Presentation on theme: "De Vera, Dela Cruz, Dela Cruz, Dela Cruz, Dela Rosa, Dimalala"— Presentation transcript:
1De Vera, Dela Cruz, Dela Cruz, Dela Cruz, Dela Rosa, Dimalala Case ConferenceDe Vera, Dela Cruz, Dela Cruz, Dela Cruz, Dela Rosa, Dimalala
2General DataJ.T. 6 years and 2 months old, Female 416 Hernandez 2nd St. Sampaloc Manila Roman Catholic Filipino Informant: Mother Reliability: Good
3Right lateral cervical mass CHIEF COMPLAINT:Right lateral cervical mass
4History of Present Illness 9 days PTC: patient had productive cough with whitish phlegm, no fever, no colds -no medications and consultations done -resolved after 2 days 7 days PTC: appearance of mass on the left lateral part of the neck. -progressed in size and became tender -sought consult = MUMPS no medications given -progression in size
5REVIEW OF SYSTEMSNo weight loss, no weight gain No rashes, no jaundice, no pruritus, alopecia No dizziness, no lacrimation, no hearing difficulties, no aural discharge, no toothache, no sore throat No chest pain, no difficulty of breathing No cyanosis, no easy fatigability No abdominal pain, change in bowel movements, melena, hematochezia No hematuria, no frequency, no discharge, no edema, anuria, oliguria, dysuria No tremors, no convulsions, no behavioral changes No polyuria, polydipsia, polyphagia, no heat/cold intolerance No weakness, no joint swellings, no limitation of motion No pallor, no bleeding, no easy bruisability
7Past Medical History2 years old: German measles No previous hospitalizations and operations
8Family membersAgeOccupationConditionFather30 years oldEmployeeHealthyMother29 years oldHousewifeSibling (Justine Richie)7 years oldGrade 1Sibling (Jama Lian)3 years oldSibling (Jermaine)2 years old
9Environmental History The patient lives with both parents and siblings in a concrete house, well-lit, and well ventilated. No factories are nearby.Pets: noneGarbage is collected everyday by a garbage truck, not properly segregated
10Physical ExaminationConscious, coherent, alert, ambulatory, well looking, well hydrated, not in cardio-respiratory distress BP: 90/60 CR: 96, regular RR: 18, regular Temp: 36.5 C Ht: 115cm z = 0 Wt: 21.2 kg z = 0 BMI: z = 0
11Physical ExaminationSkin: warm, moist skin, no lesions Head: normocephalic, thick shinny hair, no hair nits, no hair lice, no tenderness, no palpable masses Eyes: no swelling, lids not matted, pink palpebral conjunctiva, anicteric sclera, pupils 2-3 mm ERTL Ears: no swelling, no tragal tenderness, nonhyperemic EAC, impacted cerumen AU Nose: no discharge, turbinates not congested, midline septum Mouth/ Throat: moist buccal mucosa, nonhyperemic posterior pharyngeal wall, tonsils not enlarged, no dental caries, no oral ulcers
12Neck: supple neck, (+) 5cm x 3cm non movable, tender mass on the left retroauricular extending up to the angle of the mandible Lung/ Chest: no intercostal and supraclavicular retractions, symmetrical chest expansion, clear breath sounds, equal vocal fremiti Heart: adynamic precordium, apex beat at 4th Left ICS MCL, S1>S2 apex, S2>S1 base, no heaves, thrills, murmurs
13Abdomen: flat abdomen, normoactive bowel sounds, soft, nontender, no palpable masses Extremities/ Pulses: pulses full and equal, no deformities, no cyanosis, no edema Neurologic examination: unremarkable
14Salient Features:6 years old Filipino Sampaloc, Manila (+) non productive cough (+) 5cm x 3cm non movable, tender mass on the left retroauricular extending up to the angle of the mandible (-) TB exposure
19Approach to Diagnosis History Duration and laterality of adenopathy and change in size over timeAssociated symptomsIll contactsIngestion of unpasteurized animal milk or undercooked meatsDental problems or mouth soresSkin lesions or traumaAnimal exposuresImmunization statusMedicationsGeographic location and travelHistoryDuration and laterality of adenopathy and change in size over timeAssociated symptoms (weight loss, fever, arthralgias, sore throat)Ill contacts (viral respiratory infections, cytomegalovirus [CMV], Epstein-Barr virus [EBV], Streptococcus pyogenes [group A streptococcus, GAS], tuberculosis [TB])Ingestion of unpasteurized animal milk (brucellosis, Mycobacterium bovis) or undercooked meats (toxoplasmosis)Dental problems or mouth sores (anaerobes, actinomycosis, enteroviral herpangina, herpes simplex gingivostomatitis)Skin lesions or trauma (Staphylococcus aureus, GAS, herpes simplex virus [HSV], cat scratch disease, tularemia, plague)Animal exposures (cat scratch disease, toxoplasmosis [cats], brucellosis [especially goats], tularemia [especially rabbits], bubonic plague [especially prairie dogs]) Flea or tick bites (bubonic plague, tularemia) Immunization status (diphtheria, measles)Medications (eg, phenytoin, carbamazepine)Geographic location and travel (tularemia, bubonic plague, TB
20Approach to Diagnosis Physical examination Examination of the lymphatic system, including assessment of the liver, spleen, cervical lymph nodes, and noncervical lymph nodes should be performed.Hepatosplenomegaly with generalized adenitis indicates a possible infection with EBV, CMV, HIV, histoplasmosis, TB, or syphilis.These findings also may be signs of neoplastic disease, collagen vascular disease, or other noninfectious etiologyPhysical examination Examination of the lymphatic system, including assessment of the liver, spleen, cervical lymph nodes, and noncervical lymph nodes should be performed.Hepatosplenomegaly with generalized adenitis indicates a possible infection with EBV, CMV, HIV, histoplasmosis, TB, or syphilis.These findings also may be signs of neoplastic disease, collagen vascular disease, or other noninfectious etiologyThe lymph node number, location, size, shape, consistency, tenderness, mobility, and color should be recorded. "Reactive" lymph nodes are usually discrete, mobile, feel rubbery, and are minimally tender.Infected lymph nodes are usually isolated, asymmetric, tender, warm, and erythematous; they may be fluctuant; they are less mobile and discrete than reactive lymph nodes.Malignant lymph nodes often are hard, fixed or matted to the underlying structures; they are usually nontender. Oral cavity — The oral cavity should be examined for evidence of periodontal disease, herpangina, HSV gingivostomatitis, or pharyngitis. Eyes — Conjunctival injection may indicate Parinaud oculoglandular syndrome (associated with cat scratch disease) or Kawasaki disease (show picture 1). (See "Microbiology; epidemiology; clinical manifestations; and diagnosis of cat scratch disease" and see "Clinical manifestations and diagnosis of Kawasaki disease"). Skin — A generalized rash may suggest a viral illness, whereas a localized skin lesion may indicate a more specific etiology (eg, cat scratch disease (show picture 2A-2B), tularemia (show picture 3), S. aureus or GAS, HSV, etc). Less common infections in which a papular or pustular lesion is suggestive of an inoculation site include  :
21Approach to Diagnosis Physical examination The lymph node number, location, size, shape, consistency, tenderness, mobility, and color should be recorded. "Reactive" lymph nodes are usually discrete, mobile, feel rubbery, and are minimally tender.Infected lymph nodes are usually isolated, asymmetric, tender, warm, and erythematous; they may be fluctuant; they are less mobile and discrete than reactive lymph nodes.Malignant lymph nodes often are hard, fixed or matted to the underlying structures; they are usually nontender.Oral cavity —periodontal disease, herpangina, gingivostomatitis, or pharyngitisEyes — Conjunctival injectionSkin — generalized rash, pustular or papular lesionsPhysical examinationThe lymph node number, location, size, shape, consistency, tenderness, mobility, and color should be recorded. "Reactive" lymph nodes are usually discrete, mobile, feel rubbery, and are minimally tender.Infected lymph nodes are usually isolated, asymmetric, tender, warm, and erythematous; they may be fluctuant; they are less mobile and discrete than reactive lymph nodes.Malignant lymph nodes often are hard, fixed or matted to the underlying structures; they are usually nontender.Oral cavity —periodontal disease, herpangina, HSV gingivostomatitis, or pharyngitisEyes — Conjunctival injection may indicate Parinaud oculoglandular syndrome (associated with cat scratch disease) or Kawasaki diseaseSkin — A generalized rash may suggest a viral illness, whereas a localized skin lesion may indicate a more specific etiology (eg, cat scratch disease (show picture 2A-2B), tularemia (show picture 3), S. aureus or GAS, HSV, etc). Less common infections in which a papular or pustular lesion is suggestive of an inoculation site include  :
22Differentials Non-Infectious Causes Patient: 6y.o./ FemaleCollagen vascular diseasesMalignancy(+) 5x3cm, unilateral, semi-solid, tender, cervical mass on the left retroauricular area, extending to the angle of the mandible1 week durationnontender, firm, rubbery, and matted.Persistent or progressive lymphadenopathy that does not respond to antibiotic therapy suggests the need for more extensive evaluationWeeks to months(+) cough for 2 days(-) colds(-) fever(-) weight loss(-) failure of weight gainProlonged fever, rash, and arthralgiasFever, weight loss, Musculoskeletal pain, headache, mediastinal mass, testicular enlargement, peripheral blood abnormalitiesWe can remove this na
23Differentials Infectious Causes Patient: 6y.o./ FemaleBacterial InfectionViral InfectionTB Infection(+) 5x3cm – progressive in size, unilateral, semi-solid, tender (initially non-tender), fixed, mass on the left retroauricular area, extending to the angle of the mandible1 week durationMost often unilateral; but can be bilateral; usually is 3 to 6 cm in diameter, tender, warm, erythematous, nondiscrete, and poorly mobilevariablemost often bilateral some can be generalized; small, rubbery, mobile, discrete, minimally tender, and without erythema or warmthunilateral nontender firm discrete mass or matted nodes, fixed sometimes accompanied by overlying skin induration; submandibular and supraclavicular lymph node involvement also occursWeeks to months
24Differentials Infectious Causes Patient: 6y.o./ FemaleBacterial InfectionViral InfectionTB Infection(+) cough for 2 days(-) colds(-) fever(-) weight loss(-) failure to gain weighthistory of a recent URI or impetigo; fever, tachycardia, and malaise may be present, the patient usually does not appear toxichistory of an ill contact and current or recent symptoms that may include sore throat, rhinorrhea, nasal congestion, and/or coughCough/ wheezing of 2 or more weeksUnexplained fever of 2 or more weeks; loss of appetite, loss of weight, failure to gain weight; failure to regain previous state of health after infection; fatigue, reduced playfulness or activity
25t/c Primary Tuberculosis Clinical ImpressionHow can we rule out yung URTI?t/c Primary Tuberculosis
26(+) signs/ symptoms of TB Close contact of a source case Approach to Diagnosing a TB symptomatic child who has no/unknown exposure(+) signs/ symptoms of TBTBClose contact of a source caseNo/Unknown0-4 years old5-9 years oldYes…Tuberculosis in Infency and Childhood 3rd ed PPS, Inc. p.123
27Evaluate further and refer 5-9 years oldCan produce sputum?NOTSTNegativeEvaluate further and referPositiveTB DiseaseDSSMTuberculosis in Infency and Childhood 3rd ed PPS, Inc. p.123
29Traditional and New Diagnostic Approaches DIAGNOSTICSAPPLICATIONSTraditional approaches- Symptom-based-TSTTB Culture- AFB smear- Chest radiographProbable active TBEvidence of MTB InfectionBacteriologic Confirmation of active TBProbable Active TBNew Diagnostic ApproachesORGANISM BASEDColorimetric cultures systems- phage based test- Microscopic- based observation drug susceptibility (MODs) assayBacteriological confirmation of active TBProbable active Tb and detection of rifampin resistanceProbable active TB and detection of resistance
30Traditional and New Diagnostic Approaches DIAGNOSTICSAPPLICATIONSNew Diagnostic ApproachesANTIGEN BASED ASSAYSLAM detection assayIMMUNE BASED ASSAYAntibody based assay-MPB-64 skin test- T- Cell assaysSYMPTON BASEDSymptom based screeningRefined symptom based DiagnosisProbable active TBDiagnosis of Latent TB infectionScreening child contacts of adult TB casesProbable Active TBOf the all the diagnostic approach , the traditional approaches as well as tyhe symptom based screening of child contcats have been the basis for arriving at apresumptive diagnosis of TB as agreed upon in the PPS national consensus on TB
31Diagnosis of TBA positive culture with or without a positive smear for M. Tuberculosis is the gold standard for the diagnosis of TBIn the absence of bacteriologic evidence , a child is presumed to have active TB if > 3 crteria are present:Exposure to an adult/Adolescence with active TB (EPIDEMIOLOGIC)Signs and symptoms suggestive of TB (CLINICAL)Positive tuberculin test (IMMUNOLOGIC)Abnormal chest radiograph suggestive of TB (RADIOLOGIC)Other lab findings suggestive of TB (LABORATORY)
32OUR PATIENTTST – 12 mm indurationChest X –ray showed evidence of primary infectionSigns and symptoms of TB
33Chest X- ray of the patient 11/24/10 The heart is not enlarged.There is slight haziness over the right lung base and the retrocardiac region, with nodular densities over the retrocardiac region, which may be due to lymph nodes. This may represent primary infection.Both hemidiaphragm and sinuses are normal.The visualized osseous structures are unremarkable. 11/24/2010
35Objectives of Drug Therapy in TB: Cure the patient of TBPrevent death from active TBPrevent relapse of TBPrevent the development of drug resistanceDecrease transmissionBy rapidly eliminating most of the bacilliOr its late effectsBy eliminating the dormant bacilliBy using a combination of drugsto achieve these goals, is is necessary to have athorough understanding of the pathopysiology of the disease. The need for multiple drugs and prolonged duration of therapy can be explained by the fact that naturally occurring drug resistant mutants are present within large bacterial populations even before chemotherapy is started. iN addition mycobacteria replicate slowly , can remain dormant for long periods , and can be eradicated only during replication. Finally bacilli live in several sites within the host and each site contains organism with a different populationsize metabolic activity and replication rate.
36Phases of Treatment Intensive Phase - efficient killing of actively dividing organisms- relief of symptoms- terminates transmision- prevents emergence of drug resistanceContinuation Phase- kills irregularly dividing bacilli- sterilizes lesions and prevent relapse
37Drug AdministartionThe optimal dosing frequency for new patients with pulmonary TB is daily throughout the course of therapy.Alternative Regimens:A daily intensive phase followed by tree times weekly continuation phase [2HRZE/4H3R3] , provided that each dose is directly observedThree times weekly dosing throughout the therapy [2H3R3Z3E3/4H3R3] , provided that every dose is directly observed.Sytematic reviews have not found much difference in failure or relapse rates for daily versus three times weekly regimens. However , rates of acquired drug resistance were highrer among patients receiving intermittent dosing throughout. Therapy. Patients on intermittent therapy should adhere strictly to the prescribed regimen , since any missed doses leads to a significant reduction of the total quantity of the drugs received by the patient thus can lead to treatment failure.
38Essential Anti-Tuberculosis Drugs MOADOSE RANGESingle daily dose mkd3X weekly mkdINHBactericidal agent-Acts on extracellular and intracellular bacillary populations- presumed to inhibit biosynthesis of mycolic acid (cell wall component ) and effects glycolysis , nucleic acid synthesis10 -15Max 300 mg20-30Max 900 mgRifampicin- inhibits nucleic acid synthesis10-20Max 600 mg
39Essential Anti-Tuberculosis Drugs MOADOSE RANGESingle daily dose mkd3X weekly mkdPyrazinamide- weak bactericidal but with potent sterilizing activity within macrophages, areas of acute inflammation20-40Max 2 g50 mgStreptomycin- Bactericidalmax 1 gEthambutolBacteriostatic, but with some bactericidal action at higher doses- acts on intra and extracellular bacillary populations- presumed to inhibit synthesis of mycolic acid (cell wall component)15- 25Max 1.2 g30-50Max 2.5 g
40Essential Anti-Tuberculosis Drugs ADVERSE REACTIONSINH- peripheral neuropathyOther neurological disturbance, optic neuritis, toxic psychosis, generalized convulsions- systematic or cutaneous hypersensitivity reactions during the first week of treatment- hepatotoxicityRifampicinGastrointestinal intolerance- if intermittent adminidtration: rash , fever, thrombocytopenia, flu like symptoms- increases risk of hepatotoxicity if used with INHPyrazinamide- hypersensitivity reactions-moderate rise in trasaminase levels- Hyperuricemia- arthralgia, particularly of shouldersHepatotoxicity – may need to discontinue INH if with symptoms of hepatitis or trans aminase levels increase greater than 3.5 X from upper limits of normal
41Essential Anti-Tuberculosis Drugs ADVERSE REACTIONSStreptomycin- sterile abscess- vestibular, auditory function impairment- hemolytic anemiaEthambutol- retrobulbar neuritis ( reduced visual acuity, contraction of visual fields, green red color blindness)Hepatotoxicity – may need to discontinue INH if with symptoms of hepatitis or trans aminase levels increase greater than 3.5 X from upper limits of normal
42TREATMENT21 kg Isoniazid 200 mg/5mL (10 mkd) Give 5.5 mL once daily 30 minutes before breakfast Rifampicin 200mg/5mL (10 mkd)- Give 5.5 mL once daily, 30 minutes before breakfast Pyrazinamide 500 mg/5mL (20 mkd) Give 4.5 mL once daily, 30 minutes before breakfast Ethambutol 400 mg/tab (20 mkd) - 1 tab Give 1 tab once daily, 30 minutes before breakfast
43Supportive Management Multivitamins 5 mL once a dayAnticipatory Guidance
45Tuberculosis A Global Emergency One third of the world’s population is infectedTB kills 5,000 people a day – 2-3 million each yearHIV and TB co-infection is producing explosive epidemicsHundreds of thousands of children will become TB orphans this yearMDR threatens global TB controlIt is estimated that one-third of the world’s population is infected with Mycobacterium tuberculosis, and that TB kills 5000 people a day or between 2 and 3 million people each year. The combination of HIV and TB coinfection is producing explosive epidemics. Hundreds of thousands of children will be orphaned this year when their parents and caretakers die from TB. Finally, multi-drug resistant TB, or MDR, is threatening global TB control.
46Background Tuberculosis (TB) is increasing among adults in many areas TB is major cause of childhood morbidity and mortality worldwideLimited information on epidemiology of TB in childrenThere is ample evidence that TB among adults is increasing in many areas of the world. TB is an important cause of childhood morbidity and mortality worldwide, although it has been a lower public health priority in recent years. There is limited information on many aspects of TB in children, including the epidemiology of TB.
47Childhood TB Why neglected? Why is it important? Not considered important in global program or contributing to immediate transmissionNot regarded as public health riskDifficult to diagnoseWhy is it important?Health problem in childrenMay later contribute to epidemic
48Leading Infectious Disease Causes of Death, 1998 184.108.40.206.51.10.9TB is among the leading causes of death for all ages worldwide. While infections with and deaths due to HIV/AIDS are on the rise in many countries, many of these individuals are coinfected with TB, and in fact also frequently die from TB.WHO Report 2000
49TB in Children WHO estimate of TB in children 1.3 million annual cases 450,000 deaths15% of TB in low-income countries children vs. 6% in United StatesIn 1989, the World Health Organization, or WHO, estimated that there were 1.3 million annual cases, and 450,000 deaths due to tuberculosis among children less than 15 years of age. Unfortunately, these estimates have not been revised more recently. It is estimated that 15% of all TB in low-income countries occurs among children less that 15 years of age compared with only 6% in the United States, and even lower percentages in some European countries.
50Childhood TB as Sentinel Event Indicates recent transmission in a communityRapid progression from infection to disease“A deterioration in the control of TB thus immediately hurts the youngest generation” (Rieder, 1997)Children are future reservoir of diseaseDespite the relative neglect of the subject, a case of childhood TB has been described as a sentinel event, because it indicates recent transmission of M. tuberculosis in a community. Because there can be rapid progression from infection to disease in young children, it has been said that “A deterioration in the control of TB thus immediately hurts the youngest generation.” Further, children represent the future reservoir of disease. Thus, any effort to control the burden of TB over the long term needs to consider the role of infection and disease in children.Rieder H. Anales Nestle, 1997
51Childhood TB diagnosed by: Combination of :Contact with infectious adult caseSymptoms and signsPositive tuberculin skin testSuspicious CXRBacteriological confirmationSerology
52Risk factors : infection to disease HIVMalnutritionRecent exposureYoung ageShort incubation periodMore severeHighest riskMore difficult to diagnoseHost factorsEffect of HIV?
53Grzybowski S, et al. Bull Int Union Tuberc 1975;50:90-106 Tuberculous Infection Among Children by Type ofContact and Bacteriologic Status of Index Case,British Columbia and Saskatchewan,ClosePercent infectedCloseCasualCasualGrzybowski S, et al. Bull Int Union Tuberc 1975;50:90-106
54Challenges for Surveillance Difficult diagnosis of childhood TBLack of standard case definitionIncreased extrapulmonary diseaseLow public health priority of childhood TBThere are many challenges to the surveillance of childhood TB. They include the difficult diagnosis of TB in children which often relies on clinical algorithms or checklists instead of bacteriologic confirmation. In published studies and surveillance systems, there is not a standard case definition of childhood TB. Children, particularly young children, are more likely to have extrapulmonary disease which can also be more difficult to confirm bacteriologically. Finally, because many children are not smear-positive, and therefore not as infectious, childhood TB has been given a low public health priority in comparison with other aspects of TB control.
55WHO Estimated Total Cases by Age, 2000 CountryTotal CasesCases <15 yrs% in ChildrenIndia1,815,740185,23310.2China1,645,70386,9785.3Indonesia581,91815,6912.7Bangladesh325,11033,166Nigeria261,40432,31012.4Pakistan244,73661,90525.3Philippines230,21712,167South Africa220,48635,44916.1Russian Fed.183,3737,7784.2Ethiopia178,34928,675Dem. Rep. Congo148,59824,052I have abstracted these estimates for the 22 high burden countries and calculated the percent of disease which occurs in children for each country. The results of these estimates are shown on this slide and the next one. I have listed the 22 high burden countries in order of descending total of TB burden. Estimates of cases less than 15 years of age vary from a low of 2,317 cases in Thailand to a high of more than 185,000 cases in India. TB in children accounts for a highly variable percentage of all TB in a given country ranging from a low of 2.7% in Indonesia and Thailand to more than 20% in Afghanistan, Brazil, and Pakistan. In most Sub-Saharan countries, TB in children represented more than 15% of all TB cases. Had approximately 16% of all TB in children.
56WHO Estimated Total Cases by Age, 2000 CountryTotal CasesCases < 15 yrs% in ChildrenViet Nam143,0237,5595.3Kenya137,60322,12416.1Tanzania117,48918,890Brazil113,52823,52020.7Thailand85,9282,3172.7Myanmar78,4898,00710.2Zimbabwe76,29612,267Uganda75,25012,099Cambodia75,0453,966Afghanistan69,34217,54025.3Mozambique47,9097,703TOTAL6,856,537659,3979.6Using this method, there were nearly 7 million total TB cases worldwide in 2000 in the 22 high burden countries, of which nearly 660,000 or 9.6% occurred in children. Using total WHO estimates, there were a total of 884,011 cases in children. The 22 high burden countries accounted for 75% of all TB in children in 2000.While these estimates provide a bench mark, the large variability in the percent of childhod cases by country is surprising, and suggests some countries may significantly underreport childhood cases. These estimates are dependent on the number of smear-positive cases reported to WHO as well as a number of other assumptions which have not been tested.
57Extrapulmonary TB in Children Proportion in a given country could be used as measure of case detection25-44% of all childhood TB in Ugandan study43% of children in Ethiopian study21.3% of childhood TB using US surveillance dataSeveral researchers have suggested that the proportion of extrapulmonary TB in children could be used as a measure of case detection. Thus, countries reporting a high proportion of extrapulmonary TB may in fact be underdiagnosing cases of childhood pulmonary TB. A study of TB among hospitalized children in Uganda found that extrapulmonary TB accounted for from 25 to 44% of all TB in children from 1985 to In a study of 412 cases of both inpatient and outpatient childhood TB in Ethiopia over two years, 43% of all cases were extrapulmonary. By way of comparison, extrapulmonary TB accounted for only 21.3% of all childhood TB in the United States from 1990 to This proportion has remained stable over time in the US.
58TB and BCG VaccinationEfficacy for adult pulmonary TB 0-80% in randomized clinical trialsBest efficacy against serious childhood disease64% protection against TB meningitis78% protection effect against disseminated TBBCG important for young children, inadequate as single strategyFinally, in the next section, I would like to briefly mention a few topics of importance in understanding the epidemiology of childhood TB: BCG vaccination, TB/HIV coinfection, and drug resistance. BCG has an important, but limited role in the control of TB, particularly childhood TB. While the efficacy of BCG in preventing adult pulmonary TB has varied from 0 to 80% in randomized clinical trials, it has shown the best efficacy against serious forms of childhood disease. In a published meta-analysis of BCG efficacy, it had a 64% protective effect in preventing TB meningitis in children and a 78% protective effect in preventing disseminated TB among children. Clearly, BCG has an important role in preventing serious disease in young children. However, BCG alone is insufficient to prevent children from TB.Colditz GA et al. JAMA 1994; 271:
59Estimated TB incidence HIV prevalence adults 15- 49 years Relationship between TB and HIVWhat about children?800800600600Estimated TB incidence(per population)4004002002000.10.10.20.220.127.116.11.4HIV prevalence adults years
60History of M. tuberculosis Phthisis (Greek) known since ancient timesOften thought of as a hereditary condition1854 first sanatorium1882 Koch demonstrated relationship betweengerm and disease1895 Roentgen discovery of diagnostic x-ray1940’s-1950’s chemotherapy
61Around the World An estimated 1.58 million deaths occurred in 2005 from TB disease8.8 million new TB cases estimated for 20051/3 of world population has TB infection
63High Burden Countries (WHO) AfghanistanMyanmarBangladeshNigeriaBrazilPakistanCambodiaPhilippinesChinaRussian FederationDemocratic RepublicSouth Africaof the CongoThailandEthiopiaUgandaIndiaUnited Republic of TanzaniaIndonesiaViet NamKenyaZimbabweMozambique
65Pathogenesis Inhale droplet nuclei Bacteria multiplies Macrophages consume bacteria, then dieTravel through the bloodstream, lymph systemContainment-infectionMultiplication-disease
66Generation of TB Droplet Nuclei One cough produces 500 dropletsThe average TB patient generates 75,000droplets per day before therapyThis drops to 25 infectious droplets perday within 2 weeks of effective therapy
67Factors Affecting TB transmission Characteristics of source caseEnvironmentFactors increasing risk for contacts
71Signs/Symptoms Productive cough 3 weeks or longer Shortness of breath Chest painHemoptysisNight sweats/fever/chillsUnexplained weight lossFatigue
72Suspect TB: Chest x-ray Location of the infiltrate Presence of a cavityHollow areas, dense areas, fluid onthe lung or at marginsNormal x-ray = usually no infectiousTB disease
73Chest RadiographAbnormalities often seen in apical or posterior segments of upper lobe or superior segments of lower obeMay have unusual appearnce in HIV+ patients
74Sputum Collection Sputum specimens are essential to confirm TB Sputum: mucus from within the lung, notSaliva3 specimens on 3 different daysSpontaneous morning sputum moredesirable than induced specimens