Professional Documents
Culture Documents
of Tuberculosis
60
50
40
30 Percent
20
10
0
Days Weeks Months Years
Razak,Norhafizah,Norlidar,Norhashimah. C.C.HKT
2.Microbiology
Sputum AFB/AFB C+S
Most cost effective
method
Categorization for
treatment
AFB +ve
AFB -ve
3. Serology
Mantoux Test
Antibody/antigen
PCR
mm
4.CXR
Upper lobe opacity
Cavity ( 1 cavity= 1 million bacilli)
Miliary
Effusion
Radiological classification
Minimal
Slight lesion without cavitations, confined to a small part of
one or both lungs. Total extent of lesions should not
exceed the volume of lung which lies above the second
chostosternal junction and the spine of the fourth vertebra
Radiological classification
Moderately advanced
One or both lungs may be involved. Total extent of lesion
should not exceed the following:
i) Not exceeding total volume of one lung
ii)Dense lesions not exceeding one third lung volume
Pulmonary tuberculosis
Smear positive
Smear negative
Extrapulmonary tuberculosis
Pulmonary with Extrapulmonary
tuberculosis
Pulmonary Tuberculosis
Smear positive
Two sputum DS positive
One sputum positive with CXR changes of TB
One sputum positive with culture positive
Smear negative
Three DS negative with CXR abnormalities and
decision to treat as TB
Initial sputum DS negative but culture positive
Extra Pulmonary TB
Extra-pulmonary TB
TB of organs other than lung parenchyma
Based on culture, histology or strong
clinical evidence and a decision to treat
Pulmonary with extra-pulmonary
Tuberculosis involving lung parenchyma as
well as any other part of the body
Extrapulmonary TB
classification of severity
Severe
Meningitis, miliary, pericarditis, peritonitis,
bilateral or extensive pleural effusion,
spinal, intestinal, genito-urinary
Less severe
Lymph node, unilateral pleural effusion,
bone (excluding spine), peripheral joint,
skin
Definition of terms
New case
Relapse case
Chronic case
Cure
Treatment failure
Treatment after interruption
Transferred in case
Definition
New case
Newer had TB treatment or has take treatment for
less than 4 weeks in the past
Relapse case
Sputum positive relapse
Declared cured of any form of TB in the past by a
doctor has become sputum smear positive
Sputum negative relapse
As above, developed active disease based on
bacteriological, histological clinical and
radiological assessment
Definition
Chronic case
A patient who remained or becomes smear
positive again after completing a fully
supervised re-treatment regimen
Cure
A smear positive patient has negative
sputum at the end of treatment and
another negative sputum one month or
more prior to completion of treatment
Definition
Treatment failure
A patient while on treatment becomes again smear
positive 5 months or later after commencing
treatment
A patient who was initially negative became
positive after second month of treatment
Treatment after interruption
A patient who interrupts treatment for 2 months or
more then returns with smear positive or negative
but still active TB based on clinical or radiological
assessment
Definition
Transferred in case
A patient transferred from another centre
for continuation of treatment. The new
centre undertakes the responsibility of
treatment
Not considered a transfer if a patient just
come to centre for treatment only
Tuberculosis in children
T helper lymphocytes
Protective Immunopathology
Immunity and disease
Stress
Glucocorticoids
Th1 Th1 Th2
+
Tissue
damage
Macrophage
activation
TH1 cytokines---IL-12,INF
S.swaminathan et al 2002
Inhibitory cytokines IL-10
Effect of TB on HIV
Positive 50%
Chest Imaging (in HIV +ve
case)
Not used for screening
Limited to symptomatic
Variety of manifestations
Normal CXR in 15%,CT scan used only
for further diagnostic procedures
Gallium scan for PCP
CXR findings in HIV patients
(1)
Normal
PCP, MTB, Histoplasma, Kaposi
Focal infiltrates
PCP, MTB, bacterial,
Cryptococcus,aspergillus
Diffuse infiltrates
PCP, MTB, bacterial Cryptococcus,
histoplasma
CXR finding (2)
Nodular
PCP, Cryptococcus, Histoplasma, Norcardia, CMV, Toxo
Cavitary
Bacterial, PCP, MTB, Aspergilluss
Lymphadenopathy
PCP, MTB, Cryptococcus, Kaposi, lymphoma
Pleural effussion
Bacterial, PCP, MTB, lymphoma
Pneumothorax
PCP, MTB
Pneumococcal Staphylococcal Lung abscess
Acceleration of TB in HIV patients
Diagnosis Number
Bacterial 88
PCP 26
Lymphoma 25
Tuberculosis 23
Kaposi 16
NTM 15
Aspergillus 9
Lung Ca 4
CMV 2
* 242 HIV patients who had CT chest Robert et al Chest 2000; 117:1023-1030
CD4 count and lung nodule
CD4 cell count
Diagnosis 0-49 50-99 100-199 >200
Pneumonia 17 1 8 4
TB 4 5 4 1
PCP 2 0 0 1
Aspergillus 3 0 0 0
Kaposi 9 1 1 0
Diagnosis Percent
Infectious 52 (MTB 26, NTM 23)
Neoplasia 19 (KS 12, NSSCa 2, HL 2 )
Lymphoproliferative 7
Others 7
Unknown 14
Bronchoscopy
Treatment of Tuberculosis
Aims of treatment
To reduce morbidity
To prevent mortality
To prevent relapse of tuberculosis
To decrease transmission
To prevent the emergence of MDR TB
Treatment of TB
Isoniazid (H)
Rifampicin ( R )
Pyrazinamide (Z)
Streptomycin (S)
Ethambutol (E)
Treatment categories
Intensive phase
2SHRZ or 2EHRZ or 2HRZ two months of
daily doses
Continuation phase
4H2R2 or 4S2H2R2 or 4HR or 4H3R3 or
4S3H3R3 durations extended for severe
form of TB or extrapulmonary TB
Category II (Relapse, Treatment failure,
Treatment after interruption)
RIF + + +
INH + + _
PZA + _ _
SMC _ + _
Flow Chart for 6 months regimen
2SHRZ/2EHR Baseline
1. 0 mo (0 w) Z Ix:FBC,LFT,RP,HIV,R
BSSpt AFBs DS, AFB
culture
Intensive phase
HRZ for 2 months (syrup preparation)
Maintenance phase
Daily RH is preferred
Biweekly RH fully supervised
Avoid ethambutol and streptomycin
TB meningitis
Initial therapy
INH, RFP, PZA , ETM
Long term
IHN and RFP for 7 months biweekly or for
6 months after culture is negative
Antiretroviral Drugs
Nucleoside reverse transcriptase inhibitors (NRTI)
Zidovudine (AZT)
Didanosine (ddI)
Zalcitabine (ddC)
Stavudine (d4T)
Non-nucleoside reverse transcriptase inhibitors (NNRTI)
Efavirenz (Stocrin)
Nevirapine (Viramune)
Protease Inhibitors (PI)
Indinavir
Ritonavir
Saquinavir
Managing HIV/TB co-infection
RBT=rifabutin
New options
Rifampicin can be used in 3 situations:
I) NNRTI (efavirenz) + 2 NRTIs
II) Ritonavir + one or two NRTIs
III)Use of two Pis (ritonavir + saquinavir)
Use of non rifampicin included regimen
with longer duration
Pharmacologic interactions between rifampicin and
efavirenz Coltres et al
DOTS
No specific
chemotherapy
T
B
Drug susceptible TB
Specific
chemotherapy
Time
Defaulter tracing and
retrieval
Defaulter
Missed 25% of treatment doses in one
month
Retrieve by phone call, letter on same
day
Home visit if not turn up by 3rd day
Prevention of TB among Health
Care Workers (HCW)
Transmission of TB to HCWs depends
on:
Number of patients with active TB
The infectiousness of the index case
The ventilation rate of the worker
The duration of exposure
The air-exchange rate in the interior space
TB and HCW
Administrative controls
Developing and implementing effective protocols
for rapid identification, isolation and treatment
Effective work practices by education, training and
counseling
Engineering control
Prevent spread and reduce concentration of
infectious droplet nuclei (exhaust fan, unidirectional
flow, ultraviolet germicidal irradiation, biological
safety cabinets classII)
Personal respirator protection
Surveillance of HCWs for TB
48 genes involved
Ability of bacteria to respond to low
oxygen levels and increased nitric oxide
The genes transform the physiological
state, biochemical pathways and
structure of organism
Drug strategy for latency
Surgery in
Tuberculosis
Surgery in Tuberculosis
Pneumothorax
Empyema
MDRTB
Pneumothorax
Treatment
Observation & bed rest
Aspiration
Chest tube drainage
Pleurodesis
Surgery
Pneumothorax Treatment
Observation
Surgery 2%
Pneumothorax
Indications for Surgery
First episode
Tension pneumothorax
Bilateral pneumothoraces
Haemo-pneumothorax <5%
Second episode
Ipsi-lateral recurrence
Contra-lateral recurrence
Pneumothorax Treatment
Surgical Approach
Thoracotomy
Conventional
Limited muscle sparing
Paget 1896
“….unhealed empyema is, as a rule, the
direct result of patient’s neglect, or of the
surgeon’s delay, or of inadequate and
useless surgery. ”
Empyema Thoracis
5-10% mortality
American Thoracic Society
Pathological Stages
Acute
1: Exudative, pleural swelling
2: Fibrinopurulent, with heavy fibrin
deposits
Chronic
3: Organization with in growth of fibroblasts
and deposition of collagen (4-6 weeks)
Empyema Thoracis
Complications
Pulmonary fibrosis and contraction of chest wall
Spontaneous Drainage
1. empyema necessitatis
2. brochopleural fistula
3. osteomyelitis
4. pericarditis
5. mediastinal abscess
Management
Acute Empyema
Nutrition, physiotherapy, underlying
medical condition
Drainage
Management
Acute Empyema
Drainage – cornerstone
1. evacuation of pus
2. apposition of pleural surfaces and
obliteration of pleural space
Conservative
1. Closed tube drainage
2. Intra-pleural fibrinolytics (streptokinase or
urokinase)
Surgical
1. Video assisted thoracoscopy
2. Thoracotomy – limited, muscle sparing, full
Refer early
Acute Empyema
Pleural Drainage
Principle
All infected fluid and pus must be drained
Empyema Thoracis
Indications for Surgery
RESULTS:
Image-guided drainage failed in all (14/14)
patients.
Septic symptoms disappeared within 24-48 h
after surgery with decortication.
Empyema Thoracis
Intrapleural fibrinolytics
Success rate
71% (48/67)
Striffeler H. Gugger M. Annals of Thoracic Surgery. 65(2):319-23, 1998 Feb.
68% (30/44)
Lawrence DR. Ohri SK Annals of Thoracic Surgery. 64(5):1448-50, 1997 Nov.
Pneumothorax
Haemothorax
Empyema
Pleural effusion
Chylothorax
Post-op – Thoracic & cardiac
Chest Tubes
Aseptic technique
Local anesthesia with lignocaine 3mg/kg
from skin down to pleura
Aspirate air or fluid to confirm location
Insertion technique
Simple dressing
Tube Management
Monitoring
Early and daily CXR
Air leak and fluid drainage
Advantages
Cheap
Simple
Problems
Higher resistance
with fluid
accumulation
Foaming
Suction Device
Indications for Suction
Contra-indications
Massive bleeding
Pneumonectomy