PULMONARY DISEASE MANAGEMENT

LECTURE

MODULE

Pulmonary Tuberculosis

Mr. Carrera, 67-year-old retired baker and pastry chef, is admitted to the clinical area
because of a productive cough of more than 2 weeks, hemoptysis, anorexia, and weight loss.
His temperature is slightly elevated every afternoon. After performing a Mantoux skin test, he
is considered as a patient suspected with pulmonary tuberculosis.

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Description

Pulmonary tuberculosis (PTB) is a chronic respiratory disease common among

crowded and poorly ventilated areas.
● An acute or chronic infection caused by Mycobacterium tuberculosis, tuberculosis
is characterized by pulmonary infiltrates, formation of granulomas with caseation,
fibrosis, and cavitation.
● Tuberculosis is an infectious disease that primarily affects the lung parenchyma.
● It also may be transmitted to other parts of the body, including the meninges,
kidneys, bones, and lymph nodes.
● The primary infectious agent, M. tuberculosis, is an acid-fast aerobic rod that
grows slowly and is sensitive to heat and ultraviolet light.

Pathophysiology

Tuberculosis is a highly infectious, airborne disease.

● Inhalation. Tuberculosis begins when a susceptible person inhales mycobacteria
and becomes infected.
● Transmission. The bacteria are transmitted through the airways to the alveoli, and
are also transported via lymph system and bloodstream to other parts of the body.
● Defense. The body’s immune system responds by initiating an inflammatory
reaction and phagocytes engulf many of the bacteria, and TB-specific lymphocytes
lyse the bacilli and normal tissue.
● Protection. Granulomas new tissue masses of live and dead bacilli, ate surrounded
by macrophages, which form a protective wall.
● Ghon’s tubercle. They are then transformed to a fibrous tissue mass, the central
portion of which is called a Ghon tubercle.
● Scarring. The bacteria and macrophages turn into a cheesy mass that may become
calcified and form a collagenous scar.
● Dormancy. At this point, the bacteria become dormant, and there is no further
progression of active disease.
● Activation. After initial exposure and infection, active disease may develop
because of a compromised or inadequate immune system response.
● Pathophysiology and Schematic Diagram for Pulmonary Tuberculosis

Classification

Data from the history, physical examination, TB test, chest x-ray, and microbiologic
studies are used to classify TB into one of five classes.
● Class 0. There is no exposure or no infection.
● Class 1. There is an exposure but no evidence of infection.
● Class 2. There is latent infection but no disease.
● Class 3. There is a disease and is clinically active.
● Class 4. There is a disease but not clinically active.
● Class 5. There is a suspected disease but the diagnosis is pending.

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 Clinical Classifications
1. Primary TB (primary infection stage) - it follows the patient’s first exposure to the
TB pathogen, Mycobacterium tuberculosis- a rod-shaped bacterium with a waxy
capsule. Primary TB begins when the inhaled bacilli implant in the alveoli. As the
bacilli multiply over a 3- to 4-week period, the initial response of the lungs is an
inflammatory reaction that is similar to acute pneumonia.
2. Postprimary TB (reactivation TB, or secondary TB) - the reactivation of TB months
or even years after the initial infection has been controlled. Even though most patients
with primary TB recover completely from a clinical standpoint, it is important to note
that live tubercle bacilli can remain dormant for decades. If the TB infection is
uncontrolled, further growth of the caseous granuloma tubercle develops. The patient
progressively experiences more severe symptoms,including violent coughing episodes,
greenish or bloody sputum (possibly mixed with TB bacilli), low-grade fever,
anorexia, weight loss, extreme fatigue, night sweats, and chest pain. It is the gradual
wasting of the body that provided the basis for an earlier name for TB-consumption.
3. Disseminated TB (extrapulmonary TB, miliary TB, and tuberculosis-disseminated) -
refers to infection from TB bacilli that escape from a tubercle and trave; to other sites
throughout the body by means of the bloodstream or lymphatic system. In general, the
TB bacilli that gain entrance to the bloodstream usually gather and multiply in
portions of the body that have a high tissue oxygen tension. The most common
location is the apex of the lungs. Other oxygen-rich areas in the body include the
regional lymph nodes, kidneys, long bones, genital tract, brain and meninges.

Statistics and Incidences

Tuberculosis is a worldwide public health problem that is closely associated with

poverty, malnutrition, overcrowding, substandard housing, and inadequate health care.
● M. tuberculosis infects an estimated one-third of the world’s population and
remains the leading cause of death from infectious disease in the world.
● According to the WHO, an estimated 1.6 million deaths resulted from TB in 2005.
● After exposure to M. tuberculosis, roughly 5% of infected people develop active
TB within a year.

Causes

Causes of acquiring tuberculosis include the following:

● Close contact. Having close contact with someone who has an active TB.
● Low immunity. Immunocompromised status like those with HIV, cancer, or
transplanted organs increases the risk of acquiring tuberculosis.
● Substance abuse. People who are IV/injection drug users and alcoholics have a
greater chance of acquiring tuberculosis.
● Inadequate health care. Any person without adequate health care like the
homeless, impoverished, and the minorities often develop active TB.
● Immigration. Immigration from countries with a high prevalence of TB could
affect the patient.

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 ● Overcrowding. Living in an overcrowded, substandard housing increases the
spreading of the infection.

Clinical Manifestations

After an incubation period of 4 to 8 weeks, TB is usually asymptomatic in primary

infection.
● Nonspecific symptoms. Nonspecific symptoms may be produced such as fatigue,
weakness, anorexia, weight loss, night sweats, and low-grade fever, with fever and
night sweats as the typical hallmarks of tuberculosis.
● Cough. The patient may experience cough with mucopurulent sputum.
● Hemoptysis. Occasional hemoptysis or blood on the saliva is common in TB
patients.
● Chest pains. The patient may also complain of chest pain as a part of discomfort.

Prevention

To prevent transmission of tuberculosis, the following should be implemented.

● Identification and treatment. Early identification and treatment of persons with
active TB.
● Prevention. Prevention of spread of infectious droplet nuclei by source control
methods and by reduction of microbial contamination of indoor air.
● Surveillance. Maintain surveillance for TB infection among health care workers by
routine, periodic tuberculin skin testing.
Complications

If left untreated or mistreated, pulmonary tuberculosis may lead to:

● Respiratory failure. Respiratory failure is one of the most common complications
of pulmonary tuberculosis.
● Pneumothorax. Pneumothorax becomes a complication when tuberculosis is not
treated properly.
● Pneumonia. One of the most fatal complications of tuberculosis is pneumonia as it
could cause infection all over the lungs.

Assessment and Diagnostic Findings

To diagnose tuberculosis, the following tests could be performed:

● Sputum culture: Positive for Mycobacterium tuberculosis in the active stage of the
disease.
● Ziehl-Neelsen (acid-fast stain applied to a smear of body fluid): Positive for
acid-fast bacilli (AFB).
● Skin tests (purified protein derivative [PPD] or Old tuberculin [OT]
administered by intradermal injection [Mantoux]): A positive reaction (area of
induration 10 mm or greater, occurring 48–72 hr after intradermal injection of the
antigen) indicates past infection and the presence of antibodies but is not
necessarily indicative of active disease. Factors associated with a decreased

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 response to tuberculin include underlying viral or bacterial infection, malnutrition,
lymphadenopathy, overwhelming TB infection, insufficient antigen injection, and
conscious or unconscious bias. A significant reaction in a patient who is clinically
ill means that active TB cannot be dismissed as a diagnostic possibility. A
significant reaction in healthy persons usually signifies dormant TB or an infection
caused by a different mycobacterium.
● Enzyme-linked immunosorbent assay (ELISA)/Western blot: May reveal
presence of HIV.
● Chest x-ray: May show small, patchy infiltrations of early lesions in the
upper-lung field, calcium deposits of healed primary lesions, or fluid of an
effusion. Changes indicating more advanced TB may include cavitation, scar
tissue/fibrotic areas.
● CT or MRI scan: Determines degree of lung damage and may confirm a difficult
diagnosis.
● Bronchoscopy: Shows inflammation and altered lung tissue. May also be
performed to obtain sputum if the patient is unable to produce an adequate
specimen.
● Histologic or tissue cultures (including gastric washings; urine and
cerebrospinal fluid [CSF]; skin biopsy): Positive for Mycobacterium tuberculosis
and may indicate extrapulmonary involvement.
● Needle biopsy of lung tissue: Positive for granulomas of TB; presence of giant
cells indicating necrosis.
● Electrolytes: May be abnormal depending on the location and severity of infection;
e.g., hyponatremia caused by abnormal water retention may be found in extensive
chronic pulmonary TB.
● ABGs: May be abnormal depending on location, severity, and residual damage to
the lungs.
● Pulmonary function studies: Decreased vital capacity, increased dead space,
increased ratio of residual air to total lung capacity, and decreased oxygen
saturation are secondary to parenchymal infiltration/fibrosis, loss of lung tissue,
and pleural disease (extensive chronic pulmonary TB).

Medical Management

Pulmonary tuberculosis is treated primarily with antituberculosis agents for 6 to 12

months.
● First line treatment. First-line agents for the treatment of tuberculosis are
isoniazid (INH), rifampin (RIF), ethambutol (EMB), and pyrazinamide.
● Active TB. For most adults with active TB, the recommended dosing includes the
administration of all four drugs daily for 2 months, followed by 4 months of INH
and RIF.
● Latent TB. Latent TB is usually treated daily for 9 months.
● Treatment guidelines. Recommended treatment guidelines for newly diagnosed
cases of pulmonary TB have two parts: an initial treatment phase and a
continuation phase.

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 ● Initial phase. The initial phase consists of a multiple-medication regimen of INH,
rifampin, pyrazinamide, and ethambutol and lasts for 8 weeks.
● Continuation phase. The continuation phase of treatment includes INH and
rifampin or INH and rifapentine, and lasts for an additional 4 or 7 months.
● Prophylactic isoniazid. Prophylactic INH treatment involves taking daily doses for
6 to 12 months.
● DOT. Directly observed therapy may be selected, wherein an assigned caregiver
directly observes the administration of the drug.

Pharmacologic Therapy

The first line antituberculosis medications include:•

● Isoniazid (INH). INH is a bactericidal agent that is used as prophylaxis for
neuritis, and has side effects of peripheral neuritis, hepatic enzyme elevation,
hepatitis, and hypersensitivity.
● Rifampin (Rifadin). Rifampin is a bactericidal agent that turns the urine and other
body secretions into orange or red, and has common side effects of hepatitis,
febrile reaction, purpura, nausea, and vomiting.
● Pyrazinamide. Pyrazinamide is a bactericidal agent which increases the uric acid
in the blood and has common side effects of hyperuricemia, hepatotoxicity, skin
rash, arthralgias, and GI distress.
● Ethambutol (Myambutol). Ethambutol is a bacteriostatic agent that should be
used with caution with renal disease, and has common side effects of optic neuritis
and skin rash.

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