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Mycobacterial Infection :

Marshel Tendean, MD
Department of Internal Medicine UKRIDA
Jakarta
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Outline :
■ Epidemiology of Tuberculosis infection

■ Etiology & Pathogenesis

■ Classification of Tuberculosis :
■ Case definition Tuberculosis
■ Class classification
■ WHO classification

■ Diagnostics

■ Tuberculosis treatment :
■ Pulmonary Tuberculosis
■ Extrapulmonary Tuberculosis
■ MDR treatment

■ ISCTH recommendation
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Introduction

■ A spesific pulmonary infection caused by fast acid bacteria

Mycobacterium tuberculosis complex

■ Multiorgan system usually affects the lungs, although other

organs are involved in up to one-third of cases. If properly
treated, TB caused by drug-susceptible strains is curable in
virtually all cases
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AFB Smears of Mycobacterial Sp.
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Course of disease

Exposure
Bronchogeni
c
Contact Clinical
Droplet nuclei Tuberculosis
3000/ cough
Hematogenous

Skin, Gi tract, Plasenta

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Definition :

■ Tb suspect: patients with objective symptoms spesific for TB

■ TB confirmed by bacteriologi examination

■ TB diagnosed by clinical examination :

■ Negative smear TB
■ Extrapulmonary TB
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Tuberculosis Incidence
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Tuberculosis Mortality Rate
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Classifications

■ Tuberculosis with bacterial confirmation:

■ Anatomic location (pulmonary, non pulmonary)
■ Past medical history :
■ Naïve case
■ Patient with prior medication :
■ Relapse
■ Failure of treatment
■ After default (1 month exposure and 2 month loss) / lose to follow up
■ Other (Undocumented treatment history)
■ Transferred patients
■ Undetermined treatment history
■ Bacteriologic and drug resistency :
■ Diagnostif for minimal 1 smear or 2 smears
■ HIV status
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Pathogenesis :

■ Primary tuberculosis :
■ Hallmark by the presence of initial infection (the Ghon focus) is
usually peripheral and accompanied by transient hilar or
paratracheal lymphadenopathy (Ghon Complex)

■ Secondary tuberculosis :
■ Mainly adult form
■ Caused by endogenous activation of previous or latent infection
■ Affected apical and posteriot lobe
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Sign and Symptoms :

■ Mainly insidious nonspesific sign of fever, night sweat, weight

loss, general malaise, anoreksia and weakness.

■ Most common symptoms cough (90%), with productive, some

have blood streaking.

■ Hemoptysis (mild or masive) in 20% patients caused by

ruptured of rasmussen aneurysm later on complicated as
aspergiloma
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Severity :
■ Cavitary

■ Smear +

■ Extrapumonary

The most infectious patients have cavitary

pulmonary disease or, much less
commonly, laryngeal TB and produce
sputum containing as many as 105 - 107
AFB/mL
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Diagnosis :

■ Proven diagnosis is established by a minimum of 1 positive

smear or hystology of TB or spesific symptoms and radiologic
findings of tuberculosis

Patients with consideraton of Tuberculosis should be examined by minimum of

2 AFB smear (1 morning smear) or Patients with Xray suspected tuberculosis
I also determenied for AFB smear
Standart 2 and 4 International Standart for Tuberculosis care
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Other TEST :

■ IGRA (Gama Interferon)

■ Tuberculin test

■ Fast TB determination kit

■ Gene Xpert
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Treatment :

■ Goals :
■ Tuberculosis care and maintain quality of live
■ Prevent death due to active tuberculosis
■ Limit transmission

■ DOTS (Directly Observed Treatment Short Course) approach.

■ ISTC(International Standarts for Diagnosis Care) standart.

All Patients diagnosed as naïve Tuberculosis should be treated

with standart regiment for tuberculosis consist of initial phase 2
months and 4 months extended phase INH and rifampisin or
with fixed dose combination
Standart 8 International Standart for Tuberculosis care
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Tuberculosis Treatment :
Category I. 2RHZE / 4 RH
Category II. Will be depend with the facility to determine drug
resistency
If no facility for rapid detection available, start empiric treatment
and followed by culture result 2 RHZES / RHZE / 5 RHE
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Anti Tuberculosis Side Effects and
Handling
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Recommended Tuberculosis Drug
Regimen
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Novel Tuberculosis Drug

Curr Opin Pulm Med 16:186–193

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Pre-emtive Tuberculosis Treatment

■ Indicated in patients with promontent symptoms for

tuberculosis

■ Patients with urgent condition warrant tuberculosis treatment

TB menignitis, Miliary TB, Tb in HIV

Patients with productive unexplained etiology should be

screened for pulmonary Tuberculosis.
Standart 1 International Standart for Tuberculosis care
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Treatment monitoring :

■ Should be done within 2 months category 1 and 3 months

category 2

■ Same directions for smear negative TB

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DOTS
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Negative smear Tuberculosis :

1. Smear negative but positive culture for M. Tuberculosis

2. Fulfill one of the following criteria :

■ Clinical decision to treat tuberculosis
■ Radiolgic finding compatible with active tuberculosis AND
■ Strong indentification from laboratory examintion or clinical
manifestation. OR
■ If (-) HIV, unresposive to broad spectrum antibiotics.

■ However undetermined AFB smear not categorized as

negative smear, but not
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Tuberculosis due to HIV status:

■ Tuberculosis coinfected with HIV: patients is proven positive

for HIV serologic test or HIV registry and initiated with ARV

■ Tuberculosis with negative HIV

■ Tuberculosis with undetermined HIC

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Tuberculosis in special population :
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■ Negative smear TB are more common

■ Other determination from Gene X-pert, urine LAM, Culture (better

sensitivity)

■ Should be treated with anti – tuberculosis prior of giving ARV to

prevent IRIS
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■ Latent TB :
■ Could be diagnosed with tuberculine tesst
■ Not always amenable for treatment
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Tb in Pregnancy:

■ Anti-tuberculosis
is given during pregnancy
and breastfeeding
■ Patients
given rifampicin had risk for
hypoprotrombinemia and should be given vit K
1 x 10 mg
■ Offspring should also initiated with INH
profilaxis dose for 6 month continued with
Vaccination
■ Strepromycin and fluoloquinolone are
contraindicated for pregnancy
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Drug Induced Hepatitis :

■ Determined by elevation level of bilirubin and ALT

■ IF Bilirubin >2 Stop antituberculosis

■ If ALT > 5 UNN stop antituberculosis

■ IF ALT > 3 close monitoring

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Tb With Liver Probem

■ Mostof drug are considered hepatotoxic except

streptomycin and etambutol
■ Ifinitial ALT > 3X UNL, this protocol should be
considered:
■ Two hepatotoxic drug :
■ 9 months INF + RIF + ETB
■ 2 months INH + RIF + ETB + Strep + 6 Months INH +
RIF
■ One hepatotoxic drug :
■ 2 months INH + ETB + Strep + 6 Months
■ Without hepatotoxic drug :
■ 18-24 months of streptomysin, ETB, quinolone
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Extrapulmonary Tuberculosis:

■ Lymph node

■ Pleura

■ Bones and joints

■ Meninges

■ Peritoneum

■ Pericardium
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■ Lymph node :
■ The most common extrapulmonary manifestation in HIV
seropositive and seronegative (35%).
■ Commonly in supraclavicula and posterior cervical sites
(scrofula).
■ Could be discrete, matted or fistulous.

■ Pleura :
■ Occurs in 20%, manifested as pleural effusion 1 side
■ Diagnosed by exudatiyve and (+) AFB smear (25%), Culture in
(75% cases)
■ Diagnostic value increase by ADA with cut off 40 u/ml
■ Y-Ifn, lysozime may helpful, diagnosis proven by (+) granuloma or
AFB at pleural biopsy.
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■ Genitourinary tuberculosis :
■ Difficult to determine (unspesific symptoms and findings)
■ Deffinite diagnosis by :
■ Microscopic
■ Culture
■ Tissue biopsy
■ PCR
■ Spesific radiologic findings
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■ Miliary
: Tuberculosis
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Treatment of Extrapulmonary
Tuberculosis

■ Same
treatment protocol but with
longer treatment period
■ Meningitis (12 months)
■ Pericarditis, Pleural (6-9 months)
■ Bone and Joint TB (9-12 months)
■ Intestinal, lymph node (6 months)
■ Miliary(standart treatment
protocols)
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Tuberculosis requiring
steroid :
■ Pericarditis tuberculosis
■ Meningitis tuberculosis
■ Miliary tuberculosis

The recommended adult steroid (prednisone) dosage is 1 mg/kg/da

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MDR (Multi Drug Resistance)

■ PDR

■ MDR

■ XDR

■ TDR

■ Treatment are considered with 2nd line treatment and

comprise as culture results.
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Tuberculosis MDR
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Thank You Very Much For Your Kind
Attention