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Tuberculosis
Reviewed by Dr Gavin Petrie, consultant respiratory physician

What is tuberculosis?
Tuberculosis is a disease caused by an infection with the bacteria Mycobacterium tuberculosis. During the 19th century, up to 25 per cent of deaths in Europe were caused by this disease. The death toll began to fall as living standards improved at the start of the 20th c entury, and from the 1940s, effective medicines were developed. However, there are now more people in the world with TB than there were in 1950, and 3 million individuals will die this year from this disease - mainly in less developed countries. The disease is more common in areas of the world where poverty, malnutrition, poor general health and social disruption are present. In the UK, too, the number of TB cases is again rising. Alcoholics, HIV-positive individuals, some recent immigrants and healthcare workers are at increased risk. The disease is most commonly found in places such as hostels for the homeless, prisons, and centres for immigrants arriving from areas with high rates of HIV infection or inadequate health provision.

What parts of the body are affected by tuberculosis?

First and foremost, tuberculosis is a disease of the lungs. However, the infection can spread via blood from the lungs to all organs in the body. This means that you can develop tuberculosis in the pleura (the covering of the lungs), in the bones, the urinary tract and sexual organs, the intestines and even in the skin.

Lymph nodes in the lung root and on the throat can also get infected. Tuberculous meningitis is sometimes seen in newly infected children. This form of the disease is a life-threatening condition.

How do you catch tuberculosis?

The bacteria that cause the disease are inhaled in the form of microscopic droplets that come from a person with tuberculosis. When coughing, speaking or sneezing, the small droplets are expelled into the air. They dry out quickly, but the bacteria itself can remain airborne for hours. However, the tuberculosis bacteria are killed when exposed to ultraviolet light, including sunlight.

How does the disease develop inside the body?

After the tuberculosis bacteria have been inhaled they reach the lungs and, within approximately six weeks, a small infection appears that rarely gives any symptoms. This is called a primary infection. After this, the bacteria can then spread through the blood. If you have a healthy immune system, in most cases the infection will remain dormant without doing any obvious harm. Months or even years later, however, the disease can become reactivated in different organs if the immune system is weakened. The lungs are the favourite place for the illness to strike.

What are the symptoms?

Typical signs of tuberculosis are:
y chronic or persistent cough and sputum production. If the disease is at an advanced stage the sputum will contain blood. y fatigue. y lack of appetite. y weight loss. y fever. y night sweats.

Tuberculosis can mimic many forms of disease and must always be considered if no firm diagnosis has been made. Other non-tuberculous mycobacteria found in soil and water can cause disease in susceptible patients with a history of cystic fibrosis, chronic lung damage, alcoholism and immunosuppression (suppression of immune responses by a disease or drugs). These atypical mycobacteria can be present as colonising organisms without necessarily causing disease.

When should I see a doctor?

If you have a persistent cough with sputum for more than three weeks, you should contact your doctor.

How does the doctor make the diagnosis?

The doctor cannot always hear enough to make a diagnosis by just using a stethoscope. If your physician suspects there is something wrong and that it is not just a cold, you may be referred to an outpatient department for people with lung diseases or to an X-ray department.

The chest X-ray examination is the most important test. If there are changes in the lungs, a sample of sputum will be sent for microscopic examination and culture. Culture of tuberculosis bacteria will take 4 to 12 weeks. For this reason, it takes some time before an accurate diagnosis is possible. Quicker methods using DNA techniques are under development, and a skin reaction Mantoux Test can sometimes be a great help. In this test, Tuberculin, which is a substance extracted from the tubercle bacteria, is injected into the skin. If the skin shows a strong reaction after 72 hours, it means there is hypersensitivity to tuberculin protein acquired either by a previous BCG vaccination, or possibly due to an active infection.

Are there other diseases with similar symptoms?

Bronchitis, pneumonia, smoker's lung and lung cancer can all show practically the same symptoms as tuberculosis. If tuberculosis is suspected, tests will need to be done to rule out the presence of these other diseases. Examination of sputum will usually include a check for cancer if the chest X-ray raises any suspicion of this type of diagnosis.

Where can I get a vaccination against tuberculosis?

In the UK, BCG vaccination (with live but weakened tubercle bacteria) is no longer routinely given to all children of secondary school age. The highest rates of the disease occur in particular risk groups and it now makes more sense to target BCG vaccination for people who are at greatest risk of the disease. The vaccine is now recommended for:
y infants under one year of age living in areas where the incidence of TB is 40 cases per 100,000 people or higher y infants under one year of age whose parents or grandparents were born in a country with an incidence of TB of 40 cases per 100,000 people or higher y children with risk factors for TB who have not previously been vaccinated y new immigrants from countries with a high incidence of TB who have not already been vaccinated y contacts of people diagnosed with TB affecting the lungs y health care workers, veterinary staff, staff working in prisons, residential homes, shelters for the homeless or hostels for refugees y people intending to live, travel or work in countries with a high incidence of TB for more than a month.

Vaccination greatly reduces the likelihood of subsequent pulmonary TB and effectively prevents varieties of blood-borne tuberculosis such as miliary TB or tuberculosis meningitis, which can be difficult to diagnose in time and can cause devastating damage.

How is tuberculosis treated?

Today, treatment involves three or four different kinds of antibiotics given in combination over six to nine months. Multiple medicines are necessary to prevent the emergence of resistance, which would lead to treatment failure and the nightmare of multiple drug-resistant organisms. Single medicines must never be added to a failing treatment regime. Therapy should be directed by a chest physician who will have specialist knowledge of the complications and side effects of TB

medicines. Attention to the details of treatment are vital. The main cause of treatment failure is non -compliance with what is perceived as a demanding and prolonged programme of therapy. Those patients who are microscopy or smear positive are infectious and, if possible, should avoid contact with other people for two weeks. Patients do not require hospital admission in order to start treatment. Other patients with a lower bacterial load are smear negative but culture positive on testing. These patients are not as infectious but should still have therapy along conventional lines. Chemoprophylaxis with a single medicine, isoniazid, may be given for 6 to 12 months with the aim of preventing future disease in individuals who show no evidence of disease, but have a strongly positive tuberculin skin test and no evidence of previous BCG vaccine to explain the positive sk in test. Pregnant women with TB must be treated urgently as the disease may progress rapidly with high risk to both mother and baby.

Is it possible to become resistant to the medicine?

Yes, if medication is not taken every day or as prescribed by the doctor. In some parts of the world there are problems with resistance to medication and even multi drug resistance. This is a very serious situation, which has been experienced on a large scale in the Baltic States, many East European countries, certain American cities and in areas of the developing world. Treating these patients can be a long and expensive task. If there are problems with patients not taking their medicines, it may be necessary to arrange supervision either in a hospital or at home with a nurse. This programme is known as DOTS (Direct Observed Therapy Short course) and is recommended by the World Health Organisation (WHO).

How can treatment be controlled?

An undetected infectious TB victim will, on average, infect another 10 cases in a year, each of whom could transmit the disease in turn. According to the WHO and the international tuberculosis union IUATLD, all countries should have a national tuberculosis programme and authorities should also be notified about patients who have been diagnosed with TB. The treatment itself is prescribed under the supervision of chest clinics where they make sure that the patient has correctly taken a curative course of treatment. Negative culture from sputum in 6 to 12 months from the moment of the diagnosis i dicates a cure. n The clinics make sure that the environment in which the patient lives is also carefully examined. All family members will be required to undergo chest X-rays. Sometimes, the patient's workplace will also be examined.

What are the world's highest-risk regions?

Infection is possible anywhere, but tuberculosis is especially prevalent in sub-Saharan Africa and in Southeast Asia. The disease is more common in Eastern Europe than Western Europe, and Scandinavia has the lowest number of cases in the world.

Is HIV/AIDS associated with tuberculosis?

Yes. In certain African countries and many parts of Southeast Asia, HIV is becoming more and more endemic. Where tuberculosis is also endemic among the population, a weakened immune system will increase the risk of getting tuberculosis. This is an extremely worrying situation and the WHO and the IUATLD are doing all they can to prevent the disease from spreading.

Can tuberculosis be prevented?

Yes. The most important step is to find, isolate and treat all disease carriers until they are no longer an infective risk to others. It is always advisable not to get too close to people who are coughing; equally, people with a cough should be aware of those around them and try not to cough near them.

Good advice
If you travel in countries where tuberculosis is a problem, get vaccinated and avoid socialising with people who have a persistent cough. Make sure that you eat well and enjoy plenty of sunlight and exercise. Seek medical attention if you develop a cough that persists for more than three weeks. Based on a text by Dr Gunnar Pallisgaard, consultant Last updated 21.09.2005

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