Tuberculosis

Singcol, Bienvenido
Solomon, Elyssa
Songco, Bryan
• An airborne, infectious disease caused by the
bacillus - Mycobacterium tuberculosis
(MTB) and occasionally by Mycobacterium
bovis and Mycobacterium africanum.
(NATIONAL PROGRAMME FOR TUBERCULOSIS CONTROL AND CHEST DISEASES, 2016)

• Commonly affects the lungs (85%), but can

affect any other organ in the body except
nails and hair.
• Fatal within 5 years in 50–65% if left
untreated
– 1/3 died within 1 year after diagnosis
– sputum smear–positive - 65%
 In 2017, 10 million people
Tuberculosis (TB) is fell ill with TB, and 1.6
one of the top 10 million died from the
causes of death disease (including 0.3
worldwide. million among people
with HIV).
Epidemiology
(Worldwide)
In 2017, an estimated 1
million children became ill
TB is a leading killer of
with TB and 230, 000
HIV-positive people.
children died of TB
(including children with
HIV associated TB).
TB occurs in every part of the world. In 2017,
the largest number of new TB cases occurred
in the South-East Asia and Western Pacific
regions, with 62% of new cases, followed by
the African region, with 25% of new cases.

In 2017, 87% of new TB cases occurred in the

30 high TB burden countries. Eight countries
accounted for two thirds of the new TB cases:
India, China, Indonesia, Philippines, Pakistan,
Nigeria, Bangladesh and South Africa.
 Epidemiology
(Philippines)
 Tuberculosis is a major public
health problem in the
Philippines.

 In 2010, TB was the 6th leading

cause of mortality with a rate of
26.3 deaths for every 100,000
population and accounts for
5.1% of total deaths.

 TB is more prevalent among

males compared to females
and among the 25 – 55 year
old age group.

 It is also higher among the

malnourished and diabetics.
ETIOLOGIC AGENTS - M. tuberculosis

– Rod-shaped, non-spore-
forming, thin aerobic
bacterium
– 0.5 μm by 3 μm
– Neutral on Gram’s staining
• stained, cannot be
decolorized by acid alcohol

– Acid fastness – mycolic

acids, long-chain cross-
linked fatty acids, and other
cell-wall lipids
 Pulmonary
Tuberculosis
 M. tuberculosis is most commonly
transmitted from a person with infectious
pulmonary TB by droplet nuclei, which are
aerosolized by coughing, sneezing, or
speaking.

 The tiny droplets dry rapidly; the smallest

(<5–10 μm in diameter) may remain
suspended in the air for several hours and
may reach the terminal air passages when
inhaled.

 The probability of contact with a person

who has an infectious form of TB, the
intimacy and duration of that contact, the
degree of infectiousness of the case, and
the shared environment in which the
contact takes place are all important
determinants of the likelihood of
transmission.
 Primary Pulmonary TB
 Occurs after the initial infection with tubercle bacilli
 May be asymptomatic or may present with fever
and occasionally
chest pain.

 Often seen in children in areas of high TB

transmission
 Most of inspired air is distributed to the middle and
lower lung zones,
these areas are commonly involved in primary TB

 Ghon Focus - the lesion forming after initial

infection usually peripheral & accompanied by
transient hilar or paratracheal lymphadenopathy
Post Primary
(Adult -Type)
Disease
 Also referred to as
Reactivation or
Secondary TB

 Post primary TB is
probably most
accurately termed adult-
type TB because from
endogenous
reactivation of distant
LTBI or recent infection.

 Usually localized to the

apex & posterior
segments of upper lobes
 • Recent TB infection (<2 yrs)
• Abnormal CXR –with upper lobe
fibronodular disease typical of healed
TB infection
HIGH RISK

Risk • Underweight
factors •
•
Cigarette smoker (1 pack/day)
Underweight (BMI  18.5) and smoker
• DM and underweight (BMI  18.5)
SLIGHTLY • Alcohol intake of more than 40 g/day or
INCREASED with clinical Dx alcohol use disorder
RISK • Abnormal chest x-ray- granuloma
Classical Signs and
Symptoms
SIGNS AND SYMPTOMS
SIGNS AND SYMPTOMS

 A cough of at least 2 weeks duration with or without the

following symptoms:
 Significant and unintentional weight loss
 Fever
 Bloody sputum (hemoptysis)
 Chest/back pains not referable to any musculoskeletal
disorders
 Easy fatigability or malaise
 Night sweats
 Shortness of breath or difficulty of breathing
For patients < 15 years old, at least 3
of the following clinical criteria:
 •Coughing/wheezing of 2 weeks or more, especially if
unexplained;
 •Unexplained fever of 2 weeks or more after common
causes such as malaria or pneumonia have been
excluded;
 •Loss of weight/failure to gain weight/weight faltering/loss
of appetite;
 • Failure to respond to 2 weeks of appropriate antibiotic
therapy for lower respiratory tract infection;
 •Failure to regain previous state of health 2 weeks after a
viral infection or exanthem (e.g., measles); and,
 •Fatigue, reduced playfulness, or lethargy (e.g., child has
lost his/her normal energy).
 •Any one (1) of the above signs and symptoms (e.g.,
clinical criteria) in a child who is a close contact of a
known active TB case.
PRESUMPTIVE TB (For ages
15 years old and above)

 •Cough of at least 2 weeks

 •Chest X-ray suggestive of tuberculosis
 •Cough of any duration in a high risk individual or a close
contact of an active TB case (adult/adolescent)
Presumptive extra-pulmonary TB
may have any of the following:

 •Gibbus, especially of recent onset (resulting from

vertebral TB);
 • Non-painful enlarged cervical lymphadenopathy with or
without fistula formation;
 •Neck stiffness (or nuchal rigidity) and/or drowsiness
suggestive of meningitis that is not responding to antibiotic
treatment, with a sub-acute onset or raised intracranial
pressure;
 •Pleural effusion;
 • Pericardial effusion
 •Distended abdomen (i.e., big liver and spleen) with
ascites;
 • Non-painful enlarged joint
 Classifications
of TB (DOH)
1. Classification based on bacteriological status
a. Bacteriologically-confirmed- biological specimen is
positive by:
 smear microscopy
 culture
 rapid diagnostic tests (such as Xpert MTB/RIF)
b. Clinically-diagnosed
 A PTB patient who does not fulfill the criteria
for bacteriological confirmation
 diagnosed with active TB by a clinician or other
medical practitioner who has decided to give
the patient a full course of TB treatment
 cases diagnosed on the basis of CXR
abnormalities or suggestive histology, and
extra-pulmonary cases without laboratory
confirmation.
2. Classification based on anatomical
site

 Pulmonary TB (PTB)
 tuberculosis involving the lung
parenchyma
 A patientwith both pulmonary
and extra-pulmonary TB
 Extra-pulmonary TB (EPTB)
 tuberculosis involving organs
other than the lungs (e.g., larynx,
pleura, lymph nodes, abdomen,
genito- urinary tract, skin, joints
and bones, meninges)
 Laryngeal TB, though likely
sputum smear-positive, is
considered an extra- pulmonary
case in the absence of lung
infiltrates on CXR.
3. Classification based on history of
previous treatment
 A. New case
 A patientwho has never had
treatment for TB
 Has taken anti- TB drugs for less
than one (<1) month.
 Isoniazid preventive therapy
or other preventive regimens
are not considered as
previous tb treatment.
 B. Retreatment case
 Has been previously treated with
anti-tb drugs for at least one (1)
month in the past.
4. Classification based on drug-
susceptibility testing

Monoresistant-TB
 Resistance to one first-line anti-TB
drug only.

Polydrug-resistant TB
 Resistance to more than one first-
line anti-TB drug (other than both
Isoniazid and Rifampicin).

Multidrug-resistant TB (MDR-TB)
 Resistance to at least both
Isoniazid and Rifampicin.
Extensively drug-resistant TB (XDR-TB)
 Resistance to any
fluoroquinolone and to at least
one of three second-line
injectable drugs (Capreomycin,
Kanamycin and Amikacin), in
addition to multidrug resistance.

Rifampicin-resistant TB (RR-TB)
 Resistance to Rifampicin
detected using phenotypic or
genotypic methods, with or without
resistance to other anti- TB drugs.
 any resistance to Rifampicin,
whether monoresistance,
multidrug resistance, polydrug
resistance or extensive drug
resistance.
 DIAGNOSTIC
PROCEDURES
DIRECT SPUTUM SMEAR
MICROSCOPY (DSSM) CHESTX-
RAY
TBCULTURE

DRUG SUSCEPTIBILITYTEST

TUBERCULIN SKINTEST

RAPID MOLECULAR
DIAGNOSTICTESTS
Direct SputumSmear Microscopy (DSSM)

 Primary diagnostic method

 Definitive diagnosis of active TB
 Procedure is simple and
economical; mostaffordable
 Microscopy center can be put up
even in remoteareas
 This is also used to:
a) monitor progress of patients with
TB while they are on anti–TB
treatment;
b) b) confirm cure at the end of
treatment
How Should Sputum be Collected?

Encourage patient to collect sputum not saliva

Sputum spot collection on day of consultation
2 sputum specimens of good quality shall be collected
either as:
Frontloading –spot-spot 1hr apart
Spot-early morning specimens
Two specimens should be collected at most within 3 days
Chest Radiograph

Compliments
Low specificity
bacteriologic testing

Recommended for
Not differentiate drug- patients who are
susceptible from drug negative in sputum
resistant smears but are
suspected to have PTB

Adult consulting w/ chest

Classic picture: upper- radiograph suggestive of
lobe disease w/ PTB should undergo
infiltrates and cavities sputum microscopy
regardless of symptoms
TBCulture
• Primarily recommended
for patients at risk for drug
resistance
• Patients who failed
treatment
• HIV infected patients
• Smear positive patients
Tuberculin Skin Test/PPD/Mantoux
• Basic screening tool for TB infection
among children
• Uses purified protein derivative (PPD)
tuberculin solution to trigger delayed
hypersensitivity reaction among those
previously infected
• Skin test where small amount of TB
vaccine is injected into skin
• Read within 48-72 hours
• Swelling at injected site may indicate
infection (latest or progressive)
• 10mm induration considered positive
TST
• Negative tests DO NOT indicate
absence of TB
 Xpert MTB/RIFAssay

 Detects M tuberculosis and

rifampicin resistance
Rapid  Used for TB diagnosis among
Molecular presumptive DR-TB, HIV
patients with signs and
Diagnostic symptoms of TB, smear-
Tests negative adults with CXR
findings suggestive of TB,
smear-negative children, and
EPTB
DIAGNOSTICS Lung center St. Lukes Quezon City

CHEST XRAY 395 826

Acid fast stain 385 1283

Gene expert 3630 9497

Tuberculin test 350 722

CATEGORY
MANAGEMENT
TBDOTS
DIRECTLY OBSERVE TREATMENT SHORT
COURSE
Directly Observe TreatmentShort Course

• The internationally recommended

strategy for TB control

• A method developed to ensure treatment

compliance by providing constant and
motivational supervision to TB patients.

Reference: http://www.who.int/tb/dots/whatisdots/en/
FIRSTLINE ANTI-TBDRUGS
RIFAMPICIN
ISONIAZID
PYRAZINAMIDE
ETHAMBUTHOL
STREPTOMYCIN
Standard Treatment Regimen
Standard Treatment Regimen
DOSAGES:

Reference: National Tuberculosis Control Program Manual of Procedures, 5th Edition

 Treatment
Modifications
for Special
Situations
 Ascertain whether or not a
woman is pregnant before
she starts TB treatment.
1. Pregnancy
 Most anti-tuberculosis
drugs are safe for
pregnant women, except
Streptomycin, which is
ototoxic to the fetus.
 Advise a pregnant woman
that successful treatment
of TB with the
recommended
standardized treatment
regimen (i.e.,
2HRZE/4HR) is important
for a successful outcome
of pregnancy.
 Pregnant women taking
Isoniazid should be given
Pyridoxine (Vitamin B6) at
25 mg/day.
 In lactating mothers on
treatment, most anti-
tuberculosis drugs will be
2. Breastfeeding
found in the breast milk in
concentrations equal to
only a small fraction of the
therapeutic dose used in
infants. However, effects of
such exposure on infants
have not been established.
 It is recommended that
lactating mothers feed their
infants before taking
medications.
 Supplemental Pyridoxine
(i.e., Vitamin B6) should be
given at 5-10 mg/day to the
infant who is taking INH or
whose breastfeeding
mother is taking INH.
 Isoniazid, 3. Liver Disease or History of
Rifampicin, and Liver Disease
Pyrazinamide are all
associated with
hepatitis.
 Of the three drugs,
 Rifampicin: least
likely to cause
hepatocellular
damage, although
it is associated
with cholestatic
jaundice.
 Pyrazinamide:
most hepatotoxic.
4. Chronic
Liver Disease

 Patients with chronic

liver disease should
not receive
Pyrazinamide.
 Alternative regimens
are:
 2SHRE/6HR
 9RHE
 2SHE/10HE
5. Renal Failure

 Isoniazid and Rifampicin

are eliminated by biliary
excretion. These drugs,
therefore, can be given in
normal dosages
 Patients with severe renal
failure should receive
Isoniazid with Pyridoxine
to prevent peripheral
neuropathy.
 Streptomycin, Ethambutol
and metabolites of
Pyrazinamide are excreted
by the kidney, and doses
should be adjusted. If
possible, Streptomycin
should be avoided in
patients with renal failure.
 6. TB/HIV co-
infection

 the priority is to treat TB,

especially bacteriologically-
confirmed PTB to stop
transmission.
 However, patients with HIV-
related TB can have Anti-
Retroviral Therapy (ART)
and anti-TB treatment at
the same time, if managed
carefully.
 Patients with TB/HIV co-
infection should also receive
Co-Trimoxazole as
prophylaxis for other
infections.
NON-PHARMACOLOGICAL
 Fluid intake should be sufficient. It is particularly important
to avoid drinking any alcohol during the entire course of
your treatment as this could result in treatment
complications and side- effects.

 TB disease often adversely affects nutritional intake, due

to poor appetite, putting patients at risk for malnutrition. Six
smaller meals per day are advised instead of three meals.
The meals should provide enough energy and protein, and
be appetizing in appearance and taste so as to encourage
the patient to eat.

 People with HIV and/or (active) TB need more calories and

nutrients in their diet, but they may also have lower
appetites and be less able to absorb the nutrients in their
food.

 During treatment for TB, eat healthy foods and get enough
sleep and some exercise to help your body fight the
infection.