Pulmonary tuberculosis

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Pulmonary tuberculosis
DR. Yousef Noaimat MD.FCCP Consultant in
pulmonary and internal medicine.
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History

• Tubercular decay has been found in the spines of
  Egyptian mummies.
• Pictured Egyptian mummy in the British Museum

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Epidemiology

• According to the World Health Organization (WHO),
  nearly 2 billion peopleone third of the world's
  populationhave been exposed to the tuberculosis
  pathogen
• Annually, 8 million people become ill with
  tuberculosis, and 2 million people die from the
  disease worldwide

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• World TB incidence. Cases per 100,000 Red gt
  300, orange 200300, yellow 100200, green
  50100, blue lt 50 and grey n/a. Data from WHO,
  2006

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Reason for increase incidence

• HIV infections and the neglect of TB control
  programs
• drug-resistant from 2000 to 2004, 20 of TB
  cases being resistant to standard treatments and
  2 resistant to second-line drugs
• Lack of access to health care
• Poverty

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• Definition Pulmonary tuberculosis (TB) is a
  contagious bacterial infection that mainly
  involves the lungs, but may spread to other
  organs caused by the Mycobacterium tuberculosis
  and Mycobacterium bovis
• In the United States, most people will recover
  from primary TB infection without further
  evidence of the disease. The infection may stay
  non active for years and then reactivate.
• Most people who develop symptoms of a TB
  infection first became infected in the past.
  However, in some cases, the disease may become
  active within weeks after the primary infection

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Transmission

• cough, sneeze, speak, they expel infectious
  aerosol droplets 0.5 to 5 µm in diameter. A
  single sneeze can release up to 40,000
  droplets.Each one of these droplets may transmit
  the disease, since the infectious dose of
  tuberculosis is very low and the inhalation of
  just a single bacterium can cause a new infection
  
• Transmission can only occur from people with
  active  not latent 

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• When the disease becomes active, 75 of the cases
  are pulmonary TB
• the other 25 of active cases, the infection
  moves from the lungs, causing other kinds of TB

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Clinical presentation

• The primary stage of the disease usually doesn't
  have symptoms. When symptoms do occur, they may
  include
• Cough heamoptysis
• Excessive sweating, especially at night
• Fatigue
• Fever
• Unintentional weight loss
• Other symptoms that may occur with this disease
• Breathing difficulty
• Chest pain
• Wheezing

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Examination

• Examination may show
• Clubbing of the fingers or toes (in people with
  advanced disease)
• Enlarged or tender lymph nodes in the neck or
  other areas
• Fluid around a lung
• Unusual breath sounds (crackles)

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Diagnosis

• Sputum examination and cultures (ZN STAIN)
• how can I take a good sample?
• Chest x-ray
• Chest CT scan
• Bronchoscopy
• tuberculin skin test
• Gastric aspiration?
• The main problem with tuberculosis diagnosis is
  the difficulty in culturing this slow-growing
  organism in the laboratory (it may take 4 to 12
  weeks for blood or sputum culture

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• Mantoux tuberculin skin test

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• polymerase chain reaction detection of bacterial
  DNA, and assays to detect the release of
  interferon gamma in response to mycobacterial
  proteins such as ESAT These are not affected by
  immunization or environmental mycobacteria, so
  generate fewer false positive results

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Treatment

• Latent TB treatment usually uses a single
  antibiotic
• People with latent infections are treated to
  prevent them from progressing to active TB
  disease later in life. However, treatment using
  Rifampicin and Pyrazinamide is not risk-free. The
  Centers for Disease Control and Prevention (CDC)
  notified healthcare professionals of revised
  recommendations against the use of rifampin plus
  pyrazinamide for treatment of latent tuberculosis
  infection, due to high rates of hospitalization
  and death from liver injury associated with the
  combined use of these drugs

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Treatment

• while active TB disease is best treated with
  combinations of several antibiotics, to reduce
  the risk of the bacteria developing antibiotic
  resistance
• The two antibiotics most commonly used are
  rifampicin and isoniazid

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Treatment

• Initial phase 8 WKS
• rifampicin isoniazid PYRAZINAMIDE
• If resistant possible add ethmbutol or
  sterptomycin
• Give pyridoxine throughout treatment
• Continuation phase (4month)
• rifampicin isoniazid pyridoxine

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Treatment

• When can I say treatment failure?

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• Treatment failure is defined by
• culture after 3 months
• AFB stain after 5 months
• And should be treated by adding 2 more drug

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Treatment

• Main side effect
• Rifampicin hepatitis (small raise of ASTis
  acceptable . Stop if biliurubin raise)
• Isoniazid hepatitis. Neuropathy
• ethmbutol optic neuropathy
• PYRAZINAMIDE hepatitis
• (contraindicted in gout)

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Prevention

• identified people with TB and their contacts are
  and then treated
• children are vaccinated to protect them from TB.
  Unfortunately, no vaccine is available that
  provides reliable protection for adults

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• Thank you