Tuberculosis: Mr. Vinod V. Bagilkar Lecturer Department of Pediatric Nursing

TUBERCULOSIS
Mr. VINOD V. BAGILKAR
Lecturer
Department of Pediatric Nursing
Mr. Vinod V.B, Lecturer, Pedi Dept
INTRODUCTION
 One third of the world’s population is infected with Mycobacterium

tuberculosis.
 Each year, about 9 million people develop TB, of whom 2 millions die
 Of the 9 million annual TB cases, about 1 million (11%) occur in
children (under 15 years of age).
 Of these childhood cases, 75% occur annually in 22 high-burden
countries that together account for 80% of the world’s estimated incident
cases.
 In countries worldwide, the reported percentage of all TB cases occurring
in children varies from 3% to more than 25%. 2
DEFINITION
Tuberculosis is specific infection chronic disease caused by “

mycobacterium tuberculosis”.
This disease primarily affects the lungs causing pulmonary
tuberculosis. It can also affect meninges, intestine, bones,
joints, lymph glands, skin and other tissues of the body.
It was first isolated in 1882 by a German physician named
Robert Koch who received the Nobel Prize for this discovery.
TB most commonly affects the lungs but also can involve
almost any organ of the body. 3
Estimated new TB cases ('000s)
10
100
1000
10000
India
China
Indonesia
Bangladesh
Nigeria
Pakistan
Philippines
South Africa
Russian Federation
Ethiopia
DR Congo
Viet Nam
Kenya
UR Tanzania
Brazil
Thailand
Myanmar
Zimbabwe
22 high-burden countries: 80% of all new cases
Uganda
Cambodia
Afghanistan
Mozambique
4
TYPES OF TUBERCULOSIS
Tuberculosis is divided into three clinically important

categories:
 Primary TB
 Secondary Reactivated TB
 Disseminated TB
5
Primary Tuberculosis
 Primary tuberculosis refers to the infection process which

eventually eliminates the pathogen or results in a clash
between the Mycobacteria and the immune system.
 With most TB infections, the immune system is able to
contain, although not eliminate, the Mycobacteria within the
tubercle, preventing the spread of bacteria and progression of
the disease.
 M. tuberculosis can remain inactive infection for many years.6
SECONDARY OR REACTIVATED TUBERCULOSIS
 The infection can become reactivated if

the Mycobacteria are able to rupture the tubercle
and spread through the lungs.
 This reactivation typically happens to those with a
weakened or suppressed immune system.
7
Disseminated Tuberculosis
 The spread of the disease within the body may result

if infected macrophages moving through the blood
and lymph transport the bacteria to other sites.
 Once infected, symptoms of disseminated TB
correspond to the locations infected.
8
MODE OF TRANSMISSION
 MOT is mainly droplet infection and droplet nuclei

during coughing and sneezing in sputum +ve patient
of Pulmonary TB.
 Nasopharyngeal secretion.
 Infected spits
9
INCUBATION PERIOD
Incubation period may be weeks, months and

years. It depends upon host parasite relationship,
closeness of contact, extent of disease and sputum
positivity of the source cases. Average incubation
period is 4 to 8 weeks
10
CAUSES
 A person can become infected with tuberculosis bacteria when he
or she inhales minute particles of infected sputum from the air.
 The bacteria get into the air when someone who has a
tuberculosis lung infection coughs, sneezes, shouts, or spits
(which is common in some cultures).
 Tuberculosis is a serious health problem in its own right but it is
also the most likely cause of death for HIV positive people. Like
HIV, tuberculosis has had an uneven impact around the world. 11

RISK FACTORS
Risk factors for TB infection
 Children exposed to high-risk adults
 Foreign-born persons from high-prevalence countries
 Poor and indigent persons, especially in large cities
 Homeless persons
 Persons who inject drugs
 Present and former residents or employees of correctional institutions,
homeless shelters, and nursing homes
 Health care workers caring for high-risk patients
12
Progression of latent infection to disease

 Infants and children ≤4 yr of age, especially those <2 yr of age
 Adolescents and young adults
 Persons co-infected with HIV
 Persons with skin test conversion in the past 1–2 yr
 Persons who are immunocompromised, especially in cases of
malignancy and solid organ transplantation, immunosuppressive
medical treatments including anti–tumor necrosis factor
therapies, diabetes mellitus, chronic renal failure, silicosis, and
malnutrition 13
PATHOLOGY
Exposure or inhalation of infected Aerosol through droplet nuclei

(exposure to infected clients by coughing, sneezing, talking)
Tubercle bacilli invasion in the apices of the Lungs or near the pleurae of
the lower lobes
Bronchopneumonia develops in the lung tissue (Phagocytosed tubercle

bacilli are ingested by macrophages)
 bacterial cell wall binds with macrophages arrest of a Phagocytosed

which results to bacilli replication 14
Necrotic Degeneration occurs (production of cavities filled with cheese-

like mass of tubercle bacilli, dead WBCs, necrotic lung tissue)
drainage of necrotic materials into the tracheobronchial tree (eruption of

coughing, formation of lesions) called as primary focus
some bacilli traverse to the regional lymph nodes and cause reaction
there. Primary focus, regional lymph nodes and draining lymphatic
together called as primary complex
15
CLINICAL FEATURES
Incubation period: varies between 4-8 weeks
Onset: onset is generally insidious but may be

relatively sudden in case of tubercular meningitis or
miliary TB.
16
Early symptoms:
 Early clinical symptoms are vague and non descriptive.
 Over two thirds of the children are asymptomatic or they may have a mild
transient illness for few days.
 In the remaining one third of the patients the child appear irritable,
anxious and off color. Loses interest in play and fatigued easily.
Evidenced of toxemia:
 The fever is generally low grade but may be high
 Pulse rate is increased.
 Appetite is reduced and there is progressive loss of weight.
 Night sweat usually on forehead is prominent.
 Child looks pale and ill. 17
SYMPTOMS AND SIGNS DUE TO LOCAL LESIONS ARE
Primary pulmonary disease
 Nonproductive cough and mild Dyspnea are the most common symptoms.
 Systemic complaints such as fever, night sweats, anorexia, and decreased
activity occur less often.
 Some infants have difficulty gaining weight or develop a true failure-to-
thrive syndrome.
 Pulmonary signs are even less common.
 Children with bronchial obstruction have localized wheezing or decreased
breath sounds this accompanied by tachypnea or rarely respiratory distress.

18
Progressive Primary Pulmonary Disease
 Significant signs or symptoms are frequent in locally progressive disease
in children.
 High fever, severe cough with sputum production, malaise, pallor, weight
loss, and night sweats are common.
 Physical signs include diminished breath sounds, rales, and dullness over
the cavity.
Reactivation of TB
Older children and adolescents with reactivation TB are more likely

to experience fever, anorexia, malaise, weight loss, night sweats,
productive cough, hemoptysis, and chest pain than children with primary
pulmonary TB. 19
Extrathoracic tuberculosis
Is mainly found in CNS (meninges), abdomen(intestine,
peritoneum), bone, joints, lymph glands, skin and
genitourinary tract.
20
DIAGNOSIS
A complete medical diagnosis for TB includes a

review of complete medical history, physical
examination of patient, a tuberculin skin test, a chest
X-ray, and microbiologic smears and cultures.
Tuberculosis can be diagnosed by many ways:
21
Clinical features
 Clinical features of TB are vague and non descriptive.
 Onset of illness are subacute and course is prolonged
with tendency.
 Symptoms suggestive of TB include fever for more
than weeks, recent loss of appetite and weight, failure
to thrive despite adequate intake and Recurrent RTI.
22
History of contact with an infective case

 This is defined as any children living in a household with adult
taking antiTB therapy or has taken such therapy in past two years.
 History of contact is available in less than one third of the
patients.
Physical examination
 A physical examination is done to assess the patient's general
health and find other factors which may affect the TB treatment
plan.
 It cannot be used to confirm or rule out TB. 23
Tuberculin test:
 The Mantoux tuberculin skin test
 Intradermal injection of 0.1 mL
containing 5-10 tuberculin units of
purified protein derivative (PPD) on
anterior aspect of the left forearm.
 A weal of 5 mm should be raised.
 The reaction is interpreted after 48-
72 hours.
 An indurations of more than 10 mm
is suggestive of recent infection and
should be treated. 24
Tuberculin test in the vaccinated children

 BCG test is performed by intradermal injection with BCG
vaccine in the left deltoid region.
 An induration of more than 5 to 6mm after 3 days of
injection
 children vaccinated previously with BCG show positive
tuberculin test during infancy.
 In older children the interpretation does not alter by
vaccination. 25
LABORATORY INVESTIGATIONS
Microbiological studies
 A definitive diagnosis of tuberculosis can only be made by
culturing Mycobacterium tuberculosis organisms from a
specimen taken from the patient (most often sputum, but may
also include pus, CSF, etc.
 A diagnosis made other than by culture may only be classified
as "probable" or "presumed".
 For a diagnosis the possibility of tuberculosis infection, most
protocols require that two separate cultures both test negative26
Sputum
 Sputum smears and cultures should be done for acid-fast bacilli if the
patient is producing sputum.
 The preferred method for this is fluorescence microscopy (auramine-
rhodamine staining), which is more sensitive than conventional Ziehl-
Neelsen staining.
27
Alternative sampling
 In patients incapable of producing a sputum sample,
alternative sample sources for diagnosing pulmonary
tuberculosis include
 Gastric washings, laryngeal swab, bronchoscopy (with
bronchoalveolar lavage, bronchial washings, and/or
transbronchial biopsy), and fine needle
aspiration (transtracheal or transbronchial).
28
Histopathology:
Glands, liver and other tissues may be examined for histological

evidence of TB by FNAC.
Immunodiagnostic:
Diagnosis of antitubercular antigen and antibody by

radioimmunoassay can be perform as an effective one.
Routine blood counts:
Elevation of ESR
Radiology
Chest X ray and CT scan of effected part can rule out Consolidation,
pleural effusion, scar, adenopathy which may help in diagnosis. 29
PREVENTIONS
Preventive measures include strict standards for ventilation, air
filtration etc.
 A vaccine, BCG, is available and has been of some benefit in
preventing TB
 Covering of mouth by a mask is helpful in prevention from TB
 Exercise regularly to keep your immune system
 Get adequate amounts of sleep
 Get tested regularly. Experts advise getting a skin test annually
 Keep your immune system healthy. 30

 Make sure you eat plenty of healthy foods
 A drug called Isoniazid (INH) can be used as a preventative
therapy for those who are at high risk of becoming infected
with tuberculosis.
 The WHO recommends that HIV positive people who have
latent TB should be offered isoniazid preventive therapy as
needed.
31
TREATMENTS
Principle of treatment
 Diagnosis should be made early
 Treatment should be prompt, adequate, vigorous and prolonged
depending on the severity of the disease
 More than one antitubercular drug should be used for the
prevention of delayed development of resistance of tuberculin
bacilli to the drugs
 All drug should be given in a single daily dose on empty
stomach 32
 Pyridoxine is not necessary in child taking isoniazide

 Nutrition of the child should be improved by an appetizing,
nutritionally balanced diet with adequate protein and calories
 Every effort should be made to trace the reservoir of infection
or the open infective cases in family or extra familial contacts
 Living condition should be improved by better hygienic
measures and improved sanitation. Child should be exposed to
adequate sunshine and living apartment should be well
ventilated.
33
DRUGS
1st line: Majority of patients can be treated with
these drugs successfully. They are effective with
minimal toxicity and includes
34
TWICE A
WEEK
DAILY DOSAGE,
DOSAGE DOSAGE, MG/KG PER MAXIMUM ADVERSE
DRUGS FORMS MG/KG DOSE DOSE REACTIONS
Ethambutol Tablets 15–25 50 2.5 g Optic neuritis

(usually reversible),
100 mg
decreased red-green
400 mg
color
discrimination,
gastrointestinal tract
disturbances,
hypersensitivity
35
TWICE A
WEEK
DAILY DOSAGE,
DOSAGE DOSAGE, MG/KG PER MAXIMUM ADVERSE
Daily,
Isoniazid Scored 10–15 20–30 Mild hepatic
300 mg
tablets enzyme elevation,
hepatitis,
100 mg
peripheral
Twice a
300 mg neuritis,.
week,
900 mg hypersensitivity
Syrup
10 g/mL 36
TWICE A
WEEK
DOSAG DAILY DOSAGE,
E DOSAGE, MG/KG PER MAXIMUM ADVERSE
Pyrazinamide Scored 20–40 50 2g Hepatotoxic

tablets effects,
hyperuricemiaarthr
500 algias,
mg gastrointestinal
tract upset
37
DAILY TWICE A WEEK

DOSAGE DOSAGE, DOSAGE, MG/KG MAXIMU ADVERSE
DRUGS FORMS MG/KG PER DOSE M DOSE REACTIONS
Rifampin Capsules 10–20 10–20 600 mg Orange discoloration

of secretions or
150 mg urine, staining of
300 mg contact lenses,

vomiting, hepatitis,
Syrup influenza-like
formulat reaction,
ed in thrombocytopenia,
pruritus; oral
syrup
contraceptives may
from
be ineffective
capsules
38
 2nd line: used in drug resistant case or In

situations where first line drugs cannot be used
either due to toxicity or some other constraints.
Includes
39
DOSAGE, Mr. Vinod V.B,MAXIMUM
Lecturer, Pedi Dept
DRUGS FORMS DAILY DOSAGE, MG/KG DOSE ADVERSE REACTIONS
Amikacin Vials, 15–30 (IV or IM 1 g Auditory and vestibular

500 mg administration) toxic effects, nephrotoxic
and 1 g effects
Capreomycin Vials, 1 15–30 (IM 1 g Auditory and vestibular

g administration) toxicity and nephrotoxic
effects
Cycloserine Capsule 10–20, given in 2 1 g Psychosis, personality

s, 250 divided doses changes, seizures, rash
mg
Ethionamide Tablets, 15–20, given in 2–3 1 g Gastrointestinal tract

250 mg divided doses disturbances, hepatotoxic
effects, hypersensitivity
reactions, hypothyroid 40
DOSAGE, MAXIMUM
DRUGS FORMS DAILY DOSAGE, MG/KG DOSE ADVERSE REACTIONS
Kanamycin Vials 15–30 (IM or IV 1 g Auditory and vestibular

administration) toxic effects, nephrotoxic
effects
75mg/2 mL
500mg/2mL
1 g/3 mL
41
Other drugs: These are strictly reserved for drug

resistant cases and includes quinolones, rifamycine,
amikacin, imipenam and ampicillin
42
ANTITUBERCULUS REGIMEN
 Newly diagnosed patients are treated with short course chemotherapy
regimen. It consist of two phase
 Intensive phase: goal of this phase is to eliminate bacterial load and
prevent emergence of drug resistant strains. atleast 3 bactericidal
drugs are used in this phase.
 Continuation phase: Atleast two bactericidal drugs are used in this
phase to continue and complete this therapy
43
Grou Clinical presentation Mr. Vinod V.B, Lecturer, Pedi Dept
p REGIMEN
1 a. Asymptomatic Mantoux positive aged<3years 6 HR

b. Asymptomatic Mantoux positive aged<5years with grade iii or iv
malnutrition
c. Children<3yrs with history of contact
d. Children<5yrs with history of contact with grade iii or iv
malnutrition
e. Recent converter with no signs but montoux test positive
2 a. Primary complex 2HRZ+4H

b. Symptomatic montoux positive<3years without localization R
c. Symptomatic montoux positive<5years with grade iii or iv
malnutrition without localization
d. Isolated lymphadenitis
e. Pleural effusion
R-Rrifampicin, H- isoniazide, Z- pyrizinamide, S-streptomycine, E-Ethambutol 44

Clinical presentation
Group REGIMEN
3 a. Progressive pulmonary disease 2HRZE+4HR
b. Tubercular lymphadenitis involving multiple nodes. Extend
continuation phase by 3 month in event of non resolution
4 a. Military TB 2HRZE+7HR
b. Disseminated TB
c. Cavitatory TB
d. Tubercular bronchopneumonia
e. Bone and joint TB
f. Abdominal,genitourinary or pericardial TB
5. CNS TB 2HRZE+10H
RE
R-Rrifampicin, H- isoniazide, Z- pyrizinamide, S-streptomycine, E-Ethambutol

45
Nutritional management in tuberculosis
Energy
Energy needs of TB patients are increased because of the disease

itself. (Approximately 35 - 40 kCal per kilogram of ideal body
weight).
Protein
The protein intake of the diet is important to prevent the wasting

of body stores (for example muscle tissues). An intake of 1.2 -
1.5 g per kilogram body weight or 15% of energy of total daily
intake or approximately 75 - 100 g per day will be sufficient.
46
Micronutrients
A good multivitamin and mineral supplement,

therefore providing 50% -150% of the
recommended daily allowance, is advisable since it
will be most unlikely that a person with TB will be
able to meet the increased requirements for vitamins
and minerals with diet alone (due to a poor
appetite).
47
COLLABORATIVE PROBLEMS
 Malnutrition
 Adverse side effects of medication therapy: hepatitis,
neurologic changes, skin rash, GI upset
 Multidrug resistant
 Spread of TB infection to other body parts
48
NURSING MANAGEMENT
Assessment
 Complete history and physical examination
 Clinical manifestations of fever, anorexia, weight loss, growth retardation,
night sweat, fatigue, cough and sputum production
 Respiratory system for breath sounds, consolidation, air entry, respiratory rate
 Assess for signs and symptoms of dehydration
 Living condition of family
 Economic status of family
 Knowledge about the disease
 Readiness to learn about the disease, treatment
49
Diagnosis
 Ineffective airway clearance related to copious tracheobronchial
secretion.
 Imbalanced nutrition less than body requirement related to loss of
appetite
 Risk for fluid volume deficit related to excessive fluid loss aeb night
sweat
 Deficient knowledge about treatment regimen and preventive health
measures.
 Activity intolerance related to fatigue
 Ineffective family coping related to diagnosis of a infectious disease
50
NURSING INTERVENTIONS
Promoting airway clearance
 Respiratory status, vital signs should be monitored
 Increase fluid intake to liquidify the secretions
 Encourage child to cough out the expectorant
 Teach the child diaphragmatic breathing which may help to
improve ventilation and mobilize secretion without causing
breathlessness and fatigue
 Administer medication as prescribed 51
Maintaining nutritional balance

 Diet high in protein, carbohydrate to be provided
 Small frequent diet should be provided
 Weight monitoring should be done regularly
 Vitamin B6 supplementation to be provided
 Ask child about his interest while serving food
 Include different varieties of food everyday
 Serve food in a pleasant environment
52
Maintaining fluid volume

 Monitor vital signs for low BP, rapid pulse
 Assess for degree of dehydration
 Monitor fluid intake and output
 Encourage the child to take plenty of fluids
 Administer IV fluids when oral intake is not sufficient
 Provide skin care, mouth care
53
Advocating adherence to treatment regimen

 Teach the child, parents about the medications
 Clearly explain about the schedule, side effects of the medications
 Explain what to expect when they are taking medication like
orange colour urine
 Explain about importance of strict adherence to the treatment
regimen
 Important hygiene measures to be instructed like covering mouth
while coughing, sneezing
54
Improving activity tolerance

 Assess for the patients current level of functioning
 Instruct child to take rest in between activity
 Develop a proper routine of work for the child
 Teach some minor exercise that helps in ventilation of lungs
 Slowly slowly increase the time of activity
55
Improving family coping

 Explain about the disease to the family
 Explain about the preventive measures to be taken by
family
 Explain that can be treated with proper support, strict
adherence to treatment regimen
56
57

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TUBERCULOSIS

Mr. VINOD V. BAGILKAR

 One third of the world’s population is infected with Mycobacterium

Tuberculosis is specific infection chronic disease caused by “

Tuberculosis is divided into three clinically important

 Primary tuberculosis refers to the infection process which

SECONDARY OR REACTIVATED TUBERCULOSIS

 The infection can become reactivated if

 The spread of the disease within the body may result

 MOT is mainly droplet infection and droplet nuclei

Incubation period may be weeks, months and

or she inhales minute particles of infected sputum from the air.

tuberculosis lung infection coughs, sneezes, shouts, or spits

(which is common in some cultures).

 Tuberculosis is a serious health problem in its own right but it is

HIV, tuberculosis has had an uneven impact around the world. 11

Progression of latent infection to disease

Exposure or inhalation of infected Aerosol through droplet nuclei

Bronchopneumonia develops in the lung tissue (Phagocytosed tubercle

 bacterial cell wall binds with macrophages arrest of a Phagocytosed

Necrotic Degeneration occurs (production of cavities filled with cheese-

drainage of necrotic materials into the tracheobronchial tree (eruption of

Incubation period: varies between 4-8 weeks

Onset: onset is generally insidious but may be

SYMPTOMS AND SIGNS DUE TO LOCAL LESIONS ARE

Primary pulmonary disease

 Systemic complaints such as fever, night sweats, anorexia, and decreased

activity occur less often.

 Some infants have difficulty gaining weight or develop a true failure-to-

 Pulmonary signs are even less common.

 Children with bronchial obstruction have localized wheezing or decreased

breath sounds this accompanied by tachypnea or rarely respiratory distress.

Older children and adolescents with reactivation TB are more likely

A complete medical diagnosis for TB includes a

History of contact with an infective case

Tuberculin test in the vaccinated children

Glands, liver and other tissues may be examined for histological

Diagnosis of antitubercular antigen and antibody by

Routine blood counts:

Preventive measures include strict standards for ventilation, air

 A vaccine, BCG, is available and has been of some benefit in

 Covering of mouth by a mask is helpful in prevention from TB

 Exercise regularly to keep your immune system

 Get adequate amounts of sleep

 Get tested regularly. Experts advise getting a skin test annually

 Keep your immune system healthy. 30

 Make sure you eat plenty of healthy foods

 A drug called Isoniazid (INH) can be used as a preventative

therapy for those who are at high risk of becoming infected

 The WHO recommends that HIV positive people who have

latent TB should be offered isoniazid preventive therapy as

 Pyridoxine is not necessary in child taking isoniazide

Ethambutol Tablets 15–25 50 2.5 g Optic neuritis

Pyrazinamide Scored 20–40 50 2g Hepatotoxic

DAILY TWICE A WEEK

Rifampin Capsules 10–20 10–20 600 mg Orange discoloration

300 mg contact lenses,

 2nd line: used in drug resistant case or In

DRUGS FORMS DAILY DOSAGE, MG/KG DOSE ADVERSE REACTIONS

Amikacin Vials, 15–30 (IV or IM 1 g Auditory and vestibular

Capreomycin Vials, 1 15–30 (IM 1 g Auditory and vestibular

Cycloserine Capsule 10–20, given in 2 1 g Psychosis, personality