Tuberculosis

Dr Abdu Hussein Mogella

 Objectives
At the end of this session each student will be able to:
• Define tuberculosis
• Explain risk factors/aetiology of
• Explain clinical features and complications of tuberculosis
• Perform clinical assessment for a patient with tuberculosis
• Determine appropriate investigations to be performed to patients
with tuberculosis
• Treat patients with tuberculosis as appropriate
• Provide preventive measures to patients with tuberculosis
 Introduction
• Definition: Tuberculosis is a Chronic necrotizing disease caused by
Mycobacterium tuberculosis complex. It usually affects the lungs but
almost all organs can be affected. Thus it is conveniently classified
into:
• Pulmonary TB (PTB): accounts for 80% of all TB cases. Smear-
positive PTB: 75-80% of all PTB cases Smear-negative PTB: 20-25%
of all PTB cases
• Extra-pulmonary TB (EPTB): accounts for 20% of all TB cases.
 Pulmonary Tuberculosis
• Pulmonary tuberculosis (PTB) refers to disease involving the lung
parenchyma. Therefore tuberculous intrathoracic lymphadenopathy
(mediastinal and/or hilar) or tuberculous pleural effusion, without
radiographic abnormalities in the lungs, constitutes a case of
extrapulmonary TB. A patient with both pulmonary and
extrapulmonary TB should be classified as a case of pulmonary TB.
Miliary tuberculosis is classified as pulmonary TB because there are
lesions in the lungs.
CXR for a Patient with Pulmonary Tuberculosis

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 Extrapulmonary Tuberculosis
• Extrapulmonary tuberculosis (EPTB) refers to tuberculosis of
organs other than the lungs, e.g. pleura, lymph nodes, abdomen,
genitourinary tract, skin, joints and bones, meninges.
• Diagnosis should be based on one culture-positive specimen, or
histological or strong clinical evidence consistent with active EPTB,
followed by a decision by a clinician to treat with a full course of ant-
tuberculosis . The case definition of an extrapulmonary TB case with
several sites affected depends on the site representing the most severe
form of disease
 Case Definitions
• Tuberculosis suspect. Any person who presents with symptoms or
signs suggestive of TB, in particular cough of long duration (more than
2 weeks)
• Case of tuberculosis. A patient in whom TB has been bacteriologically
confirmed or diagnosed by a clinician.
• Definite case of tuberculosis: a patient with positive culture for the
M.Tuberculosis
Based on the above criteria and case definitions, a TB patient falls in to
one of the four categories of treatment. This categorization helps in
prioritizing patients and in selecting the type regime to be used in a
patient.
 Aetiology
• Mycobacterium belongs to the mycobactericidal family. The species
commonly involved are M. tuberculosis, M.bovis, M. africanum and
M.microti. But of all, M.tuberculosis is by far the commonest. M.
tuberculosis is a rod-shaped, non-spore-forming, thin aerobic
bacterium measuring about 0.5μm by 3μm. The bacterium is
demonstrated by acid fast staining technique.
 Risk Factors for Tuberculosis
• Infectivity of the contact ( patients with heavy bacterial load)
• Environment: overcrowding
• Duration of contact ( prolonged exposure )
• Intimacy ( how close the source and the subject are )
• Patients who acquire the infection may not develop the disease. The
rate of clinical disease is highest during late adolescence and early
adulthood, but the reasons are not clear. Especially young women are
affected more than men.
 Risk of Progression to Active Disease

• The risk of progression from infection to active disease depends on the

status of the individual’s immune system. Two groups of people are at
a higher risk of developing active TB disease:
i. Persons who have been recently infected with TB bacteria
ii. Persons with medical conditions that weaken the immune system.
Persons Recently Infected with Bacteria Close
Contacts of a Person with Infectious TB Disease.
• Children less than 5 years of age who have a positive TB test.
• Groups with high rates of TB transmission, such as homeless persons,
prisoners, mine workers, health care workers (HCWs), and people
who use drugs
• Persons who have immigrated from areas of the world with high
prevalence of TB.
Persons with Conditions that Weaken the Immune
System

• People living with HIV (PLHIV) have an annual risk of 5%

to 10% and a lifetime risk 20 to 30 times higher for
developing TB disease than HIV-negative individuals
• Diabetes mellitus: People with diabetes have a 1.5
times higher risk of developing TB disease than people
without diabetes mellitus
• Substance abuse, including using drugs, alcohol, and
smoking
• Severe kidney disease
Persons with Conditions that Weaken the
Immune System…
• Age (very young and elderly)
• Malnutrition
• Silicosis and chronic respiratory diseases
• Organ transplants
• Cancers
• Medical treatments such as corticosteroids
 Transmission

Adults with smear positive TB such as cavitary TB and Laryngeal TB

are the sources of infection. Patients who are culture-negative
pulmonary TB and extra pulmonary disease are not infectious.
M. tuberculosis is commonly transmitted from a patient with infectious
tuberculosis to a healthy individual through.
• Inhalation of droplets excreted via coughing, sneezing or speaking.
• Un-boiled milk could also transmit M. bovis, but the incidence
seems to be decreasing because of health education on boiling or
pasteurizing milk.
 Transmission..
• Patients who acquire the infection may not develop the
disease. The rate of clinical disease is highest during
late adolescence and early adulthood, but the reasons
are not clear. Especially young women are affected
more than men.
Other Disease Contributing TB
Development
The presence some disease conditions increase the likely of developing
active TB (Clinically over disease).
• The commonest is co-infection with HIV, which suppresses
cellular immunity.
• Hematologic and other malignancies : lymphoma, leukaemia,
malignancies,
• Chronic renal failure ,Diabetes mellitus
• Immune suppressive drugs like long-term corticosteroids (e.g.
prednisolone)
• Old age because of decreased immunity.
• Malnutrition is a very important factor for the development of
disease.
 Extra-Pulmonary Tuberculosis

• Extra-pulmonary Tuberculosis:-Commonly affected organs are lymph

nodes, pleura, meninges, genitourinary tract, bones and joints, and
peritoneum.
• Lymph-node tuberculosis (TB lymphadenitis):-
It is seen more in HIV patients.
The commonest sites are cervical and supraclavicular.
Lymph nodes are typically matted and firm, sometimes
pus may be discharging.
The diagnosis is made by fine needle aspiration and/or
lymph node biopsy.
 Pleural tuberculosis

• Pleural involvement may be asymptomatic or patients could have

fever, pleuritic chest pain and dyspnoea.
• On physical examination, typically there will be decreased tactile
fremitus, dullness and decreased breath sounds on the affected side.
• Fluid should be aspirated from pleural space (thoracentesis) and
analysed.
• Chest x-ray is also helpful in diagnosis; it may show homogenous
opacity with meniscus
• sign.
• Empyema (pus in the pleural space) may complicate tuberculosis
occasionally.
 Skeletal Tuberculosis

• It is usually reactivation of hematogenous site or extension from a nearby

lymph node. The most common sites are spine, hips and knees.
• Spinal tuberculosis is called Pott's disease or tuberculous spondylitis. In
adults, lower thoracic and lumbar vertebrae are commonly affected. Patients
may present with swelling and pain on the back with or without paraparesis
or paraplegia due to cord compression.
• Tuberculosis in other bones or joints usually present with pain and swelling.
• Joint tuberculosis: - Any joint can be affected but weight bearing joints;
particularly the hip and knee joints are commonly involved. Patients present
with progressive joint swelling, usually with pain and limitation of
movement. If left untreated, the joint may be destroyed
 Tuberculosis Meningitis

• It is commonly seen in children and immuno-compromised people

particularly patients with HIV.
• More than half have evidence of disease in the lungs.
• Patients with TB meningitis present with headache, behavioural changes
and nuchal rigidity for about two weeks or more. Patients may have cranial
nerve paralysis and seizure.
• Cerebra spinal fluid analysis is the most important modality to diagnose
TB meningitis.
• CSF examination shows increased WBC count, predominantly
lymphocytes, and high protein and low glucose content. But any of theses
could be normal in the presence of the disease. AFB can be seen in
sediment CSF in only 20% of cases; this percentage increases if examined
CSF volume is increased. Culture may be positive in about 80%, but it
takes 4 to 6 weeks to grow.
• Patients should be referred to a hospital if TB meningitis is suspected.
 Gastro Intestinal Tuberculosis
Tuberculosis can affect anywhere from the mouth to the anus. Bacteria
could reach GI by swallowing sputum, hematogenous or by ingesting raw
milk. The commonest sites are terminal ileum and cecum.
Abdominal pain, diarrhea, symptoms of intestinal obstruction and
haematochezia (frank blood on stool) may be the presenting
symptoms. There could be associated fever, night sweats, weight loss
and anorexia. There could be a palpable mass in the abdomen.
Patient could have involvement of the peritoneum, liver and spleen,
the abdomen. Patient could have involvement of the peritoneum,
liver and spleen.
 Gastro Intestinal Tuberculosis

• Tuberculosis peritonitis arises from ruptured abdominal lymph node

or hematogenous dissemination.
• Patients usually present with abdominal swelling and pain, weight
loss, fever and night sweating.
• Aspiration of peritoneal fluid (paracentesis) reveals exudative fluid
with many WBC, predominantly lymphocytes. AFB is rarely positive
and culture positivity is very low.
• Involvement of the liver and spleen is part of disseminated
tuberculosis. Patients will present with hepatomegaly and/or
splenomegaly. There could be evidence of involvement of other organs
Pericardial Tuberculosis (TB pericarditis)

• It is frequently seen in patients with HIV.

• Patients usually present with fever, retro-sternal pain, cough,
dyspnoea and generalized edema because of pericardial effusion,
Cardiac tamponade may appear later
• Constrictive pericarditis may develop as a complication of TB
pericarditis even after treatment and patients can present with
symptoms and signs of right sided heart failure.
• Diagnosis is usually reached by analysing the pericardial effusion,
which is always done in hospitals. It may show lymphocytosis, but
yield for AFB is low.
• Chest x-ray may show enlarged heart shadow, which suggests
effusion. Ultrasound should be done when available and it
demonstrates effusion.
 Miliary tuberculosis

This is secondary to hematogenous dissemination of the bacilli.

• It is more common in children and immuno-compromised patients.
• Manifestations are nonspecific with fever, night sweats, anorexia,
weakness, and weight loss. Patients may or may not have respiratory
symptoms.
• Physical examination findings include seriously sick patient with
hepatomegaly, splenomegaly and lymphadenopathy.
• Since symptoms and signs are not specific, high index of suspicious
is required for the diagnosis.
• Chest x-ray usually shows miliary pattern of infiltration bilaterally
(milliate like lesions, “dagussa” in Amharic).
Milliary TB CXR

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 Clinical Presentation of
Tuberculosis
Symptoms Signs
• Productive cough • Generalized Lymphodenopathy
• Hemoptysis • Chills
• Fever • Abdominal distension
• Weight loss
• Anorexia
• Sweats
 Complications of Tuberculosis
• Joint damage.
• Lung damage.
• Infection or damage of your bones, spinal cord, brain, lymph nodes or
skin.
• Liver or kidney problems.
• Inflammation of the tissues around your heart.
 Diagnostic Approach
• History and physical examination
• ESR
• CBC
• Sputum examination may be positive for AFB or Gene Xpert.
• Mycobacterial culture
 Diagnostic Approach…
Radiological imaging includes:
Chest X-ray,
Ultrasound,
Computed tomography scan (CT-Scan)
Magnetic resonance imaging (MRI)
 Treatment of Tuberculosis
Aim of Treatment of Tuberculosis
• To cure the patient from the diseases and prevent death and
complications
• To decrease transmission of Tuberculosis
• To prevent relapse of TB
• Prevent the development and transmission of drug resistant tubercle
bacilli
• Prevent death from active TB
 Treatment of Tuberculosis…

Treatment of tuberculosis has two phases,

• The intensive (initial) phase: combination of 3 or more drugs is
given for 2 months. In the retreatment regimen it continued for 3
months. This is to decrease the bacterial load and make the patient
non-infectious rapidly.
• Continuation phase: Two or three drugs used for 4 -5 months. This
phase follows the intensive phase and the aim is to achieve complete
cure.
Standard Regimen for Adult and Child
Tuberculosis Patients
• All new or previously treated patients should receive a six-month
regimen containing rifampicin: 2RHZE/4RH. The regimen requires
daily observed treatment by a health care provider or other designated
individual, which could include a family member or friend, throughout
the six months.
• Treatment for severe forms of EPTB in adults (spine/bone/joints,
meningitis, and milliary) should be for 12 months duration. For
patients with TB pericarditis and meningitis, adjuvant corticosteroid
therapy should be added.
Treatment of Tuberculosis…
Side Effects of common Anti TB drugs and
Treatment of side effects
 Differential diagnosis of tuberculosis

• Atypical pneumonias
• Pneumocystis jiroveci
• Lung abscess
• Chronic bronchitis/COPD
• Bronchiectasis
• Nontuberculous mycobacteriosis
• Heart failure
• Sarcoidosis
• Pneumoconiosis (silicosis, asbestosis, and coal workers diseases)
• Lung cancer
 Prevention
• Avoid close contact with people who have active TB disease.
• Wash your hands often and cover your mouth when coughing or
sneezing.
• Eat a nutritious diet and exercise regularly to keep your immune system
strong.
• If you work in a healthcare setting abroad, follow protocols for wearing
protective gear such as masks and gowns.
• If you have a latent TB infection, follow the entire treatment protocol.
• If you’re traveling to a high risk area and you have a compromised
immune system, talk with a doctor about preventive treatments.
Healthline
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