TuberculosisDivya Mathew
Mr. X, 20 years old, presented to the medicine OPD with symptoms of fever for the last one month. He also complained of generalised tiredness and loss of appetite. He was surprised to note that in the last 1 month he had lost 5 kgs of weight. For the last 2 weeks he had also developed a productive cough that had not subsided despite antibiotics given to him by his treating physician.
On examination he was found to be afebrile, thinly built. General examination was otherwise unremarkable however auscultation of the chest revealed bronchial breath sounds in the right upper lobe.
Sputum AFB positive
Diagnosis???
Objectives Causative organismPathophysiologyPulmonary tuberculosisExtra pulmonary tuberculosisMDR, XDR TuberculosisDrugs first line, second line
Causative organismMycobacterium tuberculosisGenus mycobacteriumAcid fast bacillus mycolic acid resistant to gram staining Resists destaining by acid alcohol
Slow growth rate generation time of 20- 24 hours
Robert Koch discovered M.Tb in 1882
Estimated TB incidence rate, 2007:Source: WHO Geneva; WHO Report 2009: Global Tuberculosis Control; Surveillance, Planning and Financing
Pathophysiology Transmission airborne1-5 microns droplets
Pathogenesis MTB into lungs (or to cervical nodes or abdo. nodes)Replication of organismsPrimary complex (lung and mediastinal lymph nodes) Ghon complex
Mycobacteraemia with potential for seeding
Consequence of tuberculous infectionSymptomatic illness disease (minority)immunological control (majority) with Ghon focus on Xray.Infection is contained by granuloma but not eliminated
PathogenesisTuberculous disease is a consequence of:Primary infection e.g. in children
ReactivationnaturalAssociated with immunosupression
Re infection
Pulmonary tuberculosisLungs major site for primary infection and diseasePrimary tb-Fever Pleuritic chest pain- pleural effusionMyalgia, arthralgia, fatigue, weight loss
Reactivation- Fever, night sweatsAnorexiaCough productive or non productive
Apical posterior segment of upper lobe and superior segment of lower lobe.
Clinical manifestations
Clinical manifestationsPhysical examination:Thinly builtPallorLymphadenopathyBronchial breath sounds/ decreased breath sounds (pleural effusion)Fever +/-
Complications HemoptysisPneumothoraxExtensive pulmonary destruction
Miliary tuberculosisWide dissemination1-5 mm millet seed size of lesionsHematogenous spread
Multiorgan involvement Adrenal shock
Extra pulmonary tuberculosisSkin and soft tissueLymph nodesBones and jointsIntra abdominal structures includingPeritoneumKidneysAdrenalsLymph nodesCentral nervous systemTuberculomameningitis
tuberculous lymphadenitis
Potts spine
Renal tuberculosis
Tuberculomas
Skeletal tuberculosisTB involvement of the bonesand/orjoints10 to 35 percent of cases of extrapulmonary tuberculosis, 2 percent of TB cases overall
Potts spineTuberculous arthritis
Tuberculous spondylitis (Pott's disease) most common form of skeletal TBlower thoracic and upper lumbar regionInitially involving the anterior aspect of the intervertebral joint. Spreads behind the anterior ligament to involve the adjacent vertebral bodyEventually spreads into the intervertebral space
Avascular disc diesVertebral collapseGibbus deformityRisk of paraplegiaCold abscessSubacute course progressively worsening pain, muscle spasm, characteristic aldermans gait (short deliberate steps)
Arthritis Usually monoarticularTypically hip (most common) or kneeSwelling, pain, loss of joint function over weeks to months. Cold joint Constitutional symptoms not common.Synovial proliferation, joint effusion, erosion of cartilage and joint destruction.
diagnosis microscopy, culture of infected materialMedical treatment ATT duration uncertainIndications for surgery Spinal disease and advanced neurological deficitsWorsening neurological deficits while on ATTSpinal disease and kyphosis > 40 degrees at presentationChest wall cold abscess
Antituberculous agentsFirst line isoniazid, rifampicin, ethambutol, pyrazinamide
Drug resistant tuberculosisThe term "drug-resistant TB" refers to cases of TB caused by an isolate ofM. tuberculosisthat is resistant to one of the first-line anti-TB drugs:isoniazid,rifampin,pyrazinamide, ethambutol, or streptomycin.
The term "multidrug-resistant TB" (MDR-TB) refers to an isolate ofM. tuberculosisthat is resistant to at leastisoniazidandrifampinand possibly additional agents.
The term "extensively drug-resistant TB" (XDR-TB) refers to an isolate ofM. tuberculosisthat is resistant to at leastisoniazid,rifampin, and fluoroquinolones, as well as either aminoglycosides (amikacin,kanamycin) orcapreomycinor both
The term "totally drug-resistant TB" (TDR-TB) refers to an isolate ofM. tuberculosisresistant to all locally tested medications
Primary drug resistanceSecondary drug resistance
Summary Mycobacterium tuberculosisAirborne transmissionPrimary infection, latent disease, reactivation, reinfectionPulmonary, extraulmonary tuberculosisPotts spine/ tuberculous arthritis1st line and second line drugsDrug resistant tuberculosis
Thankyou
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