1. Tuberculosis Dr.M.Karimi

4. Etiology Mycobacterium tuberculosis Aerobic Slow-Growing(24-36 hr. Doubling time) Complex cell wall Acid fast Resistant to drying

5. Epidemiology 3 Million deaths per year Reservoirs: Poor, Aids, Homeless, Immigrants, Elderly Incubation period: 2-6 W Transmission: Inhalation

6. Estimated prevalence of HIV infection in TB cases, 2003

7. Pathogenesis Inhalation Deposition in the distal airways Ingestion by alveolar macrophages Intracellular replication Migration of infected macrophages to hilar lymph nodes Delayed-type hypersensitivity Dissemination

9. Pathology Granulomas consisting of: Epithelioid cells, Langerhans giant cells,Lymphocytes

10. Why reactivation Diminish CD4+ T-Cell (helper) function: HIV Infection Age less than 3 year Immunosuppressive therapy Genetic factor Malnutrition Puberty Pregnancy

11. Primary pulmonary tuberculosis Usually asymptomatic +PPD C×R: Hilar adenopathy Malaise Low grade fever Erythema nodosum

12. Interpreting the Mantoux tuberculin skin test

13. Progressive primary disease Primary pneumonia Bronchi compression by adenopathy Hoarseness Diaphragmatic paralysis Superior vena cava syndrome Pleural effusion

14. Reactivation pulmonary tuberculosis Common in adolescents Apical segments of upper lobes or superior segments of lower lobes Little lymphadenopathy No extrathoracic infection Cavitation Fever, Night sweets, Malaise, weight loss Productive cough, Hemoptysis

15. Erythema induratum on the back of the leg

16. tuberculosis of the left knee Loss of cartilage with obliteration of the left joint space and marked loss of bone density adjacent to the joint.

17. Warty" tuberculosis (verrucosa cutis) below the knee of a child who also had pulmonary tuberculosis

19. Lobar pneumonia with bowing of the horizontal fissure in a child with tuberculosis. Many of this child's initial symptoms improved after several days of cefuroxime therapy, implying that a secondary bacterial pneumonia may have been present.

20. A posteroanterior (A) and lateral (B) chest radiograph of a child with hilar adenopathy caused by Mycobacterium tuberculosis

21. Massive tuberculous pleural effusion in an 8-year-old girl

22. Pleural tuberculosis in a 16 yr old girl

23. TB pericarditis : Fluid with lymphocytic infiltration Constrictive pericarditis TB in HIV- infected patients: More diffuse infiltrates

24. Lymphadenopathy Common in Primary pulmonary TB Cervical, Supraclavicular, Submandibular Insidious Unilateral Non tender & firm Suppuration&sinus formation Compression symptoms Fine needle aspiration Excisional biopsy

26. Miliary TB Widespread hematogenous dissemination with infection of multiple organs Fever, weakness, malaise, anorexia, weight loss, lymphadenopathy, night sweat, hepatosplenomegaly Diffuse bilateral pneumonitis Meningitis Anemia, monocytosis,thrombocytopenia, hyponatremia, hypokalemia, Abnormal LFT

27. Dense pericardial calcification demonstrated on (A,B) chest radiograph (arrows) and (C) CT. There are bilateral pleural effusions in this patient with constrictive calcific pericarditis due to previous tuberculosis

28. Miliary TB C×R: Bilateral miliary infiltrates PPD: Anergy Bone marrow or liver biopsy may be diagnostic

29. TB Meningitis Age: < 5 y/o Low grade fever Headache Personality change Kernig&Brudzinski signs Cranial nerve palsy Seizure Increase ICP Coma CNS Tuberculoma

30. TB Meningitis CT-Scan: Hydrocephalus, edema, infarctions periventricular lucencies CSF: Increased cell number (50-500 WBC/µL) ( PMN or Lymphocyte) Low glucose & High protein

31. TB Meningitis CSF Fluorescent staining: Mostly negative CSF Routine staining: Mostly negative CSF Culture: Gold standard CSF PCR: Widely available and useful PPD: Anergy

32. TB Meningitis Treatment: Four Anti TB drugs + Steroids

33. Skeletal TB Hematogenous or direct extension Insidious onset and chronic disease Bone X-ray: Cortical destruction Biopsy & Culture Spine (Pott disease) Hip Fingers

34. Abdominal TB Sputum or contaminated milk Dysphagia Pain Signs of obstruction Perforation Hemorrhage Fistula formation Colitis

35. TB Peritonitis Fever, Anorexia, Abdominal pain, Peritoneal fluid Urogenital TB Dysuria, Frequency, Urgency, Hematuria, Sterile pyuria

36. Diagnosis Mantoux test: Intradermal 5 TU PPD-S Culture: Fluid, Tissue, Sputum & Gastric material PCR

37. Tuberculosis of Skin

38. Treatment Hospitalization Infants &children with active TB Children & adolescent with cavitary TB Screening for HIV Corticosteroids Anti TB

39. Treatment Latent infection (+PPD Without active disease) INH sensitive → INH 9 mo. QD INH resistant → Rifampin 4 mo.

40. Treatment Pulmonary &Cervical lymphadenopathy 2 mo INH +Rifampin+Pyrizinamide QD 4 mo INH +Rifampin QD OR 2 mo INH +Rifampin+Pyrizinamide QD 4mo INH +Rifampin Twice week

41. Treatment Extrapulmonary (Meningitis,Miliary,Bone or joint) 2 mo INH + Rifampin+Pyrizinamide+streptomycin QD 7-10 mo INH +Rifampin QD

42. False negative PPD 1. Early in the illness 2. Inactivated antigen: poor storage, inadequate administration 3. Immunosupression: (AIDS, Malnutrition, Overwhelming TB, Illness)

43. 1-Infants born to mothers with newly diagnosed latent infection (+PPD without pulmonary TB): PPD 4-6 W and 3-4 mo. 2-Infants exposed to family members with active disease: If PPD and CXR negative treat latent TB with INH and repeat PPD and if PPD was negative discontinue INH after 3-4 mo. 3-Infants exposed with known INH resistant TB: Prophylactically treated with rifampin+ pyrazinamide

44. A 5-year-old boy, was brought to the emergency room complaining of fatigue, weight loss, and cough with purulent sputum. Fever had been noted for one week. The patient had a history of Staphylococcus aureus pneumonia, with a pyopneumothorax complication 7 months earlier. The child's immunization record was complete, including Bacillus Calmette-Guérin for tuberculosis (BCG). Upon admission the child had pallid skin, dehydration, dyspnea, and fever (38º C). Examination of the respiratory system revealed reduced breathing sounds with crackles in both lungs. Abdominal examination showed no organomegaly. There was a purulent secretion in the child's right ear. Bulging of the tympanic membranes was noted.

45. Chest X-ray revealed Lobar consolidation, perihilar infiltrate, and miliary pattern associated with small cavities in both upper lobes Three months later, the patient presented a complete clinical recovery. Chest x-ray showed a residual emphysematous pattern