TUBERCULOSIS

1. TUBERCULOSIS Prof. E. Sevda Özdoğan

2. TUBERCULOSIS • Infectious disease (airborne infection) • Lungs and all the tissues can be involved • Mycobacterium tuberculosis (AFB)

3. Source of infection is the ill (Pulmonary TB) patient: Speaking: 0-210 bacillei Coughing: 0-3500 bacillei Sneezing: 4500-1 million bacillei Droplet nuclei (Flugge droplets)

4. Natural course of Tuberculosis Eksogen reinfection Active disease Primary No infection %65-70 Adult type (reactivation) %5 %5 Basillie inhalation %31-36 Latent infection, no disease Latent infection Infection %90

5. Pathogenesis-1 (initial encounter) Capillary Alveolar makrophage Peripheral blood monocytes Hilar lymph nodes Hematogen spread Primary complex

6. Option 1 (Primary infection) Bacterial proliferation is halted and bacillary population falls substantially The primary lesion and the metastatic foci involute, leaving minimal residues The tuberculin skin test becomes reactive (2-12 wk) Option 2 (Primary disease) An insufficient immune response occurs and the patient experience progressive lung or extrapulmonary disease Evolution of Cellular immunity and Delayed type HS

7. Liquefaction and accelerated bacillary proliferation (Postprimary disease) • Pulmonary focus reactivates and undergoes liquefaction with cavity formation • Extracellular bacilli multiply exponentially during this accelerated bacillary proliferation • Patient expectorates bacillei, another person inhales them, cycle is completed

8. Immunologic reactions • Cell mediated immunity • Delayed type hypersensitivity (Type IV immune response) 2-12 weeks Tuberculin skin test (+)

9. Tb Infection: Infection with M. tuberculosis manifested by significant tuberculin skin test reaction without any sign of clinically and/or radiologically active disease • Tb disease:Clinically, bacteriologically, histologically and/or radiologically active disease

10. Differences between tb infection and tb disease

11. Risk Factors for Infection • Infectious person • Number of the bacilli in sputum (Cavitary, larhynx) • Cough frequency, sneeze • Live bacilli • Virulence of the bacilli • Environmental • Close contact (family) • Ventilation • Ultraviolet • Crowded and bad living conditions

12. Host factors • Nonspecific immunity (Ch 1 BCGr-BCGs region) • Concomitant diseases (that increase the risk of infection) • Duration of exposure to the source of infection EPİDEMİOLOGİCAL VIEW: • Number of infectious patients in the community • Delay in diagnosis • Delay in treatment

13. Risk Factors for disease progression • Recent infection (first 2 years) • Smoking • Long term corticosteroid use (15mg/day>4weeks) • Sequel infiltration (simon foci) • To be <5-10 % of the ideal body weight • To be in 0-5 or old age group

14. HIV Diabetus mellitus Silikosis Kr. Malabsorbtion Organ Transplant. Chronic renal failure Gastrectomy Jejunoileal by-pass Iv drug abuse Leukemia, lymphoma Head and neck cancers Immunosuppressive treatment

15. World tb • 1/3 of the world population is infected with tb • 8 million new tb cases are detected each year • 1,5 million people die from tb • Starwing, poverty, war, immigration, HIV infection cause the difficulties in disease control

17. Tuberculosis in Turkey (n/100 000)

18. Diagnosis • History • Physical examination • Chest x ray • Microbiology or pathology (Gold Standart) • Tuberculin test (PPD) (Not definitive diagnostic)

19. Pulmonary Cough > 3 weeks SputumandHemopthysis Chestpain, sidepain Breathlessnes Hoarseness General Fatique Loss of appetideandweight Fever Nightsweats Symptoms

20. Primary Tuberculosis Usually asymptomatic Contact history + PPD Typical radiology Complications Postprimary Tuberculosis Typical symptoms Typical radiology Clinical Presentation

21. Primary pulmonary tuberculosis

22. Postprimary pulmonary tuberculosis

25. Complications and other forms • Miliarytb • Radiologic 2-4 mm miliary nodules (latepresentation) • PPD (-) 50% • Choroidaltubercules on eye examination • Liver, bone marrow (+)

26. Pleural tb • Mainly seen in young adults • PPD (-) 30% • AFB in pleural fluid (+) 2-10% • Exudative effusion, lymphocyte predominance, low glucose, low mesothelial cells, high ADA

27. Tb lymphadenitis Frequently cervical LAP Fistulization may occur No tenderness Bone tb Vertebral tb (pott) Absscess among the muscless (Psoas) Monoartritis

28. Physical examination • Signs in respiratorysystem: No signsspecifictotuberculosis Occasionalylocalised/ posttusivecrackles • General signs: Erythemanodosum Fluctenular conjunctivitis Lymphadenitis

29. Radiology Upper zone nodular, alveolar infiltration + kavity Tipical for tb? NOO!! Tb diagnosis cannot rely on radiology only. Radiology may be normal in Endobronchial TB and in HIV (+) patients.

30. Bacteriology Microscopy: Minimum 3 sputum smear should be performed. Culture:Gold standard in diagnosis. Drug sensitivity tests: Performed in Referans laboratory.

31. Reporting • Reporting of tb cases is mandatory!!.

32. Definitions • Localization of tbdisease • Bacteriologiccondition • Previoustreatmenthistory

33. Localization of TB disease • Lung paranchyma Pulmonary TB • All tb forms without lung involvement Extrapulmonary TB • Pulmonary and extrapulmonary together  Pulmonary and extrapulmonary TB

34. Bacteriology • Smearpositivecase • Smearnegativecase

35. Smear positive case • A patient whose sputum smear is positive for AFB in at least 2 specimens • One AFB positivity in sputum smear with a clinicians judgement that the patient’s clinical and/or radiological signs and/or symptoms are compatible with tb • One AFB positivity in sputum smear with positive culture

36. Smearnegativecase • Smear negative in specimens examined twice in 2 weeks time but radiological signs compatible with active tb and no clinical or radiological response to 1 week nonspecific antibiotic treatment This decision should be made hospital based with all the differential diagnostic examination!

37. Treatment History • New Case • Relaps • Treatment Failure • Treatment after interruption • Chronic case

38. New Case • A patient who has never had drug treatment for tb or who has taken antitb drugs for<4 weeks Relapse • A patient who has been declared cured of any form of tb in the past and has developed sputum smear or culture positive disease

39. First line antitb drugs INH RIF PZA EMB SM Second line antitb drugs Thiacetasone PAS Cycloserine Ethionamide Canamycin Capreomycin Treatment

40. Principles of Treatment • Combination Therapy (6 months) • 4 or 5 drugs in the initial phase; • 2 or 3 drugs in the continuation phase • Adequate dose and duration of treatment to avoid relaps • Regular drug intake • Start the tx immediately after the diagnosis

41. Prognosis in tb

42. Prevention • Efective Treatment of infectious cases • Kemoprophylaxis (INH 6-9 months) • BCG • Infection control measures (institutions)

43. BCG (+) 0-5 mm Negative 6-14 mm due to BCG 15 mm < Positive (infection) BCG (-) 0-5 mm Negative If 6-9 mm repeat test 1 week later, again 6-9 mm Negative, 10mm < Positive 10mm< Positive Tuberculin skin test (PPD)

45. Kemoprophylaxis: INH 300mg/day 6-9 months

46. Thank you