Management of Tuberculosis

What is tuberculosis?
• is an infection that usually affects the lungs.

• It is not very common in the developed

countries. But, tuberculosis is still a serious
problem in developing countries.

• Tb, can spread through the lymph nodes and

bloodstream to any organ in the body.

• It is most often found in the lungs.

• Most people who are exposed to TB
never develop symptoms because the
bacteria can live in an inactive form in
the body.

• But if the immune system weakens,

such as in people with HIV or elderly
adults, TB bacteria can become active.
e

• In their active state, TB bacteria cause

death of tissue they infect.

• TB is treatable and preventable.

• However, TB can be fatal if not

recognized and treated.

• Identifying and treating those who are

infected, but who have not yet become
ill with active TB, can prevent the
spread of TB in the community.

3
 History
• Until mid-1800s, many
believed TB was hereditary.

• 1865 Jean Antoine-Villemin

proved TB was contagious

• 1882 Robert Koch

discovered M. tuberculosis,
the bacterium that causes TB
• Before TB drugs, many
patients were sent to
sanatoriums

• Patients followed a
regimen of bed rest,
open air, and sunshine
 DRUGS
• Drugs that could kill TB bacteria were
discovered in 1940s and 1950s
e

• Streptomycin (SM) discovered in 1943.

Isoniazid (INH) and p-aminosalicylic
acid (PAS) discovered between 1943
and 1952

• TB death rates began to drop

dramatically. Each year, fewer people
got TB
• Most TB sanatoriums had closed by
mid 1970s
• Increase in TB in mid 1980s.
• Contributing factors:

– Inadequate funding for TB control

programs
– HIV epidemic
– Increased immigration from countries
where TB is common
– Spread in homeless shelters and
correctional facilities
– Increase and spread of multidrug-
resistant TB
MİCROBIOLOGY
 Types of Mycobacteria

• belongs to the genus Mycobacterium,

• TB, is defined as a disease caused

by members of the M. tuberculosis

complex, which includes ;the tubercle

bacillus (M. tuberculosis), M. bovis,

M. africanum, M. microti, M. canetti,

M. caprae, and M. pinnipedii M. tuberculosis

• M. tuberculosis causes most TB

cases
Agram C 1 lerden fark no membrane

M. Tuberculosis / Cell envelope

• Unlike gram-negative bacteria, there
is no true outer membrane in
Mycobacterium.
• The cell envelope is a distinguishing
feature of the organisms belonging to
the genus Mycobacterium.
• The mycobacterial cell envelope is
composed of a core of three
macromolecules covalently linked to
each other (peptidoglycan,
arabinogalactan, and mycolic acids)
and a lipopolysaccharide,
lipoarabinomannan (LAM), which is
thought to be anchored to the plasma
membrane
• Mycolic acid, is the major constituent
of the cell envelope, accounting for
more than 50 percent by weight;
 Staining characteristics
• The cell wall components give
sen
Mycobacterium its characteristic
staining properties.
• The organism stains positive with
Gram stain.
• The mycolic acid structure confers
the ability to resist destaining by
acid alcohol after being stained by
dyes, leading to the term acid-fast
bacillus (AFB).
• Microscopy to detect AFB (using
Ziehl-Neelsen or Kinyoun stain) is
the most commonly used
procedure to diagnose TB in the
world, especially in developing
countries with limited laboratory
capacity.
 Growth characteristics
• A distinguishing feature of
M. tuberculosis is its slow
growth rate.

• In artificial media and

animal tissues, its
generation time is about
20 to 24 hours (as
opposed to 20 minutes
for organisms such as
Escherichia coli).

13
 Isolation in the laboratory
• Artificial media used to isolation
M. tuberculosis include potato-
and egg-based media, such as
Middlebrook 7H10 or 7H11, or
albumin in an agar base, such as
the Löwenstein-Jensen medium.

• A liquid medium, such as

Middlebrook 7H9, is used for
subcultures and for propagating
the bacillus to extract DNA for
molecular diagnostic and strain-
typing procedures.
• Three to four weeks are required
to recover the organism,
depending on the initial quantity of
organisms in the specimen
14
 TB Transmission
• are spread through the air from a person who is ill with
active TB that involves the lungs or airways.
e
• The transmission of (TB) is an important public health
concern

• Coughing and singing facilitate formation of droplet nuclei

.

• Individuals with active untreated pulmonary or laryngeal

disease are contagious, particularly when cavitary disease

•
smear positive.
F
is present or when the sputum is acid-fast bacilli (AFB)

You can catch tuberculosis from anyone who is sick with

TB.

• The germ that causes TB can travel in the tiny drops of

fluid that spray when a person coughs or sneezes.

• If you inhale those drops, you can get infected.

 Transmission depends on:
– Infectiousness of person with TB disease
– Environment in which exposure occurred
– Length of exposure
– Virulence of the bacilli
• The best way to stop transmission is to:
– Isolate infectious persons
– Provide effective treatment to infectious persons as soon
as possible
 What happens if I get infected with
TB?

• Your body's infection fighting system, called the immune system, might kill
off the germs that cause TB.

• If that happens, you will not get sick with TB.

• Your body's immune system might be able to control the germs but not
completely kill them off. This is called “latent TB.”

• People with latent TB do not get sick right away, but they can get sick later
on. act ve TB

• People who are sick with TB have “active TB.”

17
What happens if I get infected with
TB?
• Immediate clearance of the organism
• Latent infection
• Immediate onset of active disease
(primary disease)
• Onset of active disease many years
following exposure (reactivation disease)
 Primary disease esk den ch ldhood TB

metnch dad

• Symptoms include fever and chest pain.

• Retrosternal pain and dull interscapular pain have been

annem
ascribed to enlarged bronchial lymph nodes.

• The physical exam is generally normal.

• The most common chest radiograph is hilar adenopathy.

TFF
 Reactivation disease
• Reactivation TB refers to reactivation of a
previously dormant focus seeded at the
time of the primary infection.
• The apical posterior segments of the lung
are frequently involved
pr maryd sease'den farklı olarak
 What are the symptoms of active
TB?
• Typically symptoms are insidious

• may include cough, weight loss, fatigue,

fever, night sweats, chest pain, dyspnea,
and/or hemoptysis.
Immunosuppressive conditions associated with reactivation TB include:

• HIV infection and AIDS

• End-stage renal disease
• Diabetes mellitus non
un on
• Malignant lymphoma
• Corticosteroid use
• Inhibitors of TNF-alpha
and its receptor
• Diminution in cell
mediated immunity
associated with age
 The lesion typically occurs at the lung apices, and
disseminated disease is unusual, unless the host is
severely immunosuppressed
our
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 Endobronchial TB

• may develop via direct extension to the bronchi

from an parenchymal focus.

25
 olmadan zor oluyor tane bronkoskop
ray ve Ct yaptırçağ Çün
metrobüs

beyaz

26
 Laryngeal tuberculosis
çok bulaşıcı

• Since the availability of antituberculous

therapy, laryngeal TB has become rare (<1
percent of TB cases).

27
 Laryngeal tuberculosis
• Symptoms include dysphonia, cough,
dysphagia, odynophagia, stridor, and
hemoptysis
• Vocal cords, epiglottis, and false vocal
cords are the most common sites involved,
can be seen on laryngoscopy.

28
 Pulmonary complications of TB
• Hemoptysis can lead to death alone
• Pneumothorax
• Bronchiectasis
• Extensive pulmonary destruction
• Malignancy adena ca
• chronic pulmonary aspergillosis

29
• TB may affect any tissue of the body
including:
– Skin and soft tissue
– Lymph nodes TB lenfaden z
– Bones and joints
– Intra abdominal structures including
• peritoneum
• Kidneys
• Adrenal glands
• Lymph nodes
– Central nervous system
• Tuberculoma
• meningitis
 The physical appearance – Potts
disease of spine
Potts hastalığı sp ne tuberculos s
Cervical lymph node TB progressing to abscess
Bonell
Renal tuberculosis

1
calc f cat ons
peritoneal TB confirmed on biopsy – may mimic
malignancy

sample almam
lazım
 miliary TB on MRI scan
tuberclomas on CT scan

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LATENT TB
 not a d seaseform

Latent TB Infection
• Occurs when tubercle bacilli are in the body, but the
immune system is keeping them under control
• Detected by the Mantoux tuberculin skin test (TST)
or by blood tests such as interferon-gamma release
assays (IGRAs) which include:

– QuantiFERON®-TB Gold test (QFT-G)

– QuantiFERON®-TB Gold In-Tube (QFT-GIT)
– T-Spot®.TB test (T-SPOT)

İn
• People with LTBI are NOT infectious
 LTBI vs. TB Disease
act ve
Latent TB Infection (LTBI) TB Disease (in the lungs)
Inactive, contained tubercle Active, multiplying tubercle
bacilli in the body bacilli in the body
TST or blood test results TST or blood test results usually
usually positive positive
adf.EE
Chest x-ray usually normal Chest x-ray usually abnormal
Sputum smears and cultures Sputum smears and cultures
negative may be positive
No symptoms Symptoms such as cough, fever,
weight loss
Not infectious Often infectious before treatment
Not a case of TB A case of TB
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Is there a test for Latent TB?
• can be diagnosed with a skin test or with a
blood test.

• LTBI can test you for TB by giving you a shot

that contains tiny pieces of the dead TB
germ.

• Then, 2 or 3 days later, nurse will need to

look at the spot where you got the shot to
see if you form a bump, and to see how big
the bump is.

40
 What if my TB test is positive?
• The skin is examined to determine if there is
swelling (the size of the bump).

• The area may also be reddened, but redness

should not be measured.

• Anyone who has a bump larger than 15 mm is

considered to have a positive test, and some people
with a bump that is 5 mm (eg, HIV) or 10 mm (eg,
recent immigrant from a region with a high rate of
TB) are considered to have a positive test if they
are at higher risk for developing TB.

• The TB skin test indicates that TB bacteria are in

the body. It cannot determine if a person has active
TB disease or LTBI.

• Further testing is needed to determine if the person

has active or LTBI.

• People who are not sick and have latent TB must

take medicine every day for 6 to 9 months.

treatment s necessary n CTB only a h gh m port 41

 TREATMENT OF LATENT
TUBERCULOSIS
• Treating LTBI greatly reduces the
risk of the infection progressing to
active tuberculosis later in life .

• One of the most commonly used INAkullanan hastada bunlar

tehd d
treatments for LTBI is isoniazid
Tete near
mahf za
e
(INH). grants
• It is important to take the medicine
every day for nine months.

42
Treatment of TB
• Treatment for active TB lasts at least 6 months total.

• People with active TB must take 4 different medicines every day for at
least 2 months.

• After that, some people can go down to 2 medicines, but all people
must keep taking some medicines for another 4 months.

• It's hard to take medicine day after day for months. But if you do not
take all your medicine, you could get sick with TB, or the medicine
could lose its effect. If the medicine loses its effect, the infection can
become even harder to treat.

• TB is a serious disease. It can lead to death. That's why it's so

important that you take treatment very seriously
 Problems of TB therapy
• People who are being treated for TB should be monitored by a healthcare
provider at least once per month to monitor for any signs of medication
toxicity, such as liver injury. Signs of liver injury may include: unexplained
tiredness, loss of appetite, nausea, vomiting, dark-colored urine, jaundice
,fatigue, abdominal pain, or rarely, unexplained bruises.

• Anyone who experiences one or more of these problems should stop their
medication immediately and notify their healthcare provider.
 Compliance

– Treatment will not work if not taken

– DOTS (Directly Observed Therapy) if:

• Likely poor compliance
• MDRTB
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