Bronchiectasis, TB | Jindal Chest Clinic

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Bronchiectasis

• Definition
• Permanent destructive dilatation of the bronchi
  (following infection, destruction and fibrosis)
• Types
• Cystic
• Cylindrical
• Localized or diffuse

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Etiology of bronchiectasis

• Post-infectious, e.g. tuberculosis, pneumonia
  childhood infection such as measles, mumps,
  whooping cough
• Connective tissue diseases, e.g. SLE, rheum
  arthritis, Sjögrens syndrome, relapsing
  polychondritis
• Secondary to inhalation or aspiration,
• e.g. a foreign body
• Inflammatory bowel disease, e.g. ulcerative
  colitis
• Allergic bronchopulmonary aspergillosis
• Immune deficiency e.g. Secondary to ch lymphatic
  leukemia

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Congenital causes of Bronchiectasis

• Cystic fibrosis
• Ciliary defects, e.g. primary ciliary dyskinesia,
  Youngs syndrome
• Kartageners syndrome
• Immune deficiency, e.g. IgA deficiency,
• X-linked agammaglobulinemia,
• Common variable immunodeficiency
• Congenital defects e.g. tracheobronchomegaly
  (Mounier-Kuhn syndrome), pulmonary sequestration

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Clinical Features

• Chronic cough and expectoration
• Sputum Purulent/ muco-purulent, foul-smelling,
  large volume, thick and tenacious
• Haemoptysis, sometimes massive
• Recurrent exacerbations
• SIGNS General malnutrition, pallor, edema
• Digital clubbing, osteoarthropathy
• Chest Depends on site and extent of
  involvement
• If large, signs of lung volume
  reduction
• May be areas of bronchial
  breathing
• Coarse crepitations,
  Occasional rhonchi

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Investigations

• General Anemia, Hypoglobulinemia
• Chest radiography CXR, CT scan (HRCT)
• Bronchography
• Sputum examination For exacerbations.
• AFB to exclude TB, if
  suspected
• Smear for culture
• ECG, ECHO for cardiac evaluation in suspected
• chronic cor-pulmonale

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Differential Diagnosis

• Pulmonary tuberculosis
• Cystic fibrosis
• COPD
• Allergic broncho-pulmonary aspergillosis
• Interstitial lung diseases
• Eosinophilic lung diseases
• Hypersensitivity pneumonias

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Radiological features

• CXR May appear normal in early, limited disease,
  
• left lower lobe hidden behind the heart in
  PA film.
• Thickened bronchial lines- tram lines
• Cystic shadows/ cavities with fluid levels
• HRCT Almost diagnostic.
• Clear demonstration of site of involvement,
• Type of lesions, surrounding lung
  parenchyma,
• focal pneumonitis, areas of atelectasis.
• Clue to the underlying etiology (eg ABPA)

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Complications

• Recurrent pneumonias
• Recurrent hemoptysis,
• sometimes massive
• Local lung destruction and cavitation
• Aspergilloma formation (fungal ball) in a cavity
• Metastatic spread
• Pulmonary hypertension and
• chronic cor pulmonale
• Chronic malnutrition
• Amyloidosis
• Chronic respiratory failure if extensive lung
  destruction and fibrosi

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Management

• Bronchial hygiene Postural drainage,
• Chest
  physiotherapy
• Antibiotics for infections
• Expectorant and mucolytics
• Management of complications, e.g hemoptyis,
• pulmonary hypertension (Chronic cor
• pulmonale), respiratory failure
• Nutritional supplementation
• Surgical management Resection, if localized
• Management of hemoptysis
• Lung transplantation ?

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Recommendation for antibiotics use

• Bacterial infection First choice
  Second line Haemophilus influenzae
  Doxycycline,
• or Moraxella catarrhalis Co-amoxiclav
  ciprofloxacin
• Streptococcus pneumoniae Amoxicillin
  Clarithromycin
• MRSA
  Rifampicin and Rifampicin and
• 
  trimethoprim doxycycline or
• 
  or IV vancomycin linezolid
• 
  or teicoplanin
• Ps aeruginosa
  Ciprofloxacin Ceftazidime
• 
  and
  tobramycin
• 
  or
  colistin

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Prevention of infections

• Preventive vaccinations
• Bronchial hygiene measures
• Chest
  physiotherapy
• Nebulization/
• steam
  inhalation
• Respiratory muscle
  exercises
• Long term antibiotic use - Oral
• 
  Nebulized

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Kartageners Syndrome

• Ciliary dyskinesia i.e. abnormal ciliary
  movements
• Genetic abnormality
• Clinical features Bronchiectasis
• Situs
  inversus,
• 
  dextrocardia
• Chronic
  sinusitis
• Infertility

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Allergic Broncho Pulmonary Aspergillosis

• Hypersensitivity to aspergillus in the
  tracheo-bronchial tree in patients with chronic
  asthma.
• Clinical Features Severe attacks, sputum
  production hard brown plugs hemoptysis
• Radiology CXR and HRCT Fleeting opacities,
  typical patterns bronchiectasis proximal
  bronchi
• Diagnosis Skin test Immediate delayed ve
• Sputum for aspergillus ve
• Serology ve Total Asperg
  specific IgE levels
• Treatment Anti-inflammatory drugs (steroids),
• Anti-biotics, anti-fungals

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Cystic Fibrosis

• A common condition in Caucasians
• 1 in 2500 live births
• Genetic anomaly Autosomal recessive mutation on
  chromosome 7 leads to protein Cystic Fibrosis
  Transmembrane Regulator, CFTR) abnormality
• Clinical Features Multi-organ problem
• Bronchiectasis thick
  viscid sputum
• Pancreatic
  insufficiency - diarrhoea
• Liver disease biliary
  cirrhosis
• Sweat glands function
  abnormality
• Infertility
• Low bone mass

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Cystic Fibrosis- Diagnosis

• Clinical features Failure to thrive
• Intestinal obstruction
• Adults Respiratory
  infections
• Radiological investigations, CXR, HRCT
  scans etc
• Positive sweat Test High sweat chloride
  Na
• levels on pilocarpine
  stimulation
• Gene analysis demonstration of CFTR
• mutations

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Cystic Fibrosis- Treatment

• Treatment of respiratory infection with
  antibiotics Anti-pseudomonas cover
• Reduce sputum viscosity- mucolytics
• Improve airway clearance
• Management of pancreatic insufficiency
• Correction of malnutrition high calorie, high
  fat diet supplemental vitamins
• Gene therapy
• Lung transplantation

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TUBERCULOSIS

• History
• Epidemiology
• Introduction

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What is TB ?

• Infection caused by
• Mycobacterium tuberculosis (Mtb)
• i.e. Tubercle bacillus (T.b.)
• Airborne spreads by aerosols
• enters the lungs through inhalation

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HISTORY

• Ancient disease since BC era
• Also known as
• Consumption
• Wasting
• Phthisis
• Yakshma
• Kings evil
• Kochs disease

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TB in Antiquity

• Clear evidence of spinal TB
• Early Dynastic period (c.3400 BC) Egypt
• Destruction and collapse of thoracic vertebrae
  with psoas abscess in the well preserved mummy of
  a member (Nesperehan) of 21st Dynasty priesthood
  of Amin.
• 
  Cave, 1939
• Chinese Civilization
• Lung fever and Lung cough (Chinese writings
  2698 BC). Symptom of emaciation, cough,
  expectoration of blood and pus cure was
  difficult bizarre remedies dung of animals
  man, the urine of women and infants, the lungs of
  the hog and the ashes of hair.
  
• 
  Hall, 1936

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• Babylon civilization
• Mention of TB 1948 and 1905 BC
• Code of Hammurabi His wife who is afflicted
  with the disease he shall not put away. She shall
  remain in the house which she has built and he
  shall maintain her as long as she lives.
• Indo Aryans
• A consumptive who is evidently master of
  himself, who has a good digestion, is not
  emaciated and is at the beginning of the disease
  the physician can cure and the physician who
  wants great fame cures a man attacked by
  consumption.
• Webb, 1936

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TB in ancient India (Rajyakshma)

• Rig Veda (1500 BC)
• Ayur-Veda (700 BC)
• a consumptive at the beginning of disease
  the physician can cure
• Laws of Manu (1000 BC)
• sufferers from TB are unclean
• Webb GB 1936 Brown L 1941 Keers RY 1978

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Historical landmarks

• Tubercle bacillus (Mycobacterium tuberculosis)
  Discovered on March 24, 1882 by Robert Koch
  (Awarded Nobel Prize in 1905)
• Discovery of X-Ray (Wilhelm Roentgen, 1895)
• Bacillus Calmette Guerin (BCG)
• Chemotherapy Streptomycin (1944),
• P.A.S., Isoniazid
  (1952)
• Ethambutal,
  Rifampicin
• Other new drugs
• Regimens and Strategies

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Kochs postulates

• The organism should be found in each case of the
  disease
• It should not be found in other diseases
• It should be isolated
• It should be cultured
• It should, when inoculated, produce the same
  disease
• It should be recovered from the inoculated animal

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EPIDEMIOLOGY

• Incidence vs Prevalence
• Risk factors
• Disease burden
• Morbidity and mortality

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• Global health challenge
• Higher incidence in low income countries
• India accounts for about 30 of global cases

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TB is the leading single infectious cause of
death in South-East Asia
Number of deaths (1000s)
Deaths from infectious agents in South-East Asia
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TB is the leading single infectious cause of
death in India
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TB is a Leading Killer of Women
Deaths among women
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Tuberculosis A Global Emergency

• TB kills 5,000 people a day 2 million each year
• One third of the worlds population is infected
  with TB
• More than 100,000 children will die needlessly
  from TB this year
• Hundreds of thousands of children will become TB
  orphans this year
• HIV and MDRTB will make the TB epidemic much more
  severe unless urgent action is taken

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TB Epidemiology in India

• TB infection (Mx ve) 40
• Prevalence (sputum ve) 0.23
• Mortality 0.04
• Overall prevalence 0.51

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Burden of TB in India

• 2 million new patients per year
• Over 450,000 deaths from TB annually
• TB kills more woman than all other causes of
  maternal mortality combined
• More than 100,000 women rejected (due to TB)
• More than 300,000 children leave schools to work
  as a result of parental TB
• Annual cost of disease Rs. 12,000 crores
• Annual direct costs Rs. 30 crores
• Productive work days lost 100 million per year

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Risk Factors

• Immuno-deficiency states
• HIV infections
• Patients with malignancies, leukaemias, lymphomas
• Patients on immuno-suppressant drugs (e.g.
  steroids)
• Malnutrition, drug-users, psychiatric disorders
• 3. Close contacts of patients
• Infants of sputum ve mothers

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• 4. Poverty living in crowded, slum areas
• poorly ventilated houses
• 5. Alcoholism
• 6. Tobacco smoking
• 7. Patients with other diseases (comorbidities)
• - Diabetes
• - Hypothyroidism
• - Silicosis (silico-tuberculosis)
• 8. Post-operative gastrectomy

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HIV Infection TB Risk

• Annual risk about 10
• Life time risk of TB w.r.t. HIV
• - Negative 5-10
• - Positive 50
• COINFECTION (HIV TB)
• App. 1/3 of 20 million HIV pts.

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TB and AIDS
Lifetime Risk of TB
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TB Pathogenesis and Pathology
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Homeostasis unbalanced in infections
Host defenses
Pathogens
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TB An Infection

• Tubercle bacillus (T.b)
• Mycobacterium tuberculosis (MTB)
• Airborne spreads by aerosols enters the lungs
  through inhalation
• Interplay between the bacillus and the host
  defences
• Establishment of infection Lesions in the lungs
  / lymph nodes / GIT/ other organs
• Spread to other sites/ organs
• Complications and Sequelae

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Sequence of TB infection

1. Inhalation of Mtb localization in
   tracheo-bronchial tree
2. Recruitment of macrophages and lymphocytes.
   Macrophages transform as Langhans cells
3. Engulfed by alveolar macrophages (defence cells)
   either get killed or destroy the cells to
   penetrate alveolar walls and enter the
   lymphatics/ blood vessels, reach regional LN

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• Langhans cells and lymphocytes form granulomas
  (Primary lesion)
• Primary lesion and regional lymphatics and LN
  together called Primary Complex (of Ranke)
• Fibrous capsule formation may lie dormant in the
  LN (Latent TB) or spread through lymphatics/
  blood stream to bones, liver, spleen, GIT etc.
• Impart delayed type, cell-mediated immunity
  (demonstrated by Tuberculin or Mantoux test)

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Bacillary multiplication

• 1 Bacillus
• 20 hrs
• 2 bacilli
• 10 days
• 5000 (Nodule)
• 1 month
• gt 1 billion (large cavity)

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Natural history of untreated Primary TB

• Time from Infection TB involvement
• 3-8 wks Primary complex
• 3-6 mths Meningeal,
  miliary,pleural
• Up to 3 yrs GIT, Bones
  joints, LNs
• About 8 yrs Renal tract
• 3 yrs onwards Post primary disease

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Continuing Infection

• One Sputum positive
• (untreated, undetected)
• Infects
• 6-12 persons in 1st year
• upto 24 in 2 year life span

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The National Problem

• Large pool of patients
• Renewed and perpetuated
• Difficult to approach
• Difficult to find, hold and treat
• Shortage of beds