Infectious Disease [TUBERCULOSIS]

Microbiology and Epidemiology

TB is an acid-fast bacillus that stains poorly on Gram stain. It’s
spread through the aerosolized respiratory droplets and infects Primary Lesions are
the lungs. Primary TB presents like a pneumonia and localizes usually in middle and
in the middle or bottom lobe. Unable to kill the bacteria, the lower lobes
body forms cavitary lesions (aka caseating granulomas) to wall
off bacteria. Reactivation TB occurs in the apices - where
oxygen tension is highest. Cavitation results in lung Reactivation Lesions are in
fragmentation and hemoptysis. Major risk for the spread of TB is the apices
a place where there are too many people in too small a space
(military barracks, prison, and homeless shelters). Being
immunocompromised ↑ risk of contracting and reactivating
chronic disease.
Rate of TB in the US
Patient Presentation
There are two types of patients: those who are asymptomatic but
exposed and those with cavitary pneumonia presenting with night
sweats, fever, weight loss, hemoptysis, and cough. These 1930 1950 1990 2010
patients are going to follow a diagnostic algorithm separate from
each other. PPD screen if:
>5mm “Immunosuppressed”
Diagnosis HIV / AIDS
The asymptomatic screen is performed on people who aren’t Organ Transplant
symptomatic but require proof of their absence of exposure. The Steroids
Close Contacts of TB
initial test can be done with a PPD or an Interferon-Gamma
>10mm “Exposed”
Assay. The PPD is placed today and read in 48-72 hours, where Incarcerated, Homeless
the amount of induration (not erythema) is used to determine if Health Care Provider
positive or negative. The Gamma-interferon test is more Travel to Endemic Areas
expensive but tells yes or no. There’s also no need to return for >15mm “Shouldn’t Be Screened”
the assessment. When the patient has had the BCG vaccine you People from Wyoming who’s exposure is on
National Geographic
simply ignore that fact when assessing for pulmonary TB. If
forced, choose Interferon-gamma assay over PPD for those with
Asx Screen
BCG vaccine.

If a patient is symptomatic, has a positive PPD, or a positive PPD

Gamma-Interferon Assay, a chest x-ray is required to assess for
active disease. In these patients, the chest x-ray will also serve as
their annual screen (once the PPD is positive, it’ll always be Exposure No Exposure
positive).
Stop
CXR
If the CXR and they’ve never been treated, they require
Isoniazid + B6 x 9 months.

If CXR an active infection must be ruled out with AFB Infected Exposure Only
smears. This is a good time to isolate the individual. If the AFB INH x 9 mos
Smear , there’s an active infection; treat with RIPE. If the AFB +B6
Smear , the patient has latent TB; treat with Isoniazid + B6 x CXR
9 months.

For the acutely ill patient there’s no need (or time) to wait the Active TB Latent TB
48-72 hrs of the PPD. First do a CXR looking for apical lesions.
R.I.P.E. INH x 9 mos
However, if there’s a CXR it’s insufficient to rule out active +B6
disease; an AFB Smear and Culture must also be done. If the
disease is suspected a positive confirmation is desired.

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 Infectious Disease [TUBERCULOSIS]

Send out early morning sputum and at least a total of 3 cultures
8 hours apart. It’s essential to ensure it’s negative so also send out
3 early morning sputums 24 hrs apart. For AFB smear culture
(active disease) treat with RIPE. If AFB smear look for
another diagnosis such as malignancy; it isn’t TB that’s causing
the symptoms.

The culture that’s initially negative, but then comes back 6 weeks
later as positive is non-tubercular mycobacterium. It’s like MAC
– mycobacterium avian complex.

Other Diagnostic Tests

Nucleic Amplification can be used to ensure that the thing you
thought was TB is really not TB. Excellent sensitivity.

Adenosine Deaminase can be used in pleural effusions, and is

better than an AFB smear and culture.

Treatment
Anyone with a PPD or CXR is going to get at least 9 months
Isoniazid + B6.
RIPE Side Effects
For active disease we get a trial of Rifampin, Isoniazid, Rifampin Red Urine
Pyrazinamide, Ethambutol (RIPE). It’s a good idea to know the INH Neuropathy (Give B6 Ppx)
Pyrazinamide Hyperuricemia, Gout
side effects of these drugs. ALL 4 cause hepatotoxicity. Ethambutol Eye Disturbance
(optic neuritis)
To treat non-tubercular mycobacterium (MAC) treat with
Clarithromycin and Ethambutol. Note that hepatotoxicity is a side effect for all

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