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Tuberculosis

Tuberculosis. Hannah Leaver hyl1g10@soton.ac.uk. Definition. “ a multisystem disease with countless presentations and manifestations. It is the most common cause of infectious disease-related mortality worldwide”. Aetiology. Modifiable RFs: Alcoholism Silicosis

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Tuberculosis

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  1. Tuberculosis Hannah Leaver hyl1g10@soton.ac.uk

  2. Definition “a multisystem disease with countless presentations and manifestations. It is the most common cause of infectious disease-related mortality worldwide”

  3. Aetiology Modifiable RFs: • Alcoholism • Silicosis • Malnutrition and low body weight • Smoking • IV drug abuse • Immunosuppressed – HIV, Head and Neck Cancer, Diabetes Mellitus • Immunosuppressive therapy – TNFα antagonists, steroids Non-Modifiable RFs: • Age < 5 years • Elderly • Geographical - ↑ in tropical regions • Family history

  4. Healing scar Primary infection Primary complex Pathophysiology Activation of cell-mediated immunity Ghon focus Progressive disease Regional lymphadenopathy Persistence of viable bacteria (latent) Miliary TB Death Post primary TB New infection

  5. Infection Latent (90%) 2°infection 1° TB Resolution

  6. Primary Infection • Childhood exposure in endemic areas • Elderly in western regions • Immune response limits damage to a localised mid-zone area of the lung (Ghon focus) • Hilarinvolvement • Develops within 4 weeks • Calcification on chest XR.

  7. Post Primary Pulmonary TB Often due to reactivation/ reinfection Signs and Symptoms: • Persistent cough • Haemoptysis – occurs only in 1/3 • Pleurisy • Tiredness, chronic ill health • Weight loss • Fever • Night sweats Investigations: • Sputum Ziehl-Neelsen stain of AFB • Sputum culture (Takes up to 8 weeks) • XR Complications • Severe haemoptysis • Exudative Pleural effusion • Cavitation • TB empyema

  8. Pleural Effusions

  9. Chest X-rays • Consolidation in the left upper lobe. • Two densely calcified granulomas are also present on the left, one near the hilum and the second in the left lower lobe. • No convincing lymph node enlargement. 

  10. Multifocal patchy opacities in the right upper lobe with thickening • Upward shift of the minor fissure

  11. Patchy opacities in the posterior segment of the upper right lobe, consistent with post-primary tuberculosis

  12. Diffuse bilateral, largely upper lobe, consolidation and pulmonary infiltrates.   • Suggestion of small area of cavitation at the left lung apex.

  13. Extrapulmonary TB Pleural TB • Cough, pleuritic pain, unilateral effusions Lymph node TB • Cervical lymph nodes • Unilateral, painless, increased size and matted TB Meningitis • Headache, fever, mental state changes (coma), neck stiffness, CN palsies Bone/Joint TB • Potts disease of spine – back pain or stiffness • Monoarticular arthritis – hips and knees GU TB • Flank pain, dysuria, ↑f • Men – painful scrotum, prostatitis, epididymitis • Women – mimics PID GI TB • Ulcers of mouth and anus • Dysphagia • Abdominal pain • Malabsorption • Change in bowel habits

  14. * Polymorph = polymorphonuclear leukocyte or granulocyte

  15. Miliary TB • SYSTEMIC DISSEMINATION • 2 clinical syndromes occur, with malaise, weight loss and weakness • Young/HIV infected – rapid onset, high fever, very unwell • Elderly – insidious onset, chronic course and slow decline in health without fever • Diagnosis – Miliary pattern on CXR ( multiple, small nodules) and organisms may be found in sputum, bone marrow, liver and GU tract

  16. Investigations • Pulmonary TB • Ziehl-Neelsen stain • Sputum culture • Extrapulmonary • Sputum culture • Histology – granulomata/ AFB • XR (Potts) • CSF TB meningitis – lymphocytes, ↑protein, ↓glucose • Mantoux test • Measures delayed hypersensitivity reaction to intradermal purified protein derivative • +ve = previous exposure or previous BCG vaccine

  17. Management Conservative • Isolate • Contact trace • Inform local authority – TB is a notifiable disease Medical • Short form chemo • Rifampin • Isoniazid • Pyrazinamide • Ethambutol • All taken for 2 months.-Rifampin/Isoniazid taken for a further 4months. -If meninges involved, Rifampin/Isoniazid for 10 months + corticosteroid • S/Es - hepatotoxicity

  18. Differentials • EXTENSIVE!! - Such a non specific disease

  19. Prognosis • Poor prognostic markers include • Immunocompromised • older age • history of previous treatment

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