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Tuberculosis ד"ר מנדל גלזר מנהל מכון רוקח ומלש"ח ירושלים שירותי בריאות כללית, מחוז ירושלים מסונף לאוניברסיטה העברית מכון הריאה ב"ח הדסה ע"כ.

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Presentation on theme: "Tuberculosis ד"ר מנדל גלזר מנהל מכון רוקח ומלש"ח ירושלים שירותי בריאות כללית, מחוז ירושלים מסונף לאוניברסיטה העברית מכון הריאה ב"ח הדסה ע"כ."— Presentation transcript:

1 Tuberculosis ד"ר מנדל גלזר מנהל מכון רוקח ומלש"ח ירושלים שירותי בריאות כללית, מחוז ירושלים מסונף לאוניברסיטה העברית מכון הריאה ב"ח הדסה ע"כ

2 מלש"ח – מרכז לאבחון וטיפול בשחפת 9 מלש"חים בארץ לשכות הבריאות האזוריות ירושלים – מרכז רוקח

3 מרכז רפואי על שם ד " ר י. ל. רוקח

4 מלש " ח מרפאות קהילה מלש " חים אחרים לשכת הבריאות משרד הבריאות צה " ל עובדים זרים מבוטחי כל הקופות מרכז קליטה בתי חולים כלליים בי " ח ספציפיים

5 History Terms Consumption Phthisis [ Greek ] Phthisis Pulmonalis Scropula Tabes Mesenterica Kochs Disease

6 TB History 1020 – Ibn Sina [ Avicena ] described in first as contagious disease Senabsin - name Tuberculosis 1859 – First sanatorium in Germany 1882 – R.Koch found bacilli 1905 – Nobel Price 1906 – A. Galmette and Camele Gurien – first immunisation

7 TB History 1907 – National TB Association founded in US and Canada 1921 – First human vaccination used in France 1946 – Streptomycin was developed 80s – Drug resistance appeared The 20 th _ TB kills more than 100 million people

8 Incidence -8,8 million new cases and 1,4 million died in % of the world`s population are infected by M.Tuberculosis. ->95% of cases occur in developing countries.

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12 TB - USA

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15 Tuberculosis. Infectious disease caused by Mycobacterium Tuberculosis Transmitted from a person with active lung disease Airborne transmission Exposure time, host susceptibility dependant

16 MT COMPLEX. Mycobacterium Tuberculosis M ycobacterium Bovis Mycobacterium Africanum M.Microti, M.Pinnipedii, M.Carpae

17 MTB Small rod-like bacillus Aerobic Divides every hours Can identify under regular microscopy Ziehl-Neelsen stain Fluorescent microscopy Rhodamine, Ahramine stain

18 Mycobacterium TB

19 Sputum ZN Stained

20 TB

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22 Tuberculosis Active Disease L atent [ LTI ]

23 Tuberculosis MDR [ Multi drug resistance ]- Rifampicin, Isoniazid XDR [ Extensive drug resistance ] – Rif., Ison., Fluoroqinolones, Aminoglicosides HIV

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30 Lung TB

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43 TB Diagnostics Sputum Bronchoscopes Gastric Aspiration Histopathology [ Biopsy ]

44 Rapid TB Tests NAA [ Nucleic Acid Amplification ] Gen-Probe MTD Enhanced MTD Amplicor MT Test

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46 TB in Children Under 5year triad of close contact, positive TST, suggestive findings on the x-ray [ primary complex, opacification with hilar or subcarinal lymphadenopathy ] or physical examination are useful for diagnosis for active TB Gastric aspiration

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48 Relative Risk for TB AIDS HIV Transplant CA Head/Neck 16 TNF Inhibitor 1,7 – 9 Solitary Granuloma 2 Apical Fibronodules Resent TB Inf [ under 2 years ] 15

49 Relative Risk for TB CRF – Hemodialysis Silicosis 30 Anti – TNF 1,7 - 9 Young age [under 5 ] 2,2 - 5 Glucocorticoids 4,9 DM all types 2 – 3,6 Smoker 1 p/d 2 – 3 Underweight [ 85% ] 2 - 3

50 Close Contact - Disease Risk Under 1 year old 50% years 12% – 25% 2 – 5 years 5% 5 – 10 years 2% Adolescent, young adults 10% - 20% Other adults 3% - 5%

51 LTI Diagnosis TST Interferon-Gamma release assay [IGRA ]: Enzyme-linked immunosorbent assay - Quantiferon e.g. Elisa Enzyme-linked immunospot assay – Elipsot e.g. T-Spot TB assay.

52 Tuberculin test (Mantoux) Intradermal injection of 5 TU (tuberculin units) of purified protein derivative (PPD). Induration measured after hours. Booster [ two step testing ] Conversion: an increase of 6-10mm to >10mm.

53 Booster Response, Conversion Booster – 10mm or more and has increased by 6mm since the previous in the absence of exposure. Lover risk than initial positive TST Conversion – 10mm or more and has increased by 6mm since the previous up to 8weks after initial negative TST in the setting of recent exposure Reaction 10 and more mm should be referred for medical evaluation to exclude active TB

54 TST

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57 התפלגות תוצאות PPD אצל ילידי ישראל

58 Close Contact PPD Negative – Second test should undergo 8 – 12 weeks later

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60 Potential causes of false negative Tuberculin test : Technical - correctible Tuberculin material : improper storage [ exposure to light, heat ], contamination, improper dilution, chemical denaturation Administration: injection of too little tuberculin, or too deeply, or more than 20 minutes after drawing up into the syringe Reading: inexperienced or biased reader, error in recording

61 Infections: Active TB [ especially if advanced ], bacterial infections [ typhoid fever, brucellosis, typhus, leprosy, pertussis ]. HIV inf [ especially if CD count less than 200 ], viral infection [ measles, mumps, varicella ], fungal infection [ blastomycosis ] Live virus vaccination : measles, mumps, polio Immunosuppressive drugs : corticosteroids, TNF inhibit, others Metabolic disease: CRF, severe malnutrition, stress [ surgery, burns ] Diseases of lymphoid organs: Lymphoma, CLL, Sarcoidosis Age under 6 months, elderly Potential causes of false negative tuberculin tests: Biologic – not correctible

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63 LTI Diagnosis IGRAs Specificity 95%, Sensitivity 80-90% TST - Specificity 97% in non BCG, and 60% in BCG administered, Sensitivity -80% IGRAs sensitivity is diminished in HIV with lower CD4 [ TSPOT is less affected ] M.Kansasii, M.Marinum affect

64 LTI Diagnosis USA – IGRAs used, but not in addition to TST Canada – IGRAs is appropriated in the setting of negative TST UK – TST is the first-line test. If positive – may be considered IGRA depending of BCG status

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66 TB - TREATMENT DOT [ Direct Observed Therapy ]

67 TB Treatment First Line [ INH, RIF, ETH, PZM, Rifabutin] Second Line [ Cycloserine, Ethionamide, Streptomycin, Amikacin, Kanamycin, Capreomycin, PAS, Levofloxacin, Moxyfloxcin ] New drugs [ Interferon, Linezolid ] Surgery

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74 Active TB - Treatment Prolonged Treatment in cavitary, miliary TB In pericarditis, meningitis – corticosteroids Treatment failure – positive sputum culture after 4months treatment - continue 4 drug regimen

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76 Treatment Regimes for LTBI Isoniazid 6 to 9 months. Rifampicin 4 months; children 6 months. Rifampicin + Isoniazid 3 months. Liver and kidney functions monitoring.

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78 Risk of Isoniazid-Induced Hepatitis More than 65 years - more than 5% 50 – 65 years - 3-5% Less 50 years – less than 3% Less than 35years – less than 1%

79 BCG Benefits: diminished risk of TB meningitis Reaction 3-19mm in the first 3 months, after less than 10mm Should not be administrated in individuals with immune compromise

80 BCG לילודים ולילדים ממשפחות עולים חדשים ותושבים שאינם אזרחי ישראל המגיעים מארצות בהן שכיחות TB גבוה מייד אחרי לידה ועד גיל 4 [ שלא חוסן או שאין עדות על החיסון וכש HIV נשלל ]

81 BCG Adverse Events - 5% Fever - 2,9% Signif. Proteinurua - 1% Granulomatous Prostatitis - 0,9% Pneumonitis - 0,7% Granulomatous Hepatitis - 0,7% Artralgia - 0,5% Epididymitis - 0,4% Cystitis

82 BCG – Adverse Events Sepsis - 0,4% Rash - 0,3% Uretral Obstruction - 0,3% Contracted Bladder - 0,2% Renal Abscess - 0,1% Cytopenia - 0,1% Osteomyelitis

83 NTM Infection MAC M. Kansasii Rapidly Growing – M.Fortuitum, M.Abscessus, M.Chelonae

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