Welcome

Brig Gen Md. Nazim Uddin MBBS, FCPS, MD Adviser Spl in Medicine & Chest Diseases

History
Its a disease of great antiquity. Found in the vertebra of Neolithic man in

Europe and on Egyptian mummies from as early as 3700 BC.

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Tubercle Bacillus
It is a acid-fast, alcohol-fast, aerobic or

microaerophilic, non-spore-forming, non-motile bacilli. Only M. Tuberculosis, M. Bovis and M. Africanum are recognized as Tubercle Bacilli. Optimal temperature for growth is 33-39 degree Celsius at pH 6.5-6.8 in an atmosphere of 510% CO2.

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Transmission
Transmitted by the airborne route. The unit of infection is a small particle
called a droplet nucleus.

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Epidemiology
Most common infectious disease in the
world. One third of the world population is infected. 2.5 million death annually. The incidence of the disease has been increasing both in developed and developing countries.
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Pathology
Deposition of Tubercle Bacilli in the alveoli
of the lungs is followed by vasodilatation and influx of polymorphonuclear leucocytes and macrophage. Macrophages crowed together as epitheloid cells to form the tubercle.

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Pathology (contd..)
Some mononuclear cells fuse to form the
multinucleated or Langerhans giant cells. Lymphocytes surround the outer margin of the tubercle. In the centre of the lesion a zone of caseous necrosis may appear that may subsequently calcify.
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Tuberculin test:
Mantoux test: 1. Intradermal inj of .1 ml of 5 TU PPD on
the volar surface of forearm. 2. Test is read after 48-72 hours. 3. Positive: > 10 mm.

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Tuberculin test:
Heaf test:

1. Done with a gun which has 6 needle. 2. The needle puncture the skin through a thin film of PPD 3. Test is read after 3-7 days. 4. Grade: 1-4 5. Gr. 3 and 4: past or present infection.

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False negative tuberculin test

patient related factor Tuberculin related factor Method of administration factor Reading and recording factor

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BCG vaccination
Bovine strain of M. tuberculosis. 230 passage through media. Freeze-dried vaccine can be stored for

longer period. In developing countries the vaccine should be given to neonates or as early as possible to children.
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Chemoprophylaxis
Administration of chemotherapy to prevent

tuberculosis. A. Primary: usually not given. B. secondary: 1. Close contact of newly diagnosed patient. 2. Positive tuberculin test reactors with an abnormal but inactive X-ray. 3. Positive tuberculin test reactor with special clinical situations. Drug: INH-300 mg/day for 01 year.
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Congenital tuberculosis
Very rare. Three possible modes of transmission:

Haematogenous, aspiration, inhalation. C/F: wide spread disease i.e. respiratory distress, fever, hepatosplenomegaly, jaundice etc. Treatment: 3 drugs. Steroid may be added.
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Primary pulmonary tuberculosis

The first infection with tubercle bacilli . It includes: pulmonary focus plus

involvement of draining lymph node. Primary complex. C/F: may be asymptomatic. Few may be symptomatic i. e. fever, cough, failure to gain wt, wheeze or features of collapse.
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Diagnosis:
X-ray chest Tuberculin test Gastric washing and sputum for AFB and AFB

C/S. Complications: Collapse/ consolidation, bronchiectasis, obstructive emphysema, broncholith, erythema nodosum, phlyctenular conjuntivits, pleural effusion etc.
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Miliary tuberculosis
Produced by acute dissemination of
tubercle bacilli by blood stream. Seeding of bacilli in the vessel wall cause caseous vasculitis with subsequent discharge of bacilli in the blood stream.

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pathology
The millet seed sized lesions consists of
epithelioid cells, Langhans giant cells with or with out central caseation. AFB may be present.

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Clinical features:
Acute or classical miliary tuberculosis:
common in children. May have anorexia, nausea, vomiting, fever, cough, dyspnoea, haemotysis etc. Clinically: creps, HSM, neck rigidity, choroidal tubercle etc.

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Cryptic miliary tuberculosis

Common in elderly. Difficult to diagnose. Onset is with malaise,anorexia, weight

loss, fever. Variety of blood dyscrasias may be seen.

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diagnosis
Radiology Gastric lavage, sputum, transtracheal

aspirate, FOB with washing for AFB and AFB C/S. BM, spleen and liver biopsy. Blood: TC, DC, ESR. Tuberculin test.
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Complications
ARDS Immune complex nephritis.

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Post primary pulmonary tuberculosis

Most common type of pulmonary
tuberculosis. Pathogenesis- arise in one of the three ways:1.direct progression of primary lesion. 2. reactivation 3. reinfection.

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Risk factors
Nutrition Homelessness Occupation Alcoholism HIV infection Immunosuppressive drugs Immunosuppressive diseases
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Clinical features

Disease of middle aged and elderly Symptom free - discovered on routine CXR. Persistent cough with or without sputum. General malaise. Recurrent colds Pneumonia. Haemoptysis.

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Signs
No physical signs. Fever, wt loss. Post tussive creps. Signs of consolidation. Evidence of fibrosis. Evidence cavity
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Investigations

CXR Sputum Gastric aspirate Laryngeal swab FOB Transtracheal aspirate FNAC Mediastinoscopy.
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Newer diagnostic technique

TB serology PCR

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D/D
Pneumonia Ca lung Lung abscess Pulmonary infarction

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Complications

Empyema TB laryngitis Tuberculosis of other organs COPD Cor pulmonale Amyloidosis Aspergiloma ARDS
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Complications (contd..)
Pulmonary tuberculoma Poncets disease

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Treatment
Before 1950s mainstay of Rx was: bed
rest, open air and sunshine. Surgical resection and collapse therapy were also practiced. Presently short course chemotherapy is the mainstay of Rx. Short course combination chemotherapy is usually given for 6 months.
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First line drugs

Rifampicin. INH. PZA. Ethambutol. Streptomycin.

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Second line drugs

Thiacetazone. PAS. Ethionamide, prothionamide, cycloserine Kanamycin, capreomycin, viomycin.

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Newer drugs
Quinolons:
1. Ciproflxacin 2. Ofloxacin

Rifabutin Macrolides.

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Chemo regimens for PTB

Stadard short course chemo:
1. Rifampicin plus INH- 06months. 2. PZA plus ethambutol/streptomycin- 02 months.

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Thrice weekly regimen

Rifampicin, INH, PZA plus EMB/ SM daily
for 02 months followed by Rifampicin and INH thrice/week.

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Rx of MDR TB
At least 03 drugs to which the organisms
aresensitive. The drugs should be continued for 6-12 months after sputum become culture negative.

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Thank You