Tuberculosis

Scanning electron micrograph of Mycobacterium tuberculosis

Clinical definition Clinical features Diagnosis Treatment

Prevention

Clinical definition
Pulmonary tuberculosis is a bacterial infection due to Mycobacterium tuberculosis, spread by airborne route. After contamination, M. tuberculosis multiplies slowly in the lungs:
this represents the primary infection.

In immunocompetent patients, the pulmonary lesion heals in 90% of cases, but in 10%, patients develop active tuberculosis.

Tuberculosis may also be extrapulmonary:

Tuberculous meningitis, Disseminated tuberculosis, lymph node tuberculosis,

spinal tuberculosis, etc.

Patients with HIV infection have an increased risk of developing active tuberculosis. Tuberculosis is the opportunistic disease that most commonly reveals AIDS. In certain countries, up to 70% of patients with tuberculosis are co-infected with HIV.

Types
Pulmonary
If a tuberculosis infection does become active, it most commonly involves the lungs (in about 90% of cases). Symptoms may include chest pain and a prolonged cough producing sputum. About 25% of people may not have any symptoms (i.e. they remain "asymptomatic"). Occasionally, people may cough up blood in small amounts, and in very rare cases,

the infection may erode into the pulmonary artery, resulting in massive bleeding
(Rasmussen's aneurysm). Tuberculosis may become a chronic illness and cause extensive scarring in the upper lobes of the lungs.

The upper lung lobes are more frequently affected by tuberculosis than the lower
ones. The reason for this difference is not entirely clear. It may be due either to better air flow, or to poor lymph drainage within the upper lungs.

Extrapulmonary
In 1520% of active cases, the infection spreads outside the lungs, causing

other kinds of TB.

Collectively denoted as "extrapulmonary tuberculosis". Extrapulmonary TB occurs more commonly in immunosuppressed persons and young children. In those with HIV, this occurs in more than 50% of cases. Notable extrapulmonary infection sites include
the pleura (in tuberculous pleurisy), the central nervous system (in tuberculous meningitis), the lymphatic system (in scrofula of the neck), the genitourinary system (in urogenital tuberculosis), The bones and joints (in Pott's disease of the spine),

 When it spreads to the bones, it is also known as "osseous tuberculosis". a form of osteomyelitis. Sometimes, bursting of a tubercular abscess through skin results in tuberculous ulcer. An ulcer originating from nearby infected lymph nodes is painless, slowly enlarging and has an appearance of "wash leather". A potentially more serious, widespread form of TB is called "disseminated" TB, commonly known as miliary tuberculosis.

Miliary TB makes up about 10% of extrapulmonary cases.

Clinical features
Prolonged cough (> two weeks),
sputum production, chest pain, weight loss, anorexia, fatigue, moderate fever, night sweats.

The most characteristic sign is

haemoptysis (presence of blood in sputum)

Not always present and haemoptysis is not always due to tuberculosis. If sputum is smear-negative,
consider pulmonary distomatosis, melioidosis (Southeast Asia), profound mycosis or bronchial carcinoma.

The diagnosis of tuberculosis is to be considered, in practice, for all patients consulting for respiratory symptoms for over two weeks who do not respond to non-specific antibacterial treatment.

Diagnosis
Sputum smear microscopy; culture Chest X-rays are useful for the diagnosis of smear negative tuberculosis tuberculosis in children.

Infection in both lungs is marked by white arrow-heads, and the formation of a cavity is marked by black arrows. Chest X-ray of a person with advanced tuberculosis.

Treatment
The treatment is a combination of several of the following antituberculous drugs
isoniazid (H), rifampicin (R), pyrazinamide (Z), ethambutol (E), streptomycin (S).

The regimen is standardised and organized into 2 phases (initial phase and continuation phase). The treatment of drug-sensitive tuberculosis lasts a minimum of 6 months. It takes significant investment to cure a TB patient, both from the patient and the medical team. Only uninterrupted treatment for several months may lead to cure and prevent the development of resistance, which complicates later treatment. It is essential that the patient understands the importance of treatment adherence and that he has access to correct case management until treatment is completed.

Prevention
When BCG (bacillus CalmetteGurin) is correctly carried out, it confers protection that is not insignificant (probably over 50%). It has been proven that BCG protects against severe forms of the disease, in particular tuberculous meningitis and miliary tuberculosis. BCG vaccination does not diminish transmission of tuberculosis. For more information on the diagnosis, treatment and prevention of tuberculosis, and on the follow-up of tuberculosis patients, refer to the MSF handbook, Tuberculosis.

Public health campaigns in the 1920s tried to halt the spread of TB.

Tuberculosis prevention and control efforts primarily rely on the vaccination of infants and the detection and appropriate treatment of active cases. The World Health Organization has achieved some success with improved treatment regimens, and a small decrease

in case numbers