TUBERCULOSIS

Infectious Disease Series Minci © 2007

Image credit : http://sitemaker.umich.edu/medchem13/files/tb.htm

Mycobacterium tuberculosis
• Also known as Koch’s bacillus • Obligate aerobe; Gram +ve • Withstand weak disinfectants • Survive dry states in weeks • AFB : acid-fast bacilli

• Primary TB
– Pulmonary (droplet spread) – Ghon focus  Ghon complex – Asymptomatic OR – Fever, lassitude, sweats, anorexia, cough, sputum, erythema nodosum, or phlyctenular conjunctivitis – SPUTUM : AFB – CXR – GI : ileocaecal junction and associated lymph nodes

TB

Primary TB

Post-primary TB

• How would you describe this skin lesion?

Post primary TB : state of immunocompromise
 reactivation
Pulmonary Pericarditis Effusion & Constrictive Miliary

• Pulmonary : Silent or symptomatic
– Cough, sputum – Haemoptysis (massive) – Malaise – Night sweats – Weight loss – Pleurisy – Pleural effusion

Acute TB pericarditis TB

Meningeal

Peritoneal Skin (lupus vulgaris)

GU

Bone

• Miliary TB
– Haematogenous dissemination – Non-specific presentation – CXR : reticulonodular shadowing – Look for retinal TB – Biopsy : lung, liver, LN, marrow may yield AFB or granulomata.

• Meningeal TB :
– Fever, headache, nausea, vomiting, neck stiffness, photophobia.

• GU TB :
– Frequency, dysuria, loin/back pain, haematuria, sterile pyuria. – 3 EMU for AFB – Renal USS – May spread to bladder, seminal vesicles, epididymis, fallopian tubes – (endometrial TB)

• Bone TB:
– Vertebral collapse adjacent to paravertebral abscess – Pott’s vertebra – XRay + biopsies (for AFB stains and culture)

• Lupus Vulgaris – jelly-like nodules • May progress to be ulcers

• Peritoneal TB :
– Abdo pain + GI upset – AFB in ascites; need laparatomy

• Acute TB pericarditis : primary exudative allergic lesion • Chronic pericardial effusion and constrictive pericarditis:
– Chronic granulomata – Manage by giving steroids for 11 weeks + anti-TB meds to reduce need for pericardiectomy.

Diagnosis
• Culture from relevant clinical samples.
– Send multiple sputum for MC+S for AFB – Effusion : pleural aspiration/ biopsy – Negative sputum? Bronchoscopy + biopsy + lavage

• TB PCR : to identify resistance to rifampicin (or multi-drug) • Histology : caseating granuloma

CXR

• Consolidation, cavitation, fibrosis and calcification

Diagnosis continued..
• Immunological evidence:
– Tuberculin skin test : TB Ag injected intradermally and cell-mediated response at 48-72hrs recorded.
• Positive : has immunity, previous exposure/BCG, active infection • False negative : immunosupression, including miliary TB, sarcoid, AIDS, lymphoma.

– Mantoux test : serial dilutions of TB Ag to give 1,10 and 100 TU)
• Positive if produce ≥ 10mm induration • Negative <5mm

– Heaf and Tine tests : screening. Consist of a circle of primed needles which inject the tuberculin.

Treatment
• Before:
– Stress importance of compliance – Check FBC, liver & renal function – Test colour vision and acuity. Ethambutol cause reversible ocular toxicity.

Initial Phase (8 weeks on 3-4 drugs) Drugs Rifampicin Isoniazid Pyrazinamide Ethambutol *Streptomycin Dose
600-900 mg , PO (child:15mg/kg) 3x week 15mg/kg PO 3x/ week + pyridoxine 10mg/24h 2.5g PO 3x/ week (2g if < 50kg) Child : 50mg/kg 30mg/kg PO 3x/ week
*0.75-1g/24h IM Child : 15mg/kg/24h

Side effects
Hepatitis, orange urine and tears, pill inactive, flu-like syndrome

Hepatitis, neuropathy, pyridoxine deficit, agranulocytosis.

Hepatitis, arthralgia (Contraindication : gout) Optic neuritis (colour vision deteriorate)

Continuation Phase ( 4 months on 2 drugs) • Rifampicin + Isoniazid at same dose • If possible resistance, use ethambutol 15mg/kg/24h PO • Give pyridoxine throughout • Steroids may be indicated in meningeal and pericardial disease

Additional Points
• Advise HIV testing • Notify consultant in CCDC to arrange contact tracing and screening • Explain prolonged Rx is necessary • Explain taking the tablets is important. LFTS are monitored. Explain that DOT may be needed. • Explain need for respiratory isolation procedures while infectious • Check regularly for drug compliance and toxicity.