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    Tuberculosis

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    Tuberculosis

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    Tuberculosis

    Uploaded by

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    m

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    © All Rights Reserved
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    Tuberculosis

    Michael Boyle

    Epidemiology
    One of the worlds deadliest diseases
    1/3 of world infected
    Worldwide (2014)
    Incidence: 9.6 million
    Mortality: 1.5 million

    United States (2014)


    Incidence: 9,421
    Mortality is 1 to 2 per 100,000

    Rates low in developed countries


    highly susceptible: HIV-infected, Homeless, Malnourished, Immigrants
    Leading killer of HIV infected

    Africans, Native Americans and Eskimos are more susceptible than Caucasians
    Most common among the elderly

    Mycobacterium species, along with


    members of a related genus
    Nocardia, are classified as:
    Coagulase-positive bacteria
    Collagenase-positive bacteria
    Acid-fast bacteria
    Phospholipase-positive bacteria

    Etiology
    Mycobacterium tuberculosis:
    Acid fast, Gram +, obligate
    aerobic, non-motile, rod, strict
    pathogen
    M. tuberculosis bovis,
    nonpasteurized milk

    In addition to peptidoglycan, the acid-fast cell wall of Mycobacterium


    contains a large amount of glycolipids, especially ______ that make
    up approximately 60% of acid-fast cell wall.

    Beta-lactamases
    LPS
    Teichoic acids
    Mycolic acids

    Pathogenesis
    Aerosolized droplets: coughing, sneezing and talking
    Inhaled
    Deposited in alveoli
    Lower segments of the lower and middle lobes
    anterior segments of the upper lobes

    Phagocytosed by alveolar macrophages but resist killing


    Mycolic acid blocks fusion of phagosomes and lysosomes and
    allows proliferation within macrophages

    Carried from the lung to regional (hilar and mediastinal)


    lymph nodes
    Disseminated by the bloodstream
    Continued proliferate at the primary site in the lungs
    and elsewhere, including lymph nodes, kidneys,
    meninges, epiphyseal plates of long bones and
    vertebrae and apical areas of the lungs

    Signs and symptoms


    Classic clinical features:

    Cough
    Weight loss/anorexia
    Fever
    Night sweats
    Hemoptysis
    Chest pain
    Fatigue

    Signs and symptoms


    Course depends on age, immune competence, total
    burden of organisms
    Indolent, asymptomatic infection
    Destructive, disseminated disease

    Infection vs active tuberculosis


    More Pts infected than develop clinical symptoms
    Infection: organism is growing in a person, whether or not
    symptomatic disease
    Active: destructive, symptomatic disease

    Signs and symptoms


    Primary tuberculosis
    1st exposure to organism
    Either an indolent or aggressive course
    Progressive primary tuberculosis develops in less than 10% of
    infected normal adults, but more frequently in children and
    immunosuppressed patients

    Secondary (cavitary) tuberculosis

    develops long after a primary infection


    results from reactivation of dormant endogenous bacilli
    or exposure to exogenous organisms
    Always an active disease
    or reinfection with exogenous bacilli

    Miliary tuberculosis is caused by dissemination of


    tubercle bacilli to produce numerous, minute, yellowwhite lesions (resembling millet seeds) in distant organs

    Signs and symptoms


    Ghon focus (tubercle):
    lung lesion of primary tuberculosis
    found in the subpleural area of the upper segments of the lower lobes or in the
    lower segments of the upper lobes
    Initially, small, ill-defined area of inflammatory consolidation, which then drains to
    hilar lymph nodes

    Ghon complex: combination of peripheral Ghon focus and involved


    mediastinal or hilar lymph nodes
    Caseous granuloma:
    Microscopically, classic lesion of tuberculosis
    When number of bacteria is high
    Soft, semisolid core surrounded by epithelioid macrophages, Langhans giant cells,
    lymphocytes and peripheral fibrous tissue

    Tuberculous granuloma with


    central caseation
    Primary
    tuberculosis
    Hilar lymph node

    Differential diagnosis
    Acid fast stain: most commonly used in examining sputum for
    mycobacterium tuberculosis
    It is a method of staining used in bacteriology in which a smear on a slide is
    flooded with carbol fuchsin stain, decolorized with acid alcohol, and
    counterstained with methylene blue
    Acid-fast organisms resist decolorization and appear red against a blue background
    under a microscope
    This property of being acid-fast is attributable to the presence of lipids and waxes
    (mycolic acids) in the cell wall of certain bacteria

    Differential diagnosis
    PPD skin test: is the classic skin
    test for tuberculosis
    PPD may indicate an infection but
    not whether an infection is active
    Purified protein derivative (PPD)
    extracted from the mycobacterium
    tuberculosis is injected
    subcutaneously
    The area near the injection is
    observed for a delayed
    hypersensitivity reaction (necrosis)
    A positive test indicates a
    hypersensitivity to tuberculoproteins

    Differential diagnosis
    Well known for its ability to masquerade as other
    infectious and disease processes.
    The following may resemble pulmonary TB include :
    Blastomycosis
    Tularemia
    Actinomycosis
    Mycobacterium avium-intracellulare infection
    M chelonae infection
    M fortuitum infection
    M gordonae infection
    M kansasii infection
    M marinum infection
    M xenopi infection
    Squamous cell carcinoma

    Conditions to be included in the differential diagnosis


    of extrapulmonary TB include the following:
    Blastomycosis
    Tularemia
    Actinomycosis
    Hidradenitis suppurativa
    Eosinophilic granuloma
    M avium-intracellulareinfection
    M chelonaeinfection
    M fortuituminfection
    M gordonaeinfection
    M kansasiiinfection
    M marinuminfection
    M xenopiinfection
    Endemic syphilis
    Erythema induratum (nodular vasculitis)
    Erythema nodosum
    Leishmaniasis
    Leprosy
    Cat scratch disease
    Syphilis
    Syringoma
    Rheumatoid arthritis

    Diagnosis of skin infection withM


    tuberculosisinvolves the following:
    Differentiate primary-inoculation TB from ulceroglandular complexes and mycobacterioses
    Differentiate TB verrucosa cutis from diseases such as North American blastomycosis,
    chromoblastomycosis, iododerma and bromoderma, chronic vegetative pyoderma, verruca
    vulgaris, verrucous carcinoma, verrucous atypical mycobacterial infection, and verrucous lupus
    vulgaris
    Differentiate miliary TB of the skin (which appears as small, noncharacteristic, erythematous,
    papular or purpuric lesions) from drug reactions
    Differentiate scrofuloderma from suppurative lymphadenitis with sinus-tract formation, such as
    blastomycosis or coccidioidomycosis
    Differentiate TB cutis orificialis from glossitis, apotheosis, and deep fungal infections
    Differentiate lupus vulgaris from lupoid rosacea, deep fungal or atypical mycobacterial infection,
    chronic granulomatous disease, granulomatous rosacea, and Wegener granulomatosis
    Differentiate erythema induratum from nodular panniculitides (eg, Weber-Christian disease) and
    nodular vasculitides (eg, syphilitic gumma, nodular pernio)
    Differentiate papulonecrotic tuberculid from other papulonecrotic entities, such as
    leukocytoclastic vasculitis, lymphomatoid papulosis, papular eczema, and prurigo simplex with
    neurotic excoriation
    Differentiate lichen scrofulosorum from keratosis spinulosa, lichenoid sarcoid, and lichenoid
    secondary syphilis

    Treatment
    Latent TB
    isoniazid (INH)
    rifampin (RIF)
    rifapentine (RPT)

    TB disease (Active TB)

    isoniazid (INH)
    rifampin (RIF)
    ethambutol (EMB)
    pyrazinamide (PZA)

    Initial phase: 2 months


    Continuation phase: 4-7 months

    Prognosis
    Full resolution is generally expected with few
    complications in cases of non-drug resistant TB, when the
    drug regimen is completed
    Recurrence: 0-14%
    Poor prognostic markers: extrapulmonary involvement, an
    immunocompromised state, older age, and a history of
    previous treatment
    Risk factors for dying: reduced baseline TNF- response
    to stimulation (with heat-killedM. tuberculosis), low body
    mass index, and elevated respiratory rate at TB diagnosis

    Summary
    Epidemiology: HIV-infected, homeless, malnourished, immigrants
    Etiology: M. tuberculosis, acid fast, Gram +, obligate aerobic, non-motile, rod,
    strict pathogen
    Pathogenesis: Aerosolized droplets, Inhaled
    Lungsmacrophageslymph nodes
    Miliary TB: disseminated
    Mycolic acid

    Signs and symptoms: Cough, anorexia, fever, night sweats, hemoptysis, chest
    pain, fatigue
    Ghon focus, Ghon complex, caseous granuloma

    Differential diagnosis: Acid fast stain (carbol fuchsin), PPD test


    Treatment: rifampin, isoniazid, pyrazinamide, ethambutol
    Prognosis: Good with drug regimen, recurrence

    References
    Murray, Patrick, Ken Rosenthal, Michael Pfaller. Medical
    Microbiology, 7th Edition. W.B. Saunders Company,
    2013.
    Rubin. Rubin's Pathology: Clinicopathologic Foundations
    of Medicine, 6th Edition. Lippincott Williams & Wilkins.
    http://www.cdc.gov/tb/

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