TBC (PU)

8/12/2019 TBC (PU)

1/48

Prof.dr.Tamsil Syafiuddin,SpP(K)

Pulmonary Department

Faculty of Medicine

Universitas Islam Sumatera Utara

PULMONARYTUBERCULOSIS

8/12/2019 TBC (PU)

2/48

Levels of competence

Standar Kompetensi Dokter , Konsil Kedokteran Indonesia, 2006

8/12/2019 TBC (PU)

3/48

Standar Kompetensi Dokter , Konsil Kedokteran Indonesia, 2006

Level of competence 4:

Mampu membuat diagnos is k l in ik berdasarkanpem er iks aan f i s ik dan pemeriksaan tambahan

yang diminta oleh dokter (misalnya: pemeriksaan

laboratorum sederhana atau X-ray).

Dokter dapat memu tu sk an dan mampu menangan i

problem itu secara mandi r i hingga tuntas.

8/12/2019 TBC (PU)

4/48

TB

PROBLEMS

IN PUT OUT PUT(Dokter)

System/Faculty of Medicine

Medical Education as a System

8/12/2019 TBC (PU)

5/48

Definition

Tuberculosis infection means thatMycobacterium tuberculosis has infected a

host but is not causing disease

Tuberculosis disease or tuberculosis means the disease caused by M.tuberculosis

8/12/2019 TBC (PU)

6/48

Epidemiology WHO estimates >8 million new cases of

tuberculosis per year

Estimated that 19-43% of the worldspopulation is infected with M. tuberculosis

Infected persons serve as reservoirs foractivated disease to occur

Among infectious diseases, TB remainsthe second leading killer of adults in the world

More than 2 million TB-related deaths each year

8/12/2019 TBC (PU)

7/48

Tuberculosis (TB) is The Ancient Killer The GreatImitator The Giant Poverty Producing Mechanism( Guzman et al 1999 )

Indonesia : 3rd in the World MDR-TB 12 20% / year ,mortality 175.000 / year , 500 / day( WHO Report 2000 )

Pulmonary TB Indonesia)

8/12/2019 TBC (PU)

8/48

Source

Child

Young adult

AdultDMHIVNATURAL HISTORY

reservoirs

8/12/2019 TBC (PU)

9/48

Data:

Analysis

Planning

TB ?

Batuk

Umur muda

Foto

toraks

The scientific thinking

Batuk darahRiwayat demamNapsu makan

8/12/2019 TBC (PU)

10/48

Data:

Analysis

Planning

TB ?

Batuk

Umur tua

DM,HIV AIDS ? Foto Toraks

The scientific thinking

Batuk darahRiwayat demamNapsu makan

8/12/2019 TBC (PU)

11/48

Tuberculosis

History Evidence dating back to 2400 BC Called pthisis: Greek for consumption Herman Brehmer: botany student from

Poland with TB, returned from Himalayanscured; doctoral dissertation in 1854 entitledTuberculosis is a Curable Disease

1882 : Robert Koch identified organism with

newly developed staining technique Advent of x-ray technology in 1895 allowed for

assessment of severity and progression ofdisease

8/12/2019 TBC (PU)

12/48

Tuberculosis History

Early 20th century : French bacteriologistsCalumet and Guerin developed technique thatled to BCG vaccine

Advent of anti-TB chemotherapy 1940 actinomycin

1943 streptomycin

1950s combination therapy

2003 - fix dosed combination

2008 UISU students

8/12/2019 TBC (PU)

13/48

Pathogenesis M. tb ingested by macrophages in alveoli

May survive and multiply

Spread by lymphatics to hilar nodes

Cellular immunity develops 2-12 wks afterinfection and usually limits M. tb growth ingranulomas which are small, inapparent

Active disease seen in 10%, with halfwithin the first 2 years

8/12/2019 TBC (PU)

14/48

Source

Child

Young adult

AdultDMHIVNATURAL HISTORY

reservoirs

8/12/2019 TBC (PU)

15/48

Pulmonary Disease Symptoms of cough which starts non-

productive and becomes sputum

Other symptoms include pleuritic pain,

hemoptysis Physical exam is usually not helpful

Chest X ray findings are important

primary disease with middle, lower lung infiltrateswith hilar adenopathy

reactivation with upper lobe disease andcavitation

8/12/2019 TBC (PU)

16/48

Diagnosis of Tuberculosis

Clinical finding Requires positive PPD skin test and/or

Chest X ray findings consistent with TB

With confirmation by positive direct andculture AFB from specimen pulmonary disease with sputum collection (3

single specimens) or gastric aspirates in child orbronchoscopy in rare instances

specimens from urine, nodes, etc. if extrapulmonary site is suspected

8/12/2019 TBC (PU)

17/48

filling goodmoneydoctorsadvers drug

others

TSY, World TB Day 2003.

Reason for treatment cessation(Syafiud din T et al, 2003)

51 %36 %

4 %4 %4 %

8/12/2019 TBC (PU)

18/48

10 6

Time

Pattern of Myc. tbc resistance

(Basic theory of multiple drugs adm.)

++ + + +

Rise & fall phenomena

8/12/2019 TBC (PU)

19/48

Lag phase :Cessation of microbial metabolism

in period of time

Myc. tbc (72 hours )

Once a day Once for three day

Drug administration

8/12/2019 TBC (PU)

20/48

SYMPTOMS

DIAGNOSIS

TREATMENT

OUT COME

PROBLEMS and NATURAL HISTORY


8/12/2019 TBC (PU)

21/48

Delays of diagnosis:Patients delays : 4.78 Moths

Doctors delays : 3.64 Moths

8/12/2019 TBC (PU)

22/48

Clinical Manifestations

Systemic-fever, malaise, night sweats, wtloss

Extrapulmonary- disseminated (HIV andimmune compromise) with multiorganinvolvement

lymph node, pleura, GU, bone, CNS, GI,pericardial

8/12/2019 TBC (PU)

23/48

Diagnosis of Tuberculosis Use of skin test of 5 U tuberculin PPD given

intradermal >5 mm induration is positive for infection for

contacts of TB cases, HIV, Xray fibrosis (olddisease), immune suppression

>10 mm induration is positive for persons inhigh prevalence countries, IDU, prisons and

jails, medical conditions, children < 4 y/oexposed to adults in high risk categories

> 15 mm induration with no risk factors for TB

8/12/2019 TBC (PU)

24/48

National Mortality Rate

Cardiovascular diseases1 st rank )

Tuberculosis2 nd rank )

Pneumonie3 rd rank )

Asthma, bronchitis chronicand emphysema

6 th rank )

SKRT DepKes RI 1992)

8/12/2019 TBC (PU)

25/48


3 rd rank in the world

2 nd rank cause of death

lost of cases

Multi drug resistance cases Pulmonary remodelling cases

8/12/2019 TBC (PU)

26/48

* One new TB case / minute

* One new infectious TB case / 2 minutes

* One TB died / 4 minutes


8/12/2019 TBC (PU)

27/48

1 juta

2 juta

3 juta

4 juta

5 juta

1850 2050200019501900

Penemuanbasil TB

(1882)

Mulai adanyasanatorium

(1900)

PenemuanOAT I(1945)

Deklarasi WHO:TB merupakan

kedaruratan global

(1993)

Perkiraan kecenderungan jumlah kematian akibat TBdi seluruh dunia menjelang abad 21

I nt J Tuberc Lu ng Dis 1998; 2(9): 696-703.

World TB Day 2003 Rozaimah Zain-Hamid

8/12/2019 TBC (PU)

28/48

MERUPAKAN MASALAH NASIONAL

bahkan GLOBAL EMERGENCIES

PREVALENSI TB TIDAK DANANGKA KEMATIAN YANG TINGGI


8/12/2019 TBC (PU)

29/48


6 month

25 %

29 %

35 %

11 %

Duration of symptoms(Syafiud din T et al, 2003)

8/12/2019 TBC (PU)

30/48

Source

Child

Young adult

AdultDM

HIVNATURAL HISTORY

reservoirs

8/12/2019 TBC (PU)

31/48

< 1 bulan2 month3 month4-5 mnth


Duration of treatment (Syafiu dd in T et al, 2003)

24 %

26 %39 %

11 %

8/12/2019 TBC (PU)

32/48

Bidan/perawat/mantriDokter Umum

Spesialis/PPDSParuSpesialis lain


TENAGA MEDIS YANG PERTAMA KALIMEMBERIKAN PENGOBATAN KEPADA

PENDERITA TB PARU

Syafiuddin T dkk, 2003

51 %35 %

8 %6 %

8/12/2019 TBC (PU)

33/48

Pulmonary tuberculosisIndonesia)

3Rd rank in the world 2 nd rank cause of deads

Higher on lost of cases

Pulmonary remodelling cases

Multi drug resistance cases

Perception

Diagnosis

8/12/2019 TBC (PU)

34/48

TuberculosisMHLC 96 - 97 )

Insurance Private

Lost of cases 65 % 68 %

8/12/2019 TBC (PU)

35/48

Tuberculosis

Treatment Requires multidrug regimen

Susceptibility testing of initial isolatescritical

The American Thoracic Society and CDC recommend initial therapy be given with

four drugs: isoniazid, rifampin, pyrazinamide and

ethambutol or streptomycin

8/12/2019 TBC (PU)

36/48

Pulmonary tuberculosis

Clinical examination Radiologic examination

Laboratoric examinatioon

History

8/12/2019 TBC (PU)

37/48


Clinical examination

Age

Respiratory problems

8/12/2019 TBC (PU)

38/48


Radiologic examination

Cloudy swelling

Multiform

Pleural effusion

8/12/2019 TBC (PU)

39/48


Laboratory examination

Direct smear

Culture Mantoux test

DNA test

8/12/2019 TBC (PU)

40/48


Suspected pulmonary Tb Pulmonary Tb

Post pulmonary Tb

8/12/2019 TBC (PU)

41/48

Suspected pulmonary Tb

Clinically +)

History +) Radiology +) Laboratory -)

Clinically +) History -)

Radiology +) Laboratory -)1 st Category

1 st Category

8/12/2019 TBC (PU)

42/48

Pulmonary Tb

Clinically +) Radiology +)

History - ) Laboratory +)


History +) Laboratory +)2 nd Category

1 st Category

8/12/2019 TBC (PU)

43/48

Post pulmonaryTb


History +) Laboratory -)

Clinically -) Radiology -) or +)

History +) Laboratory -)No treatment

Symptomatic

8/12/2019 TBC (PU)

44/48

3 rd Category :

Guideline of anti tb drugs(tb control program in Indonesia,based on WHO recommendation)

1 st Category : ( 2 HRZE/ 4 H3R3 )( 2 HRZE/ 4 HR )

2 nd Category : ( 2 HRZES + HRZE/ 5 H3R3E3 )( 2 RHZES/ 5 RHE )(Relapse, failure, AFB + )

3 rd Category : ( 2 HRZ/ 4 H3R3 )( 2 HRZ/ 4 HR)(New cases, AFB - )

4 th Category : ( H long-life ? )(Chronic tb)

(New cases, AFB + ,AFB , Ro +, severe illness)

8/12/2019 TBC (PU)

45/48

Treatment Principles

Regiment must contain multiple drugs towhich the TB is susceptible

Drugs must be taken regularly

Drugs must be continued for sufficient time

Doses of anti tb drugs

8/12/2019 TBC (PU)

46/48

Doses of anti tb drugs(tb control program in Indonesia,based on WHO recommendation)

1 st Category

Intensive : H 300 mg , R 450 mg, Z 1500 mg, E 750 mg phase

Intermittent : H 600 mg , R 450 mgphase

2 nd Category

Intensive : H 300 mg , R 450 mg, Z 1500 mg, E 750 mgphase S 750 mg

Intermittent : H 600 mg , R 450 mgphase

8/12/2019 TBC (PU)

47/48

Doses of anti tb drugs(tb control program in Indonesia,based on WHO recommendation)

3 rd Category

Intensive : H 300 mg , R 450 mg, Z 1500 mg,

phaseIntermittent : H 600 mg , R 450 mg

phase

8/12/2019 TBC (PU)

48/48

TBC (PU)

Documents

Transcript of TBC (PU)