INDIVIDUAL ASSIGNMENT

Respiration
2 year / 4 Semester / 2021 / FMUI 2020
st st

Mohamad Arbian Karim

2006489400 – Group A

PBL Trigger 2

Differential Diagnosis and Prevention of Tuberculosis

Introduction

Tuberculosis (TB) is a disease caused by the bacteria Mycobacterium tuberculosis. Because it

primarily affects the lungs, pulmonary illness is the most prevalent manifestation. The
respiratory system, the gastrointestinal (GI) system, the lymphoreticular system, the skin, the
central nervous system, the musculoskeletal system, the reproductive system, and the liver
are also typically impacted organ systems. There has been a concentrated global campaign to
eliminate TB during the last few decades. Despite advances in TB control and a decrease in
both new cases and death, the disease continues to carry a massive morbidity and mortality
burden globally.1

Infection with Mycobacterium tuberculosis kills 1.5 million people each year, more than any
other infectious illness. Once infected, the individual is most likely to acquire TB illness
within the first two years, although they may be at risk for the rest of their lives. The
population with a latent tuberculosis infection (LTBI) is usually referred to as "one-third" of
the world population, representing a reservoir of around 2.3 billion people.2

Because of the massive infection this bacteria has given to the human population. It is
important for us to understand the differential diagnosis of and prevention of this disease as
to effectively curb this disease in the near future. We will be discussing this topic for this
LTM.

Topics Discussion
A. Tuberculosis as The Great Mimicker

Tuberculosis is a major public health issue in the developing world, and it continues
to be a health-care concern in the industrialized world. It has the potential to influence
practically every organ system in the body. Tuberculosis diagnosis is frequently
challenging. Many TB patients have vague symptoms, a negative pure protein
derivative skin test result, and a negative culture material. Cross-sectional imaging
using ultrasound, multidetector computed tomography, and magnetic resonance
imaging are critical in TB diagnosis. Tuberculosis has a number of radiologic
characteristics that vary depending on the organ affected and can resemble a number
 of other disease types. Cross-sectional imaging alone cannot provide a definitive
diagnosis. Tuberculosis is a great mimicker since its radiologic symptoms can mimic
many different illnesses throughout the body systems. However, detection and
comprehension of the frequent and unusual radiologic symptoms of TB should raise
awareness of tuberculosis in the high-risk group and permit proper treatment.3

B. Differential Diagnosis of Tuberculosis

Tuberculosis is an excellent mimic and should be considered in the differential
diagnosis of a variety of systemic diseases. The following is a non-exhaustive list of
conditions to be strongly examined while examining the probability of pulmonary
TB:1

1. Pneumonia
2. Malignancy
3. Non-tuberculous mycobacterium
4. Fungal infection
5. Histoplasmosis
6. Sarcoidosis

We will be discussing about two of the diseases that is oftenly misdiagnosed as

Tuberculosis, which are Pneumonia and Non-Tuberculous Mycobacterium.

a. Pneumonia
Acute tuberculous pneumonia (TP) is a severe type of pulmonary tuberculosis.
However, acute tuberculosis and non-tuberculous community-acquired
pneumonia are readily mistaken, resulting in TP worsening because to delayed
treatment. As a result, timely and precise identification of acute TP is critical
for preventing TB transmission. Furthermore, the development of novel
diagnostic tools (technology and techniques) as well as the flexible
implementation of various therapeutic schemes will assist to lower the
prevalence of TP and advance the objective of eliminating the TB pandemic.4

Pneumonia is characterized as a lung parenchymal infection. Instead of seeing

pneumonia as a single disease, health care providers must remember that it is
an umbrella word for a set of syndromes produced by a range of organisms,
resulting in a variety of presentations and consequences.5

Pneumonia is further categorized in a variety of ways. These are mostly

clinical categories that highlight distinctions in the likely pathogen spectrum
involved. The most prevalent classification is based on the patient's location at
the time of infection.4
 Table 1. Classification of pneumonia.4

Although there are several diagnostic approaches, one of the most difficult
aspects of TP diagnosis is distinguishing it from non-tuberculous CAP. Due to
similar symptoms, it is possible to misdiagnose PTB as CAP (community-
acquired Tsukamurella pneumonia) in some locations with high TB incidence.
Nonetheless, the two have distinct properties. Acute TP should be considered
during CAP therapy if the patient receives ineffective antibiotic treatment. In
addition, the patient should be tested for HIV.4

Table 2. Difference between tuberculous pneumonia and non-tuberculous CAP.4

M. tuberculosis lung infection often manifests as chronic consumptive illness,

although it can also cause acute pneumonia. TP can be readily misdiagnosed
under the cover of various forms of pneumonia, leading to more serious
disease development. Whether in a high or low TB incidence location, the
attending clinician should be on the lookout for M. tuberculosis infection in
patients with suspected pneumonia.4

Diagnostic techniques with high sensitivity, specificity, and ease of use are
required for the quick and reliable diagnosis of M. tuberculosis infection.
 However, many diagnostic tests are insufficient for young children who are
prone to TP. The cost of diagnostic instruments is a key concern in low-
income communities where tuberculosis is widespread.4

b. Non-Tuberculous Mycobacterium
There are approximately 170 mycobacteria species in the non-tuberculous
mycobacteria (NTM) family. Human pulmonary illnesses, on the other hand,
are usually caused by M. avium complex (MAC), M. kansasii, and M.
abscessus species. Human infections caused by NTM are generally acquired
from the environment, while the exact method of transmission is unknown.
NTM infections commonly affect the lymphatic, skin, and soft tissues in
addition to the lungs. Furthermore, underlying health conditions such as
chronic obstructive pulmonary disease (COPD), pneumoconiosis,
bronchiectasis, a history of tuberculosis (TB), post-radiotherapy fibrosis,
chronic pulmonary aspiration, cystic fibrosis (CF), immune deficiency, HIV
infection, alcoholism, cancer, and diabetes mellitus (DM) increase the risk of
NTM infections.6

In clinical specimens, differentiating Mtb and NTM species is difficult and

frequently misleading since both Mtb and NTMs exhibit positive to the
traditional smear acid-fast staining approach. As a result, the prevalence of
NTM has been overestimated in several TB-endemic countries.6

The susceptibility and symptoms of infection, as well as the success of

therapy, are influenced by bacterial features and host variables in both TB and
NTM pulmonary illnesses. Over the last 50 years, we've learned a lot more
about the epidemiology, risk factors, and pathophysiology of pulmonary
tuberculosis in humans. However, for NTM disorders, these regions remain
neglected. Similarly, there are more diagnostic and therapy options for TB
care than for NTM illnesses. Nonetheless, exciting novel diagnostic tools and
treatment approaches for all kinds of tuberculosis and NTM sickness are in the
works. The table below assesses development in the domains of Mtb and
NTM infections in humans, focusing on epidemiology and diagnosis.6
 Table 3. Summary of key features of pulmonary TB and NTM diseases6

C. Prevention of Tuberculosis
The key to preventing TB transmission is prevention. It includes of early detection
and treatment of active tuberculosis to avoid infectiousness, active disease prevention
in exposed or known latently infected patients, and immunization. Unfortunately,
vaccination with the Bacillus Calmette-Guerin (BCG) vaccine is usually unsuccessful
in stopping transmission. A more effective vaccine, on the other hand, has the
potential to induce a significant shift in TB care.7 Here are some preventions that can
be done to limit the transmission or infection of TB.

1. Living in less dense population and have better ventilation

TB transmission to susceptible contacts primarily occurs in enclosed, poorly
ventilated locations. High risk locations for transmission are high density
congregate living environments such as hospitals, care homes, prisons or
student/migrant worker hostels.7 The WHO prevention and control of TB can be
summarized from the picture below.
 Fig. 1 TB Infection Prevention and Control8

2. Usage of surgical masks

Surgical masks used by infected patients with multidrug-resistant tuberculosis on

a hospital ward decreased transmission by 56% compared to periods when masks
were not worn.7

3. Prophylactic Treatment

The typical treatment regimen for latent tuberculosis infection is nine months of
isoniazid, often known as isoniazid prophylaxis (IPT). Pyrodoxine should be used
in conjunction with isoniazid. In 2011, a study of a new 12-dose isoniazid and
rifapentine regimen revealed better completion rates and no loss of effectiveness
when compared to regular 9-month isoniazid therapy. The 12-dose regimen has
since been incorporated into US recommendations, but it is not recommended for
children under the age of two, people with HIV/AIDS who are receiving
antiretroviral therapy (ART), people suspected of having INH or rifampin-
resistant M. tuberculosis, pregnant women, or women expecting to become
pregnant while on this regimen.7

 Why HIV patients should not get IPT?

A recent mass isoniazid preventive experiment among South African mine

workers found no reduction in TB incidence and prevalence after 9 months
of IPT, suggesting that transmission is not halted in high TB burden
regions and that the unchanging incidence is attributable to reinfection
(Churchyard et al. 2014).7

There is substantial dispute on the duration of IPT in HIV-infected patients

since trial data from severely exposed South African miners indicated that
the preventive benefit of IPT quickly fades, with the protective effect
fading within one year. This is most likely due to IPT eliminating any
latent infection and hence avoiding reactivation illness, but not preventing
re-infection following therapy completion. 7
 Individuals living in locations with a high background incidence of HIV
and TB should receive prolonged IPT (36 months) based on WHO
suggestion.7

4. BCG Vaccine

The only TB vaccine now available is the bacillus Calmette-Guerin (BCG)

vaccine, which was produced in 1921 via serial passage of Mycobacterium bovis.
BCG is the most extensively used vaccination in the world, yet estimates of its
efficiency range from 0% to 80%.7

However, studies have repeatedly demonstrated a protective benefit against the

most severe types of juvenile tuberculosis, including TB meningitis. A meta-
analysis of all published trials yielded an estimate of 50% overall effectiveness
and 80% efficacy in avoiding TB meningitis.7
Summary

In relation to the trigger, the 56-year-old woman came with the complaints of: fever,
persistent cough with green phlegm and a report of previous presence of blood spots,
decreased appetite, and weight loss. She also had uncontrolled diabetes mellitus and lived in a
dense area with poor lighting and ventilation.

Tuberculosis is an excellent mimic and should be considered in the differential diagnosis of a

variety of systemic diseases. It should be noted for this patient to be checked for TB infection
and its differential diagnosis such as non-tuberculous CAP, Non-Tuberculous
Mycobacterium, and etc.

If she happened to suffer from TB, I would recommend her to wear a mask to prevent
transmission to other people. I would also recommend her to move to a less dense population
with better ventilation and lighting to prevent transmission or re-infection if possible.

References

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Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK441916.
2. Houben RMGJ, Dodd PJ. The Global Burden of Latent Tuberculosis Infection: A Re-
estimation Using Mathematical Modelling. Metcalfe JZ, editor. PLOS Med [Internet].
2016 Oct 25;13(10):e1002152. Available from:
https://dx.plos.org/10.1371/journal.pmed.1002152
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Harisinghani M. Tuberculosis—The Great Mimicker. Semin Ultrasound, CT MRI
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Available from: https://linkinghub.elsevier.com/retrieve/pii/S128645792030099X
5. Jain V, Vashisht R, Yilmaz G, et al. Pneumonia Pathology. [Updated 2022 Apr 12]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK526116/.
6. Gopalaswamy R, Shanmugam S, Mondal R, Subbian S. Of tuberculosis and non-
tuberculous mycobacterial infections – a comparative analysis of epidemiology,
diagnosis and treatment. J Biomed Sci [Internet]. 2020 Dec 17;27(1):74. Available
from: https://jbiomedsci.biomedcentral.com/articles/10.1186/s12929-020-00667-6
7. Heemskerk D, Caws M, Marais B, Farrar J. Tuberculosis in Adults and Children
[Internet]. Cham: Springer International Publishing; 2015. (SpringerBriefs in Public
Health; vol. 2). Available from: http://link.springer.com/10.1007/978-3-319-19132-4
8. WHO. WHO issues updated recommendations on TB Infection Prevention and Control
[Internet]. World Health Organization. World Health Organization; [cited
2022May23]. Available from: https://www.who.int/news/item/14-03-2019-who-issues-
updated-recommendations.