infectious pulmonary TB PTs. 3) Consider HIV testing
Stop isolation only after >2 sputum cultures are AFB negative esp if high-risk group, or young (who don’t usually get TB. ?HIV)
2) Chemotherapy 4) Contact tracing & notification
Check liver and renal functions, as well as color vision due to ethambutol ocular toxicity. Household contacts of sputum-smear positive PTs
Give Pyridoxine throughout treatment to prevent isoniazid induced neuropathy 2/3-step contact tracing
Directly Observed Therapy (DOT) to ensure compliance – daily Rx at TB control unit (CDC) o week 0 – do Mantoux, read at day 2-4
and polyclinics. Alternative: Intermittent DOT (3x/week). 97% cure rate
♦ if >15mm, means seroconvert – give prophylaxis
♦ if <15mm, repeat Mantoux
Short-course regimen
o week 2 – do Mantoux
Initial phase (8 wks *Rifampicin 600-900mg PO 3X/wk
♦ if increase cf week 0’s test by >10mm, means that first
/2mths on 3-4 drugs) *Isoniazid 15mg/kg PO 3X/wk
Mantoux reactivated previously exposed immune system, now
*Pyrazinamide 2.5g PO 3X/wk pt is displaying competent immune response – don’t need
Monitor LFTs wkly Ethambutol 30mg/kg PO 3X/wk Add ethambutol or prophylaxis
Streptomycin 0.75-1g/day IM streptomycin if ♦ if <10mm, do third Mantoux
resistance is suspected.
3. o week 12 – do Mantoux
♦ if increase >10mm cf week 0, means pt has seroconverted, pt
has LTBI, give prophylaxis
♦ if increase <10mm, no need prophylaxis
5) Chemoprophylaxis
Consider for:
o Severely immunosuppressed PTs (eg HIV +)
o Unvaccinated contacts with recent MT +
Isoniazid 300mg/day PO for 9 mth/ rifampicin 4 months if Mantoux positive as described
6) BCG vaccination at birth.
Only protects against childhood miliary and CNS TB.
Repeat vaccination in adolescence not found to affect outcome / risk of TB, and is no
longer indicated.
7) Rx of Latent TB Infection
Preventive ChemoRx
Isoniazid (6mths locally, 9mths in USA) – effective in eradicating latent TB in 70%.
Resistance to isoniazid not known to occur in the remainding 30% despite monotherapy.
Digitally signed by DR WANA HLA SHWE
DN: cn=DR WANA HLA SHWE, c=MY, o=UCSI
University, School of Medicine, KT-Campus,
Terengganu, ou=Internal Medicine Group,
email=wunna.hlashwe@gmail.com
Reason: This document is for UCSI year 4 students.
Date: 2009.02.24 14:06:33 +08'00'