TBC MANULA 2014
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Transcript of TBC MANULA 2014
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TB AND THE ELDERLYPATIENTdr SALIM S THALIB Sp.P2014
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Dr SALIM S THALIB Sp.P
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Caused by Mycobacterium tuberculosis
Spread by Airbone route
Droplet nuclei
Affected by Infectioussness of patient
Environmental condotions
Duration of exposure
Most persons exposed do not become infected
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1/3 of the world infected
2-3 million deaths/year Diagnosis is slow
Tx is long, complicated and toxic Resistance is rising
David Schlossberg, 2004
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7th
Stomach cancer
HIV
Suicide
1990
Murray & Lopez: Lancet 1997
2020
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Tuberculosiscomplex
M. Tuberculosis
M. BovisM. Africanum
M. microti
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Mycobacterium tuberculosis (MTB) is a
pathogenic bacterial species in the genus
Mycobacterium and the causative agent of
most cases of tuberculosis
The physiology of M. tuberculosis is
highly aerobic and requires highlevels of oxygen
M. tuberculosis requires oxygen to grow.
M. tuberculosis divides every 1520 hours
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Caused by Mycobacterium tuberculosis (M.
tuberculosis)
Spread person to person through airborne particles
that contain M. tuberculosis, called droplet nuclei Transmission occurs when an infectious person
coughs, sneezes, laughs, or sings
Prolonged contact needed for transmission 10% of infected persons will develop TB disease at
some point in their lives
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One cough produces 500 droplets nuclei
The average TB patient generates 75,000
dropletsper day before therapy
This drops to 25infectious droplets per
day within 2 weeks of effective therapy
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Number and Size of Organisms Liberated
Wells 1934, Duguid 1945, Wells/Riley 1953, et al.
Sejumlah organisme bertebaran:
Berbicara>o 200
Batuk.>0 3.500
Bersin>4.500 1. 000 000.
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FACTORS AFFECTING TB TRANSMISSION
Characteristics of the source case
Environment
Factor increasing risk for contacts
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The source
Cough,
Duration of symptoms
Cavitary disease
Sputum smear positive for AFB
RISK FACTORS FORTRANSMISSION TB
FAKTOR RESIKO DARI SUMBER PENULARAN
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The length of time you spend near the person
The distancebetween you and the person
The amount of clean airmoving through thespaces
Size and openness of space
Effectiveness of ventilation
RISK FACTORS FORTRANSMISSION TB
FROM A PERSON WITH INFECTIOUS TB DISEASE
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Disease in the lung, airway, or larynx
Presence of cough or other forceful expiratory
measures. Presence of acid-fast bacilli (AFB) in the sputum
Failure of patient to coverthe mouth and nose
when coughing or sneezing.
CHARACTERISTICS OF TB PATIENTS
THAT ENHANCE TRANSMISSION
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POTENSI PENULARAN PASIEN TB
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PRIMARY LESION
Uncontrolled spreadAbortive infection
Latency TB
Primary infectionMycobacteria- containing
droplets
PATHOGENESA TUBERCULOSIS
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LATENT ACTIVE
POST PRIMARY TB
Exogenous reinfection
Endogenous reactivation
PATHOGENESA TUBERCULOSIS
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Occurs whenperson breathes in bacteria
and it reaches the air sacs (alveoli) of lung
Immune system keeps bacilli containedand under control
Person is not infectious and has no
symptoms
LATENCY TB INFECTION (LTBI)
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Person:
Not ill
Not contagious
Normal chest x-ray
Germs:
Sleeping but still alive
Surrounded (walled off) by
bodys defense system Usually positive skin test
GRANULOMA
TB BACILLI
LATENCY TB INFECTION (LTBI)
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Wall breaks down due to aweakened immune system
WHAT CAUSES TB INFECTION TO
BECOME TB DISEASE ?
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RISK FACTOR RELATIVE RISK
HIV / AIDS 50-100
JEJUNOCAECAL SHUNT 27-63
SOLID TUMOURS 1-36
SILICOSIS 8-34
DIABETES MELITUS2-4
HEAD AND NECK NEOPLASMS 16
HEMODYALISIS 10-15
HAEMOTOLOGICAL NEOPLASMS 4-15
FIBROTIC LESIONS 2-15
IMUNOSUPPRESSIVE DRUGS
2-12
HEAVY SMOKING 5
LOW BODY WEIGHT 2-4
GASTRECTOMY 2-4
NORMAL POPULATION 1
RISK FACTORS ASSOCIATED WITH DEVELOPING TB DISEASE
RELATIVE RISK WITH RESPECT TO THE NORMAL POPULATION
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TB AND THE ELDERLYPATIENTdr SALIM S THALIB Sp.P
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TB AND THE ELDERLYPATIENT
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TBIN THE ELDERLY
The majority of TB in theelderly is secondary to
reactivation of latent TB
infection
With age, the T-cellmediated immune
response wanes allowing
for latent TB to become
active.
Kaufmann SHE. Nature Reviews Immunology 2001;1:20-30.
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TBIN THE ELDERLY
Other factors contributing to reactivation of TBinclude:
Age-associated diseases:
cardiovascular disease, COPD
Poor nutrition Chronic renal failure
Chronic institutionalization:
2-3 fold higher incidence of TB in nursinghome residents
Leung et al. J Am Geriatr Soc 2002;50:1219-26.
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PRESENTATIONOF TB IN OLDER ADULTS
May be difficult to diagnose TB in older adults
May not have classic presentation:
-less likely to have hemoptysis, fever, night sweats
than younger patients
Nonspecific symptoms are common including: Changes in activities of daily living
Chronic fatigue/weakness
Cognitive impairment
Anorexia/weight loss Persistent low-grade fever
Symptom duration may be greater in the elderly
Korzeniewska-Kosela M et al. Chest 1994;106:28-32.
Van Den Brande P et . Journal of Gerontology 1991;46:204-9.
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May be confused with age-related illnesses:
Malignancy
Diabetes mellitus
Malnutrition
Often only diagnosed postmortem
Lee et al.found that in their study of young and elderlypatients with pulmonary TB, initial diagnosis of TB wasmade correctly in 94.2% of younger patients, and only in
66.4% of elderly patients (p
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TYPICAL TB CHESTX-RAY
Liaw YS et al. J Am Geriatr Soc 1995;43:256-60
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TYPICAL TB CHESTX-RAY
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ELDERY TB CHESTX-RAY
TYPICAL TB CHESTX-RAY
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TYPICAL TB CHESTX-RAY
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TREATMENT
Since most cases result from reactivation, drugresistance is less of a concern in elderlypatients
Resistance should be considered if patient is:
1)From an area where there is a high
prevalence of multi-drug resistance (MDR)
2) A contact to a case with MDR
3) Had previous inadequate treatment for activetuberculosis
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DRUGTREATMENT
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DRUGTREATMENT
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ADVERSEDRUG EFFECTS
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ADVERSEDRUG EFFECTS
Yee D et al. Am J Resp Crit Care Med 2003;167:1472-77.
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Yee D et al. Am J Resp Crit Care Med 2003;167:1472-77
ADVERSEDRUG EFFECTS
17-34 years
35-59 years
60 years and older
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Hepatotoxicity:
incidence of INH-associated hepatotoxicity increases with age
risk of liver damage at age 50: 2.3%
severity of hepatitis also increases with age, with a higher
mortality in patients older than 50
ADVERSEDRUG EFFECTS
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DRUG INTERACTIONS
Many elderly patients have multiple medical problems
including:
Diabetes
Heart disease
Chronic lung disease
End-stage renal disease
High potential for interaction with Rifampicineand other
medications
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Finch et al. Intern Med.2002;162:985-992.
http://www.drugs.com/drug_interactions.html
DRUG INTERACTIONS
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Finch et al. Intern Med.2002;162:985-992.
http://www.drugs.com/drug_interactions.html
DRUG INTERACTIONS
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OUTCOMES
Increased mortality due to TB noted in older populations
Wang et al.reported a 26.5 % one-yearmortality in
patients >60 years old, versus 4.1% mortality in patient
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THANK