2 Learning Objectives List the 4 principle components of a TB evaluation Describe the criteria which differentiate PTB+ from PTB-Describe the 3 major indications for culture and DST
3 Common Sites of TB Disease LungsPleuraCentral nervous systemLymphatic systemGenitourinary systemsBones and jointsDisseminated (miliary TB)
4 Systemic Symptoms of TB FeverChillsNight sweatsAppetite lossWeight lossFatigue
5 Evaluation for TB HIV test Medical history Physical examination Bacteriologic or histologic exam(Chest radiograph if indicated)
6 Medical History HIV status Symptoms of disease History of TB exposure, infection, or diseasePast TB treatmentDemographic risk factors for TBOther medical conditions that increase risk for TBdisease (e.g., diabetes)
7 Symptoms of Pulmonary TB Productive, prolonged cough(duration of 2-3 weeks)Chest painHemoptysis (bloody sputum)Signs may vary based on HIV status
8 Specimen Collection Procedure Obtain 3 sputum specimens for smear examinationand cultureSpot, first morning, spotFollow infection control precautions duringspecimen collection
9 Sputum Smear Examination Specimens should be sent to the lab immediately to preserve the quality of the specimensAlways aim for three specimens at each examAlways store at a cool temperature and away from sunlight to preserve the quality of specimens3 respiratory specimens will detect 90% of smear-positive cases
10 AFB smear-microscopyAcid-fast bacilli (AFB) (shown in red) are tubercle bacilli
12 Smear-positive PTB vs. Smear-negative PTB- PTB+ (Pulmonary TB smear-positive)One AFB-positive smear; i.e. any patient with at least one positive smear result (irrespective of quantity of AFBs seen on microscopy)Recommendations to improve the diagnosis of smear negative pulmonary and extrapulmonary TB among adults in HIV prevalent and resource constrained settings.Draft for discussion by Strategic and Technical Advisory Group of Stop TB Department of WHOJune 2006
13 Smear-positive PTB vs. Smear-negative PTB- PTB- (smear-negative)Any pulmonary TB case that does not meet the definition of being smear-positive. This includes:1. Patients with three negative smear results and radiological findings and doctor’s decision to treat for TB2. Patients with negative smear results and a positive culture result for M. tuberculosis3. Patients who are unable to produce sputum and with highly suspicious radiological and clinical findings and doctor's decision to treat for TB
14 Other Acid Fast Bacilli Mycobacteria other than those comprising the M. tuberculosis complex are called Non-Tuberculous Mycobacteria (“NTM”) or Mycobacteria Other Than Tuberculosis (“MOTT”).These mycobacteria may cause pulmonary disease resembling TB. Increasingly, cases from these organisms are being reported in patients with weakened immune systems, especially due to HIV.It is important to note that infection with MOTT also may produce AFB-positive sputum smear results and positive Mantoux skin test readings mimicking M. tuberculosis. Culture can distinguish between M. tuberculosis and MOTT. Disease due to MOTT is usually unresponsive to first-line anti-TB drugs.
15 Chest RadiographDiagnosis of PTB solely on basis of CXR not encouragedMay have unusual appearance inHIV-positive personsCXR is helpful in HIV+, smear- negative patientsCannot confirm diagnosis of TBFROM WHO__ (Is this consistent with Manual) ? Although chest radiographic abnormalities are common in HIV-infected persons without TB, chest x-ray plays an important role in the diagnosis of TB among PLWHA. CXR presentations of TB in HIV patients are now well characterised and should no longer be considered ‘atypical’ for TB in HIV-prevalent settings. CXR plays a significant role in shortening the delay of diagnosis and should be done early in the course of investigation of a TB suspect. CXR can also be an important entry point to diagnosing non-TB chest diseases, which are common among PLWHA. However, the limitations that exist for its wider use such as unavailability at peripheral health facilities and difficulty of interpreting results, even by trained physicians need to be acknowledged and dealt with accordingly. Research is needed to identify innovative ways to enhance the ability of clinicians, including non-physicians, to interpret CXRs accurately, to assess the feasibility and added value of peer reviewing of CXRs and to evaluate novel imaging techniques that might replace conventional radiography.Arrow points to cavity inpatient's right upper lobe.
16 Cultures Should be requested for ALL retreatment patients RelapseFailureReturn after defaultCulture is indicated forNew and retreatment PTB cases still smear- positive at end of intensive phaseSymptomatic contacts of known MDR casesColonies of M. tuberculosisgrowing on media
17 Diagnosis in Children HIV test Patient history Contact to PTB+ Symptoms consistent with TBHIV testClinical ExamTSTBacteriological confirmationInvestigations for PTB and EPTBGuidance of National Tb Programmes for the Management of TB in Children WHO/HTM/TB/
18 Key Risk Factors in Children Risk Factors For Children Include:Household contact with a newly diagnosed smear-positive caseAge less than 5 yearsHIV infectionSevere malnutrition.
19 Key Features of TB in Children The presence of three or more of the following should strongly suggest a diagnosis of TB:Chronic symptoms suggestive of TBPhysical signs highly of suggestive of TBA positive tuberculin skin testChest X-ray suggestive of TB(The presentation in infants may be more acute, resembling acute severe pneumonia and should be suspected when there is a poor response to antibiotics. In such situations, there is often an identifiable source case, usually the mother.)