Pul Tuberculosis

8/3/2019 Pul Tuberculosis

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History

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

Europe and on Egyptian mummies from asearly as 3700 BC.


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Tubercle Bacillus

It is a acid-fast, alcohol-fast, aerobic ormicroaerophilic, non-spore-forming, non-motile

bacilli. Only M. Tuberculosis, M. Bovis and M. Africanumare recognized as Tubercle Bacilli.

Optimal temperature for growth is 33-39 degreeCelsius at pH 6.5-6.8 in an atmosphere of 5-10% 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 theworld.

One third of the world population isinfected. 2.5 million death annually.

The incidence of the disease has beenincreasing both in developed anddeveloping countries.


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Pathology

Deposition of Tubercle Bacilli in the alveoliof the lungs is followed by vasodilatation

and influx of polymorphonuclearleucocytes and macrophage.

Macrophages crowed together as

epitheloid cells to form the tubercle.


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Pathology (contd..)

Some mononuclear cells fuse to form themultinucleated or Langerhans giant cells.

Lymphocytes surround the outer margin ofthe tubercle.

In the centre of the lesion a zone of

caseous necrosis may appear that maysubsequently 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 athin film of PPD3. Test is read after 3-7 days.

4. Grade: 1-45. 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 forlonger period.

In developing countries the vaccine shouldbe given to neonates or as early aspossible to children.


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Chemoprophylaxis

Administration of chemotherapy to preventtuberculosis.

A. Primary: usually not given.

B. secondary:1. Close contact of newly diagnosed patient.2. Positive tuberculin test reactors with anabnormal but inactive X-ray.

3. Positive tuberculin test reactor with specialclinical 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. respiratorydistress, fever, hepatosplenomegaly, jaundiceetc.

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 togain wt, wheeze or features of collapse.


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Diagnosis:

X-ray chest Tuberculin test

Gastric washing and sputum for AFB and AFBC/S.

Complications: Collapse/ consolidation,bronchiectasis, obstructive emphysema,broncholith, erythema nodosum, phlyctenularconjuntivits, pleural effusion etc.


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Miliary tuberculosis

Produced by acute dissemination oftubercle bacilli by blood stream.

Seeding of bacilli in the vessel wall causecaseous vasculitis with subsequentdischarge of bacilli in the blood stream.


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pathology

The millet seed sized lesions consists ofepithelioid cells, Langhans giant cells with

or with out central caseation. AFB may bepresent.


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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, weightloss, fever.

Variety of blood dyscrasias may be seen.


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diagnosis

Radiology Gastric lavage, sputum, transtracheal

aspirate, FOB with washing for AFB andAFB 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 pulmonarytuberculosis

Most common type of pulmonarytuberculosis.

Pathogenesis- arise in one of the threeways:1.direct progression of primarylesion. 2. reactivation 3. reinfection.


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Risk factors

Nutrition Homelessness

OccupationAlcoholism 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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Newer diagnostic technique

TB serology PCR


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Complications (contd..)

Pulmonary tuberculoma Poncets disease


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Treatment

Before 1950s mainstay of Rx was: bedrest, open air and sunshine.

Surgical resection and collapse therapywere also practiced. Presently short course chemotherapy is

the mainstay of Rx.

Short course combination chemotherapy isusually 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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Thrice weekly regimen

Rifampicin, INH, PZA plus EMB/ SM dailyfor 02 months followed by

Rifampicin and INH thrice/week.


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Rx of MDR TB

At least 03 drugs to which the organismsaresensitive.

The drugs should be continued for 6-12months after sputum become culturenegative.


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Pul Tuberculosis

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