PARMESHVAR DAS VAISHNAV
INTRODUCTION <ul><li>10-20% of all tuberculosis </li></ul><ul><li>Due to failure of TB control in adults. </li></ul><ul><l...
SOURCE OF INFECTION <ul><li>Adult or family member with sputum smear positive. </li></ul><ul><li>Frequency of infection in...
PREDISPOSING FACTORS <ul><li>Extent of exposure to infectious droplet nuclei. </li></ul><ul><li>Infant whose mother has sp...
ClINICAL SYMPTOMS <ul><li>No specific features. </li></ul><ul><li>Failure to thrive </li></ul><ul><li>Weight loss( growth ...
DIAGNOSIS <ul><li>Particularly  difficult because they rarely cough up  sputum. </li></ul><ul><li>Exposure </li></ul><ul><...
TREATMENT <ul><li>A symptomatic child with a positive Mantoux test(>10mm) is to be treated as a case regardless of BCG vac...
CHEMOPROPHYLAXIS <ul><li>For infant whose mother or any other houshold member is smear-positive,then  </li></ul><ul><li>Ch...
Guidelines IF AND  THEN child has symptoms of TB  An MO determines  (preferably in consultation with a paediatrician) that...
TUBERCULOSIS & HIV
INTRODUCTION <ul><li>To make global situation worse, </li></ul><ul><li>tuberculosis has formed lethal partnership  </li></...
<ul><li>HIV infection infection increases the risk of developing  active TB by a factor of 100. </li></ul><ul><li>Levels o...
EPIDEMIOLOGICAL IMPACT <ul><li>Reactivation of latent infection:  </li></ul><ul><li>25-30% more likely to develop the dise...
CLINICAL FEATURES <ul><li>Depend on the count of the CD4 cells. </li></ul><ul><li>high  low </li></ul><ul><li>Pulmonary re...
DIAGNOSIS <ul><li>Clinical symptoms are similar as in people without HIV infection in the early stage. </li></ul><ul><li>D...
<ul><li>(c) Chest radiography may be less useful- less cavitation – decreased immune response </li></ul><ul><li>(d) Cases ...
In short screen: <ul><li>Sputum smear microscopy </li></ul><ul><li>positive  negative( suspected) </li></ul><ul><li>start ...
TREATMENT <ul><li>Standard treatment regimens are equally efficacious in  HIV  +ve and –ve patients.  </li></ul><ul><li>ad...
<ul><li>interaction between ART and rifamycins </li></ul><ul><li>Development of rifampin monoresistance with widely spaced...
<ul><li>IRIS is an immune response elicited by antigens released as bacilli are killed during effective chemotherapy </li>...
<ul><li>Rifampicin a potent inducer of enzyme of the cytochrome P450 system – lower the serum level of many HIV protein in...
TB IN PREGNANCY
INTRODUCTION <ul><li>Encountered in 1-2% of pregnant women. </li></ul><ul><li>Course of TB is unmodified during pregnancy....
EFFECT OF TB ON PREGNANCY <ul><li>Pulmonary TB does  not affect  fertility unless there is associated genital TB. </li></u...
<ul><li>Greater danger  is the possibility of infection of the newborn by close contact when the mother has open TB. </li>...
MANAGEMENT <ul><li>Problem- Possible effect on the foetus of the chemotherapeutic drugs. </li></ul><ul><li>Time of institu...
<ul><li>Rifampicin 10 mg/kg daily not to exceed 600 mg daily. </li></ul><ul><li>duration – 9 months </li></ul><ul><li>Rout...
<ul><li>Congenital TB:  foetus affected either haematogenously  or through the umbilical vein . </li></ul><ul><li>The fetu...
NEONATAL RISK AND THE MANAGEMENT. <ul><li>Tuberculin +ve mother without active disease doesnot pose any risk . </li></ul><...
 
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  1. 1. PARMESHVAR DAS VAISHNAV
  2. 2. INTRODUCTION <ul><li>10-20% of all tuberculosis </li></ul><ul><li>Due to failure of TB control in adults. </li></ul><ul><li>Commonest age group is 1-4 years. </li></ul><ul><li>Most children are sputum –ve and not infectious to others. </li></ul>
  3. 3. SOURCE OF INFECTION <ul><li>Adult or family member with sputum smear positive. </li></ul><ul><li>Frequency of infection in a given population depends on: </li></ul><ul><li>(A) no: of infectious cases </li></ul><ul><li>(B) closeness of contact with an infectious </li></ul><ul><li>case </li></ul><ul><li>(C) age of child when exposed and the age </li></ul><ul><li>structure of the population </li></ul>
  4. 4. PREDISPOSING FACTORS <ul><li>Extent of exposure to infectious droplet nuclei. </li></ul><ul><li>Infant whose mother has sputum smear positive PTB. </li></ul><ul><li>Chance of developing infection is greatest shortly after infection </li></ul><ul><li>Children under 5 yrs- less developed immune system. </li></ul><ul><li>Young age is a risk factor for sread of disease to other part of body,i.e. dissemination.. </li></ul>
  5. 5. ClINICAL SYMPTOMS <ul><li>No specific features. </li></ul><ul><li>Failure to thrive </li></ul><ul><li>Weight loss( growth faltering) </li></ul><ul><li>Respiratory symptoms( cough> 3 weeks in child who received a course of broad spectrum anti- biotics. </li></ul>
  6. 6. DIAGNOSIS <ul><li>Particularly difficult because they rarely cough up sputum. </li></ul><ul><li>Exposure </li></ul><ul><li>Tuberculin skin test </li></ul><ul><li>Chest X ray. </li></ul>
  7. 7. TREATMENT <ul><li>A symptomatic child with a positive Mantoux test(>10mm) is to be treated as a case regardless of BCG vaccination in past </li></ul><ul><li>Dosages of anti-TB medication for children:- </li></ul>DRUGS THERAPY PER DOSE (THRICE A WEEK) Isoniazid 10-15 mg/kg Rifampicin 10mg/kg Pyrazinamide 35mg/kg Streptomycin 15mg/kg Ethambutol 30mg/kg
  8. 8. CHEMOPROPHYLAXIS <ul><li>For infant whose mother or any other houshold member is smear-positive,then </li></ul><ul><li>Chemoprophylaxis should be given for 3 months. </li></ul><ul><li>Then a mantoux test is done… </li></ul><ul><li>.If test is negative-stop chemoprophylaxis </li></ul><ul><li>and BCG is given </li></ul><ul><li>.If test is positive,chemoprophylaxis is </li></ul><ul><li>continued for a total duration of 6 months.. </li></ul>
  9. 9. Guidelines IF AND THEN child has symptoms of TB An MO determines (preferably in consultation with a paediatrician) that the child has TB…. A full course of anti TB treatment (CAT3) should be given… The child does not have symptoms of TB. . A tuberculin test is not available . .A tuberculin test is available Chemoprophylaxis for 6 months (Isoniazide daily-5mg/kg) The child should receive 3 months of INH chemoprophylaxis IF IF THEN The induration is less than 6mm in diameter Stop chemoprophylaxis and give BCG . The induration is 6mm or more in diameter Continued INH chemoprophylaxis for another 3 months
  10. 10. TUBERCULOSIS & HIV
  11. 11. INTRODUCTION <ul><li>To make global situation worse, </li></ul><ul><li>tuberculosis has formed lethal partnership </li></ul><ul><li>with HIV. </li></ul><ul><li>Co-infection of tb &hiv has increased the risk of activation of infection from </li></ul><ul><li>10% over the lifespan to 10%per year. </li></ul><ul><li>worldwide approximately 1/3 rd of all AIDS related deaths are associated with TB. </li></ul>
  12. 12. <ul><li>HIV infection infection increases the risk of developing active TB by a factor of 100. </li></ul><ul><li>Levels of plasma HIV RNA increase in setting of active TB and decline in setting of successful l TB treatment. </li></ul>
  13. 13. EPIDEMIOLOGICAL IMPACT <ul><li>Reactivation of latent infection: </li></ul><ul><li>25-30% more likely to develop the disease than the people only with TB. </li></ul><ul><li>Primary infection </li></ul><ul><li>Recurring infection </li></ul><ul><li>In the community </li></ul>
  14. 14. CLINICAL FEATURES <ul><li>Depend on the count of the CD4 cells. </li></ul><ul><li>high low </li></ul><ul><li>Pulmonary reactivation disseminated disease diffuse or lower </li></ul><ul><li>fever, cough, dyspnoea, lobe, reticulonodular infiltrates </li></ul><ul><li>Weight loss, night sweats, miliary spread, pleural effusions, </li></ul><ul><li>Chest X ray: cavitary apical hilar and/or mediastinal adenopathy. </li></ul><ul><li>disease of upper lobes </li></ul>
  15. 15. DIAGNOSIS <ul><li>Clinical symptoms are similar as in people without HIV infection in the early stage. </li></ul><ul><li>Diagnosis is more difficult in advanced HIV because: </li></ul><ul><li>(a) Higher frequency of –ve sputum smears. </li></ul><ul><li>Sputum culture required for confirmation. </li></ul><ul><li>(b) Tuberculin skin test fails- immune system damaged- false negative results. </li></ul>
  16. 16. <ul><li>(c) Chest radiography may be less useful- less cavitation – decreased immune response </li></ul><ul><li>(d) Cases of extra pulmonary tuberculosis seem to be more common in people who are co-infection. </li></ul>
  17. 17. In short screen: <ul><li>Sputum smear microscopy </li></ul><ul><li>positive negative( suspected) </li></ul><ul><li>start </li></ul><ul><li>treatment </li></ul><ul><li>treatment if if sputum culture not </li></ul><ul><li>sputum culture done, treatment given </li></ul><ul><li>positive according to X ray </li></ul><ul><li>findings </li></ul>
  18. 18. TREATMENT <ul><li>Standard treatment regimens are equally efficacious in HIV +ve and –ve patients. </li></ul><ul><li>adverse effects are more pronounced. </li></ul><ul><li>Thiacetazone- fatal skin reactions- not used nowadays. </li></ul><ul><li>Three important considerations: </li></ul><ul><li>an incresed frequency of paradoxical reactions. </li></ul>
  19. 19. <ul><li>interaction between ART and rifamycins </li></ul><ul><li>Development of rifampin monoresistance with widely spaced intermittent treatment. </li></ul><ul><li>IRIS- Immune Reconstitution Inflammatory Syndrome: It is the exacerbation in signs, symptoms, radiographic and laboratory manifestations of TB due to ART administration. </li></ul><ul><li>IRIS more common in advanced immunosuppressed and extrapulmonary TB. </li></ul>
  20. 20. <ul><li>IRIS is an immune response elicited by antigens released as bacilli are killed during effective chemotherapy </li></ul><ul><li>Temporarily associated with improved immune function. </li></ul><ul><li>Managed by symptomatic treatment with glucocorticoids. </li></ul>
  21. 21. <ul><li>Rifampicin a potent inducer of enzyme of the cytochrome P450 system – lower the serum level of many HIV protein inhibitors and some NNRTIs. </li></ul><ul><li>Rifabutin- has much less enzyme inducing </li></ul><ul><li>activity. So recommended in place of Rifampicin. </li></ul>
  22. 22. TB IN PREGNANCY
  23. 23. INTRODUCTION <ul><li>Encountered in 1-2% of pregnant women. </li></ul><ul><li>Course of TB is unmodified during pregnancy. </li></ul><ul><li>Lesions remaining the same, there is no difference in mortality between pregnant and non-pregnant. </li></ul>
  24. 24. EFFECT OF TB ON PREGNANCY <ul><li>Pulmonary TB does not affect fertility unless there is associated genital TB. </li></ul><ul><li>Usually there is no effect on the course of pregnancy except for a slight increase in the incidence of the abortion and premature </li></ul><ul><li>labour. </li></ul><ul><li>Rarely affect the foetus by transplacental route. </li></ul>
  25. 25. <ul><li>Greater danger is the possibility of infection of the newborn by close contact when the mother has open TB. </li></ul><ul><li>Diagnosis is based on symptoms, sputum examination and chest radiographs. </li></ul>
  26. 26. MANAGEMENT <ul><li>Problem- Possible effect on the foetus of the chemotherapeutic drugs. </li></ul><ul><li>Time of institution of the treatment should be irrespective of period of gestation. </li></ul><ul><li>the anti TB drug considered safe are: </li></ul><ul><li>Ethambutol- 5-25mg/kg daily </li></ul><ul><li>Isoniazid – 5 mg/kg not to exceed 300mg daily </li></ul><ul><li>Pyridoxine- 50mg daily to reduce risk of INH induced neuropathy. </li></ul>
  27. 27. <ul><li>Rifampicin 10 mg/kg daily not to exceed 600 mg daily. </li></ul><ul><li>duration – 9 months </li></ul><ul><li>Routine AN care should be continued and foetal monitoring should be done to diagnose IUGR. </li></ul><ul><li>Streptomycin, pyrazinamide - teratogenic- contraindicated </li></ul>
  28. 28. <ul><li>Congenital TB: foetus affected either haematogenously or through the umbilical vein . </li></ul><ul><li>The fetus infected by aspiration of infected contents at delivery. </li></ul><ul><li>Breastfeeding: shouldnot be discouraged. </li></ul>
  29. 29. NEONATAL RISK AND THE MANAGEMENT. <ul><li>Tuberculin +ve mother without active disease doesnot pose any risk . </li></ul><ul><li>If mother is sputum –ve in the last 3 month of gestation with active TB, the risk to infant is negligible. </li></ul><ul><li>If the mother is sputum +ve, then the neonate needs to be evaluated for active TB. </li></ul><ul><li>If there is no active TB in neonate, it should receive INH prophylaxis for 3 months until the mother’s sputum becomes –ve. </li></ul>

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