Tuberculosis

TB is an infectious disease caused by the bacillus Mycobacterium

tuberculosis. It typically affects the lungs (pulmonary TB) but can affect
other sites as well (extra pulmonary TB). The disease is spread in the air
when people who are sick with pulmonary TB expel bacteria for example
by coughing.

Infectious agents:
Mycobacterium tuberculosis complex which include: M. Tuberculosis .
M. Bovis. M. Africanum. M. Microti. M. Canetti.

TB Transmission:
1. Inhalation: TB spread from person to person through the air via
droplet nuclei. M. tuberculosis may be expelled when an infectious
person (Cough, Sneeze, Speaks, Sings).Transmission occurs when
another person inhales droplet nuclei .
2. Ingestion: Ingestion of contaminated milk (M. bovis).
3. Extra-pulmonary TB other than laryngeal TB was non infective.

TB Pathogenesis:
Pathogenesis is defined as how an infection or disease develops in the
body.
a. Latent TB Infection (LTBI): Occurs when tubercle bacilli are in the
body, but the immune system is keeping them under control. This
infection usually detected by the Mantoux skin test.
b. TB Disease: Develops when immune system cannot keep tubercle
bacilli under control . It may develop very soon after infection or many
years after infection. About 10% of all people with normal immune
systems who have LTBI will develop TB disease at some point in their
lives.

Clinical features:
General Symptoms of TB Disease:
Fever, Chills, Night sweats, Weight loss, Appetite loss, Fatigue and
Malaise.
Symptoms of Pulmonary TB Disease :
Cough lasting 3 or more weeks, Chest pain and Coughing up sputum or
blood.
Symptoms of extra pulmonary TB disease depend on part of body that is
affected.

Case definition:
A case of TB is defined as a patient in whom tuberculosis has been
confirmed by bacteriological or clinical diagnosis.

Case definition depends on:

1. Site of disease:
TB affect the lung → pulmonary TB.
TB in other organs → Extra pulmonary TB.
2. Severity of disease:
Depend on bacteriological load, extent of disease and anatomical
site.
3. Bacteriological results of sputum examination:
a. Smear positive pulmonary TB which represent either:
1. At least 2 sputum smears positive for AFB by
microscopically diagnosis.
2. One sputum smears positive for AFB plus X-ray findings
consistent with TB and clinical decision.
3. One sputum smears positive for AFB plus culture positive
for AFB.

b. Smear negative pulmonary TB : Patient should full all the

following criteria:
1. At least 3 sputum smears negative (one of them at early
morning).
2. Radiological findings consistent with TB.
3. Lack of response for antibiotics.
*Extra-pulmonary TB: TB of organs other than the lung.
4. Case classification according to previous treatment:
1. New case (Positive, Negative& Extra-pulmonary).
2. Defaulter.
3. Relapse.
 4. Treatment failure.
5. Chronic Case (drug resistances MDR-TB).
New case: A patient who has never had treatment for TB or who has
taken anti-tuberculosis drugs for Less than four weeks.
Relapse: A patient who has been declared cured of any form of TB
in the past by a physician after one full course of chemotherapy and
has become sputum smear-positive .
Defaulter: A patient who interrupts treatment for two months or
more, and returns to the health service with smear-positive sputum
consider as treatment failure or sputum negative continue his
treatment but from the start.
Chronic case: A patient, who remains or becomes again smear-
positive, after completing a fully supervised retreatment regimen.
Treatment failure: A patient who remains or becomes again smear-
positive after five months or later during treatment or change from
negative to positive after second month of treatment.

Diagnosis
1. Medical history.
2. Physical examination.
3. Tuberculin test.
4. Chest x-ray.
5. Bacteriological examination

DOTS Strategy:
DOTS (directly observed therapy, short-course) is a strategy which
primary health services are using to detect and cure TB patients. Health
workers counsel and observe their patients swallowing each dose of
medicine and monitor the patient’s progress until cured.

Anti-TB drugs:
Isoniazid (H), Rifampin (R( , Pyrazinamide (Z), Ethambutol (E) and
Streptomycin (S).
Treatment category:
CATEGORY - I TREATMENT:
TYPE OF Patients
1. New sputum positive.
2. New sputum negative and seriously ill (Extensive parenchyma
damage).
3. New extra pulmonary seriously ill (Severe form).
CATEGORY - II TREATMENT:
TYPE OF PATIENTS
1. Sputum smear positive relapse .
2. Sputum smear positive treatment after default.
3. Sputum smear positive failure.
4. Other previously treated.
CATEGORY III TREATMENT
TYPE OF PATIENTS
1. New sputum negative and not seriously ill.
2. New extra pulmonary and not seriously ill.

Classification of extra-pulmonary TB
Standard Short course regimen of Anti-TB drugs (WHO)
Treatment divided into 2 phases including (intensive phase and
continuation phase).
Category I : 2HRZE(S)/4HR
Category II : 2HRZES/HRZE/5HRE
Category III : 2HRZ/4HR
Category IV: Chronic case with MDR-TB .
MDR-TB : multi drug-resistant tuberculosis defined as resistance to at
least isoniazid and rifampin which emerged as a threat to TB control.
MDR-TB treatment requires the use of second-line drugs that are less
effective, more toxic, and costlier than first-line isoniazid- and rifampin-
based regimens.