Tuberculosis The greatest killer in the history of mankind Brig Jawad Ansari FCPS,FCCP,FRCPE Professor of Medicine & Pulmonologist

EPIDEMIOLOGY 1/3rd of world population is infected TB contribute 25% of avoidable deaths 95% cases in developing world 98% of TB deaths in developing world 75% of TB cases in productive age group Pakistan is 7th in ranking with reported cases 0f 361000 per annum and prevalence of 1810/100,000

What are these ?

Acid Fast Bacilli

What is this ?

Tubeculous Granuloma

Mycobacterium TB Complex (Tubercle bacilli) (Acid Fast bacilli:AFB) M.tuberculosis (majority) M. bovis M.africanum Can remain dormant / persist for many years Atypical Mycobacterium/ Opportunistic

Transmission of Infection Coughing patient of pulmonary TB Single cough: 3000 droplets nuclei Also spread by talking, sneezing, spitting , singing Direct sunlight kill AFB in 5 minutes Transmission is mostly indoor Risks of exposure; concentration of droplet nuclei and the time spent in contaminated air Bovine TB: cervical lymph node/ intestinal TB

Is TB transmitted by following? Food Water Sexual intercourse Blood transfusion mosquitoes

Is TB transmitted by following? Food Water Sexual intercourse Blood transfusion mosquitoes NO

Infection to disease 90% of infected individuals do not develop disease Only evidence of infection is positive tuberculin test Chances of disease are higher soon after infection Higher in infants and children Emotional and physical stress HIV infection

Natural History of TB If Untreated: then by 5 years 50%: will be dead 25%: cured by their immune system 25%: become chronic

WHO/CDS/TB/2003.313TREATMENT OF TUBERCULOSIS:GUIDELINESFOR NATIONAL PROGRAMMESTHIRD EDITION 2003

is much more common than Pulmonary TB is much more common than Extra-pulmonary TB ( 80% v 20%) Ladies and gentleman, Solitary nodules in lung field are not uncommon, but sometimes it is very hectic and tiring to find out the exact cause, which is infact very important to treat these cases effectively.

EXTRA-PULMONARY TB (WHO Categorization) Meningitis Miliary Pericarditis Peritonitis Bilateral/ Extensive pleural effusion Spinal Intestinal Genitourinary SEVERE FORMS: Cat 1

EXTRA-PULMONARY TB (WHO Categorization) Meningitis Miliary Pericarditis Peritonitis Bilateral/ Extensive pleural effusion Spinal Intestinal Genitourinary Lymph nodes Unilateral pleural effusion Bones ( excluding spine Peripheral joints Adrenal glands SEVERE FORMS: Cat 1 LESS SEVERE FORMS: Cat 3

First year MBBS Teacher to student “Be good You will be fine”

In 3rd year Must Work Hard Man

Must Work Very Hard You Know In fourth year Must Work Very Hard You Know

Can You hear me ? You must work hard In final year Can You hear me ? You must work hard

Diagnosing Tuberculosis

Diagnosis: Clinical Suspicion Cough for more than 2-3 weeks Sputum production Weight loss Night sweats Fatigue & tiredness No sign is specific

Diagnosis: Lab Tests Culturing of AFB & sensitivity Chest X-ray Detection of AFBs in sputum smears Culturing of AFB & sensitivity Chest X-ray Tuberculin Skin Test ? ESR ??? PCR

SPUTUM SAMPLING At least three isolated samples Sputum and not saliva Early morning samples preferable If no cough: Assisted cough Induced Sputum Alternate to sputum Gastric washings Bronchial washings

Slide reporting Using 1000x magnification Number of bacilli Result reported No AFB 1-9 AFB per 100 oil immersion fields Scanty 10-99 AFB per 100 oil immersion fields + 1-10 AFB per oil immersion field ++ 11-100 AFB / oil immersion field +++

Interpretation Smear positive Smear Negative Indeterminate At least 2 smears examined and both positive for AFB Smear Negative At least 02 smears reported as negative Indeterminate Only one smear examined 03 smears examined and only one reported as positive

MYCOBACTERIAL CULTURES Growing AFB on culture confirms diagnosis AFB grown can be tested for their sensitivity against various drugs Methods Lowenstein Jensen Liquid media Bactec Limitations: 6-8 weeks, skilled lab,

Tuberculin Skin Test In population with high prevalence of TB, skin test is of little diagnostic value Does not distinguish disease from infection

Positive Tuberculin Test Active TB Previous TB Previous BCG vaccination Atypical mycobacteria Sarcoidosis ( in less than 30%)

False Negative Tuberculin Test HIV infection Malnuitrition Immunosupressive drugs like steroids Severe bacterial infection Milliary TB/ Fulminant TB Viral infections like measles, chicken pox, glandular fever Cancer Incorrect injection of PPD

ESR AND TB It can not be relied upon for the diagnosis of Tuberculosis and should not be advised in routine. Not recommended by WHO and by local guidelines

Role of Raidiology There is no radiological findings which can be diagnostic of Pulmonary Tuberculosis But There are certain typical patterns, where TB can be strongly suspected

GHON’S COMPLEX PRIMARY TB

Tuberculous Pericarditis

TUBERCULOMAS

TREATMENT OF TUBERCULOSIS

Tuberculosis Pulmonary Extra-pulmonary Smear positive Smear negative Histopathology Cultures WHO/CDS/TB/2003.313TREATMENT OF TUBERCULOSIS:GUIDELINESFOR NATIONAL PROGRAMMESTHIRD EDITION 2003

(plus) c/s + M. tuberculosis Smear positive ( PTB+ ) >02 sputum smear pos 01 sputum smear pos (plus) c/s + M. tuberculosis 01 sputum smear pos (plus) radiological evidence of active TB WHO/CDS/TB/2003.313TREATMENT OF TUBERCULOSIS:GUIDELINESFOR NATIONAL PROGRAMMESTHIRD EDITION 2003

WHO/CDS/TB/2003.313TREATMENT OF TUBERCULOSIS:GUIDELINESFOR NATIONAL PROGRAMMESTHIRD EDITION 2003

DRUG SENSITIVE TB Tuberculosis where AFBs are sensitive to first line anti-tuberculosis drugs

FIRST LINE DRUGS RIFAMPICIN (R) ISONIAZID (H) ETHAMBUTOL (E) PYRIZINAMIDE (Z) VERY POTENT LESS SIDE EFFECTS ECONOMICAL SHORT DURATION (6-8 months)

DIRECTLY D O T S OBSERVED TREATMENT SHORT- COURSE

Treatment after default TB case Previous ATT NO YES New case Re-treatment case Rarely sputum smear negative never taken ATT or ATT < 1 month relapse Completed ATT Treatment after default Incomplete ATT Treatment failure Not responded to standard regimen chronic after re-treatment regimen WHO/CDS/TB/2003.313 Treatment Of Tuberculosis:guidelinesfor National Programmesthird Edition 2003

New Cases (PTB +/- and Extra PTB) 04 Drugs-02months 2 HRZE Initial phase Check sputum smear Smear - Smear + Repeat initial phase-01month 1 HRZE Smear - 02 Drugs-06months 6 HE 02Drugs-05months 5 HE Continuation phase 4HR 4HRE Guidelines for Diagnosis & Management of Tuberculosis. Pakistan Chest Society. March 2002.

Re-treatment cases (Relapse, Failures, Default: Smear positive) 2 HRZES / 1 HRZE Initial phase Check sputum smear Smear - Smear + 1HRZE If smear+, send c/s 5 HRE 4 HRE Continuation phase Still smear positive Chronic case MDR-TB ? Guidelines for Diagnosis & Management of Tuberculosis. Pakistan Chest Society. March 2002.