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What is the diagnosis?What is the diagnosis?
CHILDHOODCHILDHOOD
Dr Mohammad Nurul HuqDr Mohammad Nurul HuqWORLD TB DAY 24 MARCH
TB Key Facts:TB Key Facts: 30% world population infected!30% world population infected!
22ndnd
only to AIDS as the greates...
 TB can mimic any SS;TB can mimic any SS; speaks every languagespeaks every language
 Malnutrition and TB go hand in han...
MDG6: met already!MDG6: met already!
Reducing MM of TB by 50% by 2015Reducing MM of TB by 50% by 2015
Progress in Banglade...
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SEAR: 95% in India, Indonesia, BD, Thailand, BurmaSEAR: 95% in India, Indonesia, BD, Thailand, Burma
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-
S.E. Asia has ...
HIV plus TB:HIV plus TB: Expensive and fatal !Expensive and fatal !
 1/31/3rdrd
HIV have TBHIV have TB
 Untreated:Untrea...
Bangladesh ScenarioBangladesh Scenario
 TB is a major PH problemTB is a major PH problem
 66thth
among 22 high TB burden...
 TB CARE IITB CARE II (USAID):(USAID): helps DOT, Rx of MDR-TB; works withhelps DOT, Rx of MDR-TB; works with
NTP in line...
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Prevalence In Our ChildrenPrevalence In Our Children
Not knownNot known
 Globally:Globally: 450k die/y450k die/y
 One...
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DefinitionDefinition
It is a chr.It is a chr. granulomatousgranulomatous IDID c/by certain strains ofc/by certain strai...
EtiologyEtiology
 M tuberculosis (commonest)M tuberculosis (commonest)
 M bovisM bovis
 M africanusM africanus
Non-Tb. ...
Synonyms/KeywordsSynonyms/Keywords
 Tuberculosis, TB, consumption, phthisisTuberculosis, TB, consumption, phthisis
 Myco...
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TerminologyTerminology
Primary TBPrimary TB:: First-time inf.First-time inf.
Mainly children. Characterized byMainly c...
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Positive TST/MT
Likely infection. 2-12w after primary (~3-4 wk)
Exposed person
Recent contact with open PTB but negat...
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Source case
who transmits M tuberculosis
Latent TB Infx (LTBI)
positive MT but normal PE, CXR or healed focus
(calcif...
EpidemiologyEpidemiology
 Tb occurs everywhere, in every race, gender, ageTb occurs everywhere, in every race, gender, ag...
Predisposing factorsPredisposing factors
 PovertyPoverty, poor housing, - hygiene, - sanitation, poor housing, - hygiene,...
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PathogenesisPathogenesis
Spread:Spread: aerosol, infected milk. Rarely verticalaerosol, infected milk. Rarely vertical
...
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Tubercle
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Tubercle
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Usual Susceptible OrgansUsual Susceptible Organs
Reactivated/unmasked TBReactivated/unmasked TB
 DMDM
 CorticosteroidsCorticosteroids
 Malignancy, cytotoxicsMalignancy,...
Clinical typesClinical types
 Pulmonary and extrapulmonaryPulmonary and extrapulmonary
 OpenOpen (PTB: smear positive: 7...
3322
Severe and less severe extra-PTB
Severe
TM Meningitis (TBM)
Less Severe
Lymph nodes (gland TB)
Miliary TB (MTB)
TB Pe...
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PTBPTB (90%)(90%)
 Usually 1 Primary focusUsually 1 Primary focus (25% >1 foci); mostly RUL(25% >1 foci); mostly RUL
s...
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LymphangiitisLymphangiitis
Tubercle in LUL with fineTubercle in LUL with fine
lines of drainage to enlargedlines of draina...
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Primary and Post-1y TBPrimary and Post-1y TB
PrimaryPrimary (children)(children)
 First time exposureFirst time exposu...
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BigBig
tuberculomatuberculoma
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airway
calcification
Hilar LN compress/erode into BV
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TB mediastinal LAP. Rt.TB mediastinal LAP. Rt.
paratracheal LAP withparatracheal LAP with
central necrosis and the Rcen...
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Follow-up of PTBFollow-up of PTB
1978:1978: no active d.no active d. 5/1989:5/1989: a mix of exudation and cavities in ...
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““Tree in bud"Tree in bud"
CT:CT: ill-defined small nodules adjacent to peripheralill-defined small nodules adjacent to...
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CXR and CT of a cavityCXR and CT of a cavity in the apical segment of RUL (K). The drainingin the apical segment of RUL...
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Immunity in TBImmunity in TB
Immunity is complex andImmunity is complex and incompleteincomplete::
 CMICMI
 Humoral:H...
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Fate of Primary ComplexFate of Primary Complex
Best described in PTBBest described in PTB
 MostlyMostly healheal (70%;...
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PTB with large cavitationPTB with large cavitation
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CXR and CT of productive TB with multiple nodules (nodulesCXR and CT of productive TB with multiple nodules (nodules
of...
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Complications from 1y ComplexComplications from 1y Complex
 Enlarged LN:Enlarged LN: Pressure; dischargePressure; disc...
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PressurePressure by enlarged LNby enlarged LN
 Stridor, wheeze, hoarsenessStridor, wheeze, hoarseness
 DysphagiaDysph...
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Gross emphysema
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Caseation LN (matted)Caseation LN (matted)
Complications from 1y FocusComplications from 1y Focus
 CavitationCavitation
 Pl. effusion, pneumothoraxPl. effusion, pn...
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PTBPTB
pneumothoraxpneumothorax
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PTB with fibrosisPTB with fibrosis
and emphysemaand emphysema
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Endobronchial spreadEndobronchial spread:: eroding a bronchus: caseated material iseroding a bronchus: caseated materia...
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Disseminated TBDisseminated TB
 Within 2-6mo of 1y inf.Within 2-6mo of 1y inf.
 Commonly venous; occasionally arteria...
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Newborn with MTBNewborn with MTB (mother had active TB)(mother had active TB)
MTB:MTB: diffuse small pulmonary nodules in a random (haemotogenous) distributiondiffuse small pulmonary nodules in a rand...
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MTB of lungsMTB of lungs
Spleen in MTBSpleen in MTB
MTB seedling
of peritoneum
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TB Pleural EffusionTB Pleural Effusion (exudative)(exudative)
 Localized PE is part of primary TBLocalized PE is part ...
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Extensive pleural effusionExtensive pleural effusion
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Clinical Features TBClinical Features TB
 Predisposing factorsPredisposing factors
 Age U-5, 15-45Age U-5, 15-45
 Ge...
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GeneralGeneral
 Evening F, night sweatsEvening F, night sweats
 ANV, wt. loss, fatigue, lassitude,ANV, wt. loss, fati...
Gibbous: Pott disease:Gibbous: Pott disease: Pre-op. and post-op. pix. of a childPre-op. and post-op. pix. of a child
with...
Spina ventosa
TB of hip jointTB of hip joint
Skin TB: lupus vulgarisSkin TB: lupus vulgaris
TB wart ok Skin (verrucosa cutis)TB wart ok Skin (verrucosa cutis)
Scrofulo...
Suspect TB in a childSuspect TB in a child
MayMay mimic any S/Smimic any S/S
ClassicalClassical
Cough >3w (persistentCou...
Phlyctenular
Keratoconjunctivitis
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Diagnosis (PTB)Diagnosis (PTB)
 2 sputum (1 spot, 1 early morning).2 sputum (1 spot, 1 early morning). 50% sensitivity...
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Tuberculin Skin Testing (TST)/Mantoux TST (MT)Tuberculin Skin Testing (TST)/Mantoux TST (MT)
Standard method to know inf....
IndurationInduration
≥5mm≥5mm is positiveis positive
inin
- HIV- HIV
- A recent contactA recent contact
- changes on CXRch...
False-Positive ReactionsFalse-Positive Reactions
Non-tb mycobacteriaNon-tb mycobacteria
BCG vaccinationBCG vaccination
...
How Often Can TSTs Be Repeated?How Often Can TSTs Be Repeated? NNo risk to repeato risk to repeat
What is a Boosted Reacti...
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Other testsOther tests
 Gastric aspirateGastric aspirate
 ICTICT
 Inflammatory fluidInflammatory fluid
 PCRPCR
 FN...
ALSALS (Antibodies in lymphocyte secretion)(Antibodies in lymphocyte secretion)
AdvantagesAdvantages
 Sensitivity >93 %; ...
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Treatment: aims:
 To cure, prevent disabilityTo cure, prevent disability
 To prevent relapse, drug resistance and tox...
Case classification by Rx historyCase classification by Rx history
 New:New: received no Rx or treated for <1moreceived n...
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Directly Observed Therapy (DOT)Directly Observed Therapy (DOT)
 ATD are given directly to the pt. by HW (not friend) a...
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ATDATD
 First line:First line: Rifampicin, INH, streptomycinRifampicin, INH, streptomycin
 22ndnd
line:line: thiacetazon...
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Side EffectsSide Effects
Seek helpSeek help in renal-, hepatic-, and pregnancy TBin renal-, hepatic-, and pregnancy TB
...
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Standard ATD TherapyStandard ATD Therapy
Initial/intensive PhaseInitial/intensive Phase
3-4 drugs (2 mo)3-4 drugs (2 m...
Categories of Standard RxCategories of Standard Rx
CategoriesCategories Pt. categoriesPt. categories InitialInitial
phasep...
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Drug Resistance in BDDrug Resistance in BD
 StreptomycinStreptomycin 59.3%59.3%
 INHINH 17.4%17.4%
 RFMRFM 3.5%3.5%
...
MDR TBMDR TB. FU over. FU over
8y:8y:
1981: widespread1981: widespread
destruction,destruction,
1985: cavity in RLL,1985: ...
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Supportive RxSupportive Rx
 Treatment of symptomsTreatment of symptoms
 Correction of malnutritionCorrection of malnu...
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Treatment FailureTreatment Failure
 Commonest:Commonest: noncompliancenoncompliance
 MDR/XDR-TBMDR/XDR-TB
 Inadequat...
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Coricosteroids in TBCoricosteroids in TB
In PE, TBM, pericarditis, HIV-TB, endobronchial TB, TBIn PE, TBM, pericarditis...
Congenital TBCongenital TB
 RareRare
 Primary complex usually lies in the liverPrimary complex usually lies in the liver...
PreventionPrevention
 Contact tracing and Rx are primary goals (13% un-Contact tracing and Rx are primary goals (13% un-
...
WHO responseWHO response toto control TB.control TB. Stop TB StrategyStop TB Strategy
 Global leadershipGlobal leadership...
Stop TB (WHO)
 Vision:Vision: A TB-FREE WORLDA TB-FREE WORLD
 Goal:Goal: to dramatically reduce TB by ‘15 (MDG6)to drama...
Components of the Stop TB strategyComponents of the Stop TB strategy
1. HQ DOT1. HQ DOT expansion:expansion: political wil...
3. Strengthening primary HC:3. Strengthening primary HC: improve policies,improve policies,
develop HW, effective running;...
SummarySummary
 TB occurs everywhereTB occurs everywhere
 Mostly PTBMostly PTB
 It is curable and preventableIt is cura...
Who is most at risk?Who is most at risk? All ages!All ages!
 Mostly young adults in their most productive yearsMostly you...
Dx:Dx: Many countries still rely on smear: misses numerousMany countries still rely on smear: misses numerous
casescases
...
MDR-TBMDR-TB
do not respond to INH and rifampicin (2 most powerful)do not respond to INH and rifampicin (2 most powerful)
...
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Points to PonderPoints to Ponder
 TB may mimic any S/S; oTB may mimic any S/S; oftenften under-diagnosedunder-diagnos...
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 Infection necessarily is not a diseaseInfection necessarily is not a disease
 Adult PTB is mostly open, child PTB i...
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 ComplianceCompliance is essential:is essential:
– prevents spreadprevents spread
– less drug resistanceless drug res...
Extra Pulmonary TB:
CNS
Disseminated TB
Lymphatics, pleura, bones and joints
Urogenital
Skin
scrofulascrofula
Phlyctenular conjunctivitisPhlyctenular conjunctivitis
OSPEOSPE
Look at the CXR of a child whose mother hasLook at the CXR of a child whose mother has
persistent cough, irregula...
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Answer KeysAnswer Keys
 Miliary mottling in both lung fieldsMiliary mottling in both lung fields
 MT, gastric aspirate f...
MCQMCQ
 BCG vax. prevents TBBCG vax. prevents TB
 Childhood TB is mostly contagiousChildhood TB is mostly contagious
 N...
MCQMCQ
 TB can mimic any sign or any symptomTB can mimic any sign or any symptom
 Most primary infx. healsMost primary i...
Next Lec.Next Lec.
EPI TargetEPI Target
DiseasesDiseases
123THANK YOU
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  1. 1. 4
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  4. 4. 7 What is the diagnosis?What is the diagnosis?
  5. 5. CHILDHOODCHILDHOOD Dr Mohammad Nurul HuqDr Mohammad Nurul HuqWORLD TB DAY 24 MARCH
  6. 6. TB Key Facts:TB Key Facts: 30% world population infected!30% world population infected! 22ndnd only to AIDS as the greatest killer as single infx.only to AIDS as the greatest killer as single infx.  9.6million cases (9.6million cases (3 million of these "missed“);3 million of these "missed“); 1.5 million1.5 million (450k children) death/y.(450k children) death/y. 480k have MDR-TB480k have MDR-TB  1 of top 5 killers of women 15-44y1 of top 5 killers of women 15-44y  >95% cases and deaths occur in DCs>95% cases and deaths occur in DCs  HIV is x30 at risk.HIV is x30 at risk. 25% of HIV deaths25% of HIV deaths  Met MDG6 ! : to reduce MR 50% by 2015Met MDG6 ! : to reduce MR 50% by 2015  >20% of TB are attributable to smoking>20% of TB are attributable to smoking multidrug resistant TB (MDR-TB). DCs: developing countriesmultidrug resistant TB (MDR-TB). DCs: developing countries
  7. 7.  TB can mimic any SS;TB can mimic any SS; speaks every languagespeaks every language  Malnutrition and TB go hand in handMalnutrition and TB go hand in hand  In suspected BA, TB must be excludedIn suspected BA, TB must be excluded  It isIt is ""a global health emergencya global health emergency””  MDR-TB: is x100 expensive (Rx x2y), often fatalMDR-TB: is x100 expensive (Rx x2y), often fatal  BCGBCG has a high efficacy against TBM and MTB, buthas a high efficacy against TBM and MTB, but variable efficacy against adult PTBvariable efficacy against adult PTB  Let no one die from PUO without trial by ATDsLet no one die from PUO without trial by ATDs ATD: anti TB drugs. SS: symptoms and signs. MDR: multi-drug resistanceATD: anti TB drugs. SS: symptoms and signs. MDR: multi-drug resistance
  8. 8. MDG6: met already!MDG6: met already! Reducing MM of TB by 50% by 2015Reducing MM of TB by 50% by 2015 Progress in BangladeshProgress in Bangladesh  Case detection up to 72%Case detection up to 72%  Rx success 93%Rx success 93%  NGO participationNGO participation TB is declining but v. slowly:TB is declining but v. slowly: incidence fell 1.5%/yincidence fell 1.5%/y since 2000)since 2000) MM: morbidity and mortality
  9. 9. 13 SEAR: 95% in India, Indonesia, BD, Thailand, BurmaSEAR: 95% in India, Indonesia, BD, Thailand, Burma 2 - S.E. Asia has 38% of all TB cases WPR 25% AFR 18% EMR 8% EUR 6% AMR 5% SEAR 38%
  10. 10. HIV plus TB:HIV plus TB: Expensive and fatal !Expensive and fatal !  1/31/3rdrd HIV have TBHIV have TB  Untreated:Untreated: 90% die in months90% die in months  More in young peopleMore in young people  More primary infx., more reactivationMore primary infx., more reactivation  More MDR-TBMore MDR-TB  Rapid progressionRapid progression HIV cases should be treated freeHIV cases should be treated free
  11. 11. Bangladesh ScenarioBangladesh Scenario  TB is a major PH problemTB is a major PH problem  66thth among 22 high TB burden (80%) countriesamong 22 high TB burden (80%) countries  60% population infected;60% population infected; 7 million diseased7 million diseased  >300k new cases/y>300k new cases/y (1/every 2min)(1/every 2min)  70k die/y70k die/y (1/8 min)(1/8 min)  No estimate on childhood TBNo estimate on childhood TB:: grossly underdiagnosedgrossly underdiagnosed  MDR TB: 2.2%, but among previously treated cases: 15%MDR TB: 2.2%, but among previously treated cases: 15% PH: public healthPH: public health
  12. 12.  TB CARE IITB CARE II (USAID):(USAID): helps DOT, Rx of MDR-TB; works withhelps DOT, Rx of MDR-TB; works with NTP in line ofNTP in line of Stop TBStop TB StrategyStrategy.. Its achievements:Its achievements: – improved access to quality servicesimproved access to quality services – lab quality assurancelab quality assurance – social support for MDR TB pts.social support for MDR TB pts. – effective delivery of TB services at all levelseffective delivery of TB services at all levels DOT: directly observed therapy. MDR: multi-drug resistantDOT: directly observed therapy. MDR: multi-drug resistant NTP: national TB control programNTP: national TB control program Bangladesh Scenario …Bangladesh Scenario …
  13. 13. 17 Prevalence In Our ChildrenPrevalence In Our Children Not knownNot known  Globally:Globally: 450k die/y450k die/y  One ofOne of 1010 top U-5 killerstop U-5 killers  Recurrent infx., Mn., and TB go hand in handRecurrent infx., Mn., and TB go hand in hand  Often under-diagnosedOften under-diagnosed Mn: MalnutritionMn: Malnutrition 10 child killers:10 child killers: ARI, D, Mn, malaria, AIDs, TB, LBW, B. Asphyxia,ARI, D, Mn, malaria, AIDs, TB, LBW, B. Asphyxia, drowning, accidentsdrowning, accidents
  14. 14. 18 DefinitionDefinition It is a chr.It is a chr. granulomatousgranulomatous IDID c/by certain strains ofc/by certain strains of Mycobacteria mainly affecting the lungsMycobacteria mainly affecting the lungs  Commonly children <5 y of age are affectedCommonly children <5 y of age are affected  Less common 5-15yLess common 5-15y
  15. 15. EtiologyEtiology  M tuberculosis (commonest)M tuberculosis (commonest)  M bovisM bovis  M africanusM africanus Non-Tb. and non-leprous mycobacteria (Non-Tb. and non-leprous mycobacteria (environmentalenvironmental-- oror atypical -)atypical -) causecause non-Tb mycobacterial diseasenon-Tb mycobacterial disease M bovis:M bovis: TB in cattle. Humans affected by milk; causes moreTB in cattle. Humans affected by milk; causes more extrapulmonary TBextrapulmonary TB.. Typically resistant to PZATypically resistant to PZA
  16. 16. Synonyms/KeywordsSynonyms/Keywords  Tuberculosis, TB, consumption, phthisisTuberculosis, TB, consumption, phthisis  Mycobacterial infx., primary TB, reactivation/adult TB,Mycobacterial infx., primary TB, reactivation/adult TB, unmasked TBunmasked TB  Miliary TB, MTB, TB meningitis, TBM, MDR-TB, XDR-TBMiliary TB, MTB, TB meningitis, TBM, MDR-TB, XDR-TB  Pulmonary TB, endobronchial TB, extrapulmonary TBPulmonary TB, endobronchial TB, extrapulmonary TB  TB lymphadenopathy,TB lymphadenopathy, scrofulascrofula, vertebral TB, vertebral TB  Pott disease, TB spondylitis, bone TB, joint TB, skeletalPott disease, TB spondylitis, bone TB, joint TB, skeletal TB, congenital TB, etc.TB, congenital TB, etc.
  17. 17. 21 TerminologyTerminology Primary TBPrimary TB:: First-time inf.First-time inf. Mainly children. Characterized byMainly children. Characterized by Primary ComplexPrimary Complex Post-primary/reactivatedPost-primary/reactivated or Adult-onset/or Adult-onset/ Unmasked TBUnmasked TB Reactivation of dormant inf. Mainly adults. CharacterizedReactivation of dormant inf. Mainly adults. Characterized byby parenchymal damageparenchymal damage
  18. 18. 22 Positive TST/MT Likely infection. 2-12w after primary (~3-4 wk) Exposed person Recent contact with open PTB but negative TST, normal PE, and CXR TB Disease CF and/or X-Ray signs of TB
  19. 19. 23 Source case who transmits M tuberculosis Latent TB Infx (LTBI) positive MT but normal PE, CXR or healed focus (calcification in lung, LN, or both)
  20. 20. EpidemiologyEpidemiology  Tb occurs everywhere, in every race, gender, ageTb occurs everywhere, in every race, gender, age  1 open case can infect 15/y1 open case can infect 15/y  90% infected do not get disease90% infected do not get disease  Most fatal in 1Most fatal in 1stst y of lifey of life  +ve MT indicates infx., not necessarily the disease+ve MT indicates infx., not necessarily the disease Broadly 2 forms:Broadly 2 forms: pulmonary (90%) and extra-pulmonarypulmonary (90%) and extra-pulmonary
  21. 21. Predisposing factorsPredisposing factors  PovertyPoverty, poor housing, - hygiene, - sanitation, poor housing, - hygiene, - sanitation  Overcrowding, illiteracyOvercrowding, illiteracy  Mn., pollutionMn., pollution  SmokingSmoking  Raw milkRaw milk  Dm,Dm, HIV,HIV, immunodeficiency, anticancer Rximmunodeficiency, anticancer Rx  Family TB, illicit drugsFamily TB, illicit drugs
  22. 22. 26 PathogenesisPathogenesis Spread:Spread: aerosol, infected milk. Rarely verticalaerosol, infected milk. Rarely vertical  Lag period/IP: 2-12w (MT positive)Lag period/IP: 2-12w (MT positive)  Mostly heal (90%)Mostly heal (90%)  Any organ. PTB commonest: subpleural site, more in RULAny organ. PTB commonest: subpleural site, more in RUL Basic lesion:Basic lesion: tubercle (central caseation); spread bytubercle (central caseation); spread by lymphohematogenous route: LN, other organslymphohematogenous route: LN, other organs 2 reactions:2 reactions: exudative (effusion) andexudative (effusion) and granulomatous (tubercle)granulomatous (tubercle) Mn: malnutrition. RUL Right upper lobe
  23. 23. 27 Tubercle
  24. 24. 28 Tubercle
  25. 25. 29 Usual Susceptible OrgansUsual Susceptible Organs
  26. 26. Reactivated/unmasked TBReactivated/unmasked TB  DMDM  CorticosteroidsCorticosteroids  Malignancy, cytotoxicsMalignancy, cytotoxics  MalnutritionMalnutrition  Whooping cough, measles, KA, HIV; overwhelming inf.Whooping cough, measles, KA, HIV; overwhelming inf.  Immunodeficient statesImmunodeficient states
  27. 27. Clinical typesClinical types  Pulmonary and extrapulmonaryPulmonary and extrapulmonary  OpenOpen (PTB: smear positive: 70%)(PTB: smear positive: 70%)  ClosedClosed (no spread)(no spread)  Primary and reinfectionPrimary and reinfection  New and retreatmentNew and retreatment Smear negativeSmear negative: when 2 sputum samples are negative: when 2 sputum samples are negative
  28. 28. 3322 Severe and less severe extra-PTB Severe TM Meningitis (TBM) Less Severe Lymph nodes (gland TB) Miliary TB (MTB) TB Pericarditis Bone (excluding spine) Bilateral/extensive TB pleural effusion Spinal TB Intestinal TB Pleural effusion (unilateral) Peripheral joint
  29. 29. 34 PTBPTB (90%)(90%)  Usually 1 Primary focusUsually 1 Primary focus (25% >1 foci); mostly RUL(25% >1 foci); mostly RUL subpleuralsubpleural  Regional lymphangiitisRegional lymphangiitis  Regional LAPRegional LAP Together:Together: Primary ComplexPrimary Complex
  30. 30. 36
  31. 31. LymphangiitisLymphangiitis Tubercle in LUL with fineTubercle in LUL with fine lines of drainage to enlargedlines of drainage to enlarged HLN. DD: bronchial CaHLN. DD: bronchial Ca
  32. 32. 38 Primary and Post-1y TBPrimary and Post-1y TB PrimaryPrimary (children)(children)  First time exposureFirst time exposure  Mostly closedMostly closed  LNs more affectedLNs more affected  More caseationMore caseation  Less fibrosisLess fibrosis  Dissemination commonDissemination common  Heals by calcificationHeals by calcification  Less cavitationLess cavitation Post-primaryPost-primary (adults)(adults)  Reactivation/re-infectionReactivation/re-infection  OpenOpen  Parenchyma moreParenchyma more  LessLess  MoreMore  UncommonUncommon  FibrosisFibrosis  CommonCommon
  33. 33. 39 BigBig tuberculomatuberculoma
  34. 34. 40 airway calcification Hilar LN compress/erode into BV
  35. 35. 41 TB mediastinal LAP. Rt.TB mediastinal LAP. Rt. paratracheal LAP withparatracheal LAP with central necrosis and the Rcentral necrosis and the R perivascular node betweenperivascular node between the ascending aorta andthe ascending aorta and superior VCsuperior VC
  36. 36. 42 Follow-up of PTBFollow-up of PTB 1978:1978: no active d.no active d. 5/1989:5/1989: a mix of exudation and cavities in RUL anda mix of exudation and cavities in RUL and a big exudative lesion in LUL.a big exudative lesion in LUL. 8/1989:8/1989: lesions in RUL decreased due tolesions in RUL decreased due to healing; exudative mass on L has necrosed and eroded a bronchus.healing; exudative mass on L has necrosed and eroded a bronchus. Necrosis is emptied to form cavityNecrosis is emptied to form cavity 10/1989:10/1989: residuum on R are fine linear opacities. L cavity shrunk andresiduum on R are fine linear opacities. L cavity shrunk and the surrounding consolidations have resolvedthe surrounding consolidations have resolved
  37. 37. 43 ““Tree in bud"Tree in bud" CT:CT: ill-defined small nodules adjacent to peripheralill-defined small nodules adjacent to peripheral bronchovascular structures. Called tree in budbronchovascular structures. Called tree in bud
  38. 38. 44 CXR and CT of a cavityCXR and CT of a cavity in the apical segment of RUL (K). The drainingin the apical segment of RUL (K). The draining bronchus is visible (arrow). CT (2mm slice)bronchus is visible (arrow). CT (2mm slice)
  39. 39. 45 Immunity in TBImmunity in TB Immunity is complex andImmunity is complex and incompleteincomplete::  CMICMI  Humoral:Humoral: many antibodiesmany antibodies  MO may stay viable inside healed LN for decades;MO may stay viable inside healed LN for decades; unmasks when immunity fallsunmasks when immunity falls
  40. 40. 46 Fate of Primary ComplexFate of Primary Complex Best described in PTBBest described in PTB  MostlyMostly healheal (70%; calcified). If progress(70%; calcified). If progress ⇒⇒ cavitycavity  DiseaseDisease from focus and LNfrom focus and LN  DisseminationDissemination within 6mowithin 6mo  ComplicationsComplications:: LAP and 1y focusLAP and 1y focus
  41. 41. 47 PTB with large cavitationPTB with large cavitation
  42. 42. 48 CXR and CT of productive TB with multiple nodules (nodulesCXR and CT of productive TB with multiple nodules (nodules of MTB are smaller)of MTB are smaller)
  43. 43. 49 Complications from 1y ComplexComplications from 1y Complex  Enlarged LN:Enlarged LN: Pressure; dischargePressure; discharge of caseous materials:of caseous materials:  1y focus:1y focus: cavity,cavity, pl. effusion, pneumothorax,pl. effusion, pneumothorax, fibrosisfibrosis
  44. 44. 50 PressurePressure by enlarged LNby enlarged LN  Stridor, wheeze, hoarsenessStridor, wheeze, hoarseness  DysphagiaDysphagia  Bronchiectasis , collapse, emphysemaBronchiectasis , collapse, emphysema DischargeDischarge of Caseous Materialsof Caseous Materials  Into BV, lymphatics:Into BV, lymphatics: disseminated TBdisseminated TB  Into bronchus:Into bronchus: TB Br.Pn.TB Br.Pn.  Fistula, pl. effusion, pneumothoraxFistula, pl. effusion, pneumothorax  Severe hgeSevere hge
  45. 45. 51 Gross emphysema
  46. 46. 52 Caseation LN (matted)Caseation LN (matted)
  47. 47. Complications from 1y FocusComplications from 1y Focus  CavitationCavitation  Pl. effusion, pneumothoraxPl. effusion, pneumothorax  Collapse, consolidationCollapse, consolidation  Bronchiectasis, fibrosisBronchiectasis, fibrosis  HgeHge
  48. 48. 55 PTBPTB pneumothoraxpneumothorax
  49. 49. 56 PTB with fibrosisPTB with fibrosis and emphysemaand emphysema
  50. 50. 57 Endobronchial spreadEndobronchial spread:: eroding a bronchus: caseated material iseroding a bronchus: caseated material is aspirated (TB Br.Pn). Lesions are bigger and not well defined as in MTBaspirated (TB Br.Pn). Lesions are bigger and not well defined as in MTB
  51. 51. 58 Disseminated TBDisseminated TB  Within 2-6mo of 1y inf.Within 2-6mo of 1y inf.  Commonly venous; occasionally arterialCommonly venous; occasionally arterial ((local MTB)local MTB)  Endobronchial:Endobronchial: ac. TB Br.Pnac. TB Br.Pn  May be asymptomatic:May be asymptomatic: balance of inf.balance of inf.~~defencedefence  2 gravest forms: ac. MTB and TBM2 gravest forms: ac. MTB and TBM  Multi-organMulti-organ features. Mfeatures. Mainly liver, kidneys, other partsainly liver, kidneys, other parts of lungs, skin, LN, brain, etc.of lungs, skin, LN, brain, etc. Bone, uro-genital involvement very latelyBone, uro-genital involvement very lately
  52. 52. 59 Newborn with MTBNewborn with MTB (mother had active TB)(mother had active TB)
  53. 53. MTB:MTB: diffuse small pulmonary nodules in a random (haemotogenous) distributiondiffuse small pulmonary nodules in a random (haemotogenous) distribution
  54. 54. 61 MTB of lungsMTB of lungs Spleen in MTBSpleen in MTB MTB seedling of peritoneum
  55. 55. 62 TB Pleural EffusionTB Pleural Effusion (exudative)(exudative)  Localized PE is part of primary TBLocalized PE is part of primary TB  Huge exudation may occurHuge exudation may occur  Ac. onset, fever, chest pain, SoBAc. onset, fever, chest pain, SoB  Diminished chest movement and B. SoundDiminished chest movement and B. Sound  Stony dull percussion noteStony dull percussion note
  56. 56. 63 Extensive pleural effusionExtensive pleural effusion
  57. 57. 64 Clinical Features TBClinical Features TB  Predisposing factorsPredisposing factors  Age U-5, 15-45Age U-5, 15-45  General features:General features:  Organ specific features:Organ specific features:
  58. 58. 65 GeneralGeneral  Evening F, night sweatsEvening F, night sweats  ANV, wt. loss, fatigue, lassitude,ANV, wt. loss, fatigue, lassitude, loss of initiativeloss of initiative  HA, irritability, chr. ill health, GLAP, etc.HA, irritability, chr. ill health, GLAP, etc. Organ specificOrgan specific  PTB:PTB: chr. cough, hemoptysischr. cough, hemoptysis  Abdo. TB:Abdo. TB: RAP, distension, diarrhea, constipationRAP, distension, diarrhea, constipation  Bone TB:Bone TB: arthritis, gibbousarthritis, gibbous  CNS TB:CNS TB: HA, epilepsy.HA, epilepsy. Skin:Skin: L. vulgarisL. vulgaris  Renal TB:Renal TB: hematuria, etchematuria, etc  TBM:TBM: slow onset of meningitisslow onset of meningitis
  59. 59. Gibbous: Pott disease:Gibbous: Pott disease: Pre-op. and post-op. pix. of a childPre-op. and post-op. pix. of a child with kyphosis corrected by osteotomywith kyphosis corrected by osteotomy
  60. 60. Spina ventosa
  61. 61. TB of hip jointTB of hip joint
  62. 62. Skin TB: lupus vulgarisSkin TB: lupus vulgaris TB wart ok Skin (verrucosa cutis)TB wart ok Skin (verrucosa cutis) Scrofuloderma: chr. effect of skin overlyingScrofuloderma: chr. effect of skin overlying a TB process, typically LAP, osteoarticular d.a TB process, typically LAP, osteoarticular d. or epididymitis. Subcut. TB leads to coldor epididymitis. Subcut. TB leads to cold abscessabscess
  63. 63. Suspect TB in a childSuspect TB in a child MayMay mimic any S/Smimic any S/S ClassicalClassical Cough >3w (persistentCough >3w (persistent cough)cough) RRTIRRTI FTT, malnutritionFTT, malnutrition Recurrent asymmetricRecurrent asymmetric wheezeswheezes  Rec. fever, PUORec. fever, PUO  RAP with positive MTRAP with positive MT  Chr./rec. diarrheaChr./rec. diarrhea  Cx LAPCx LAP  Phlyctenular conj.Phlyctenular conj.
  64. 64. Phlyctenular Keratoconjunctivitis
  65. 65. 72 Diagnosis (PTB)Diagnosis (PTB)  2 sputum (1 spot, 1 early morning).2 sputum (1 spot, 1 early morning). 50% sensitivity50% sensitivity  CXR PA and Lateral view. CT, MRICXR PA and Lateral view. CT, MRI  Pleural fluid, pleural biopsy, USGPleural fluid, pleural biopsy, USG  AFB culture: sputum, gastric juice, aspirate (70%)AFB culture: sputum, gastric juice, aspirate (70%)  MT (v. imp. in children)MT (v. imp. in children)  Xene expert testXene expert test (Dx and drug sensitivity)(Dx and drug sensitivity) High index of suspicion is essential. CBC do not confirm orHigh index of suspicion is essential. CBC do not confirm or exclude. CXR is non-specificexclude. CXR is non-specific
  66. 66. 73
  67. 67. Tuberculin Skin Testing (TST)/Mantoux TST (MT)Tuberculin Skin Testing (TST)/Mantoux TST (MT) Standard method to know inf. withStandard method to know inf. with M tbM tb V. imp. in children. Stronger MT: more active TBV. imp. in children. Stronger MT: more active TB 0.1 ml PPD i.d.:0.1 ml PPD i.d.: needle bevel facing upneedle bevel facing up (pale wheal 6-10mm)(pale wheal 6-10mm) Read 48-72h later. If pt. does not return: repeatRead 48-72h later. If pt. does not return: repeat Measure induration,Measure induration, not erythema in mm. in long axisnot erythema in mm. in long axis CI:CI: severe reaction (necrosis, blistering, anaphylaxis, orsevere reaction (necrosis, blistering, anaphylaxis, or ulcerations) to a previous TSTulcerations) to a previous TST BCG:BCG: reacts up to 2-3yreacts up to 2-3y
  68. 68. IndurationInduration ≥5mm≥5mm is positiveis positive inin - HIV- HIV - A recent contactA recent contact - changes on CXRchanges on CXR - with transplantswith transplants - ImmunosuppressedImmunosuppressed ≥≥10mm10mm is positiveis positive - Recent immigrants- Recent immigrants (<5y) from endemic(<5y) from endemic countriescountries - IDU- IDU - Residents and- Residents and employees of high-riskemployees of high-risk congregate settingscongregate settings - lab personnel- lab personnel - Infants, children, and- Infants, children, and adolescents exposed toadolescents exposed to adults in high-riskadults in high-risk categoriescategories ≥≥15mm15mm is positiveis positive in any person,in any person, including personsincluding persons without riskwithout risk factors.factors.
  69. 69. False-Positive ReactionsFalse-Positive Reactions Non-tb mycobacteriaNon-tb mycobacteria BCG vaccinationBCG vaccination Incorrect methodIncorrect method Incorrect interpretation, incorrect antigenIncorrect interpretation, incorrect antigen False-Negative ReactionsFalse-Negative Reactions Faulty tech.(Faulty tech.(commonest),commonest), anergy, malnutrition,anergy, malnutrition,  First 6–10w of inf.First 6–10w of inf. Severe sys. d., immunosuppressionSevere sys. d., immunosuppression V. old TB inf. (many years)V. old TB inf. (many years) <6mo age; overwhelming d<6mo age; overwhelming disseminated TBisseminated TB Recent live-virus vax (measles and smallpox)Recent live-virus vax (measles and smallpox) Some viral illnesses (measles and chicken pox)Some viral illnesses (measles and chicken pox)
  70. 70. How Often Can TSTs Be Repeated?How Often Can TSTs Be Repeated? NNo risk to repeato risk to repeat What is a Boosted Reaction?What is a Boosted Reaction? Reaction to PPD may wane over time (false-negative). But,Reaction to PPD may wane over time (false-negative). But, TST may stimulate the immune sys, causing a boostedTST may stimulate the immune sys, causing a boosted reaction later (2-step testing)reaction later (2-step testing) It is useful for HCW/nursing home residentsIt is useful for HCW/nursing home residents Can TSTs Be Given To Persons Receiving Vax?Can TSTs Be Given To Persons Receiving Vax? Vax –live-viruses may interfere with TSTVax –live-viruses may interfere with TST Do it either on the same day of vax or 4-6w laterDo it either on the same day of vax or 4-6w later Do it at least 1 mo after smallpox vaxDo it at least 1 mo after smallpox vax
  71. 71. 78
  72. 72. 79
  73. 73. 80 Other testsOther tests  Gastric aspirateGastric aspirate  ICTICT  Inflammatory fluidInflammatory fluid  PCRPCR  FNACFNAC  BiopsyBiopsy ALSALS
  74. 74. ALSALS (Antibodies in lymphocyte secretion)(Antibodies in lymphocyte secretion) AdvantagesAdvantages  Sensitivity >93 %; correlate clinically; an early biomarkerSensitivity >93 %; correlate clinically; an early biomarker of active infectionof active infection  Rapid detection of active TBRapid detection of active TB  Diseased specimen not requiredDiseased specimen not required  May be preserved for long timeMay be preserved for long time DisadvantagesDisadvantages  Cannot be applied if MT done within 40dCannot be applied if MT done within 40d  It is a complementary test to other testsIt is a complementary test to other tests  Rx is not given if only ALS is positiveRx is not given if only ALS is positive
  75. 75. 82 Treatment: aims:  To cure, prevent disabilityTo cure, prevent disability  To prevent relapse, drug resistance and toxicityTo prevent relapse, drug resistance and toxicity  To prevent transmissionTo prevent transmission  RehabilitationRehabilitation RxRx  SpecificSpecific  SupportiveSupportive  Rx of complicationsRx of complications
  76. 76. Case classification by Rx historyCase classification by Rx history  New:New: received no Rx or treated for <1moreceived no Rx or treated for <1mo  Relapse:Relapse: treated previously (completed and cured)treated previously (completed and cured)  Rx failure:Rx failure: smear is still positive after 5mo Rxsmear is still positive after 5mo Rx  Rx after default:Rx after default: Rx after incomplete RxRx after incomplete Rx  MDR-TB:MDR-TB: resistant to INH and RFMresistant to INH and RFM  XDR-TB:XDR-TB: resistant to 2resistant to 2ndnd line drugs: 1 fluroquinolones plusline drugs: 1 fluroquinolones plus any of amikacin, capreomycin, kanamycinany of amikacin, capreomycin, kanamycin
  77. 77. 84 Directly Observed Therapy (DOT)Directly Observed Therapy (DOT)  ATD are given directly to the pt. by HW (not friend) and documented. Prevent DR and spread  Non-cooperation is rare and illegal (PH law)  Coverage in Bangladesh 99% 5-point package: – political commitment, fund – case detection – standard Rx with supervision and support – effective drug supply – monitoring
  78. 78. 86
  79. 79. ATDATD  First line:First line: Rifampicin, INH, streptomycinRifampicin, INH, streptomycin  22ndnd line:line: thiacetazone, PZA, ethambutolthiacetazone, PZA, ethambutol Reserved:Reserved: ethionamide, PAS, amikacin, prothionamide,ethionamide, PAS, amikacin, prothionamide, cycloserine, ciprofloxacin, ofloxacin, capreomycincycloserine, ciprofloxacin, ofloxacin, capreomycin They are safe and well tolerated; SE are uncommon inThey are safe and well tolerated; SE are uncommon in children; no routine LFT, no routine B6children; no routine LFT, no routine B6 PZA: pyrazinamide. PAS:PZA: pyrazinamide. PAS: p-aminosalicylic acid
  80. 80. 88 Side EffectsSide Effects Seek helpSeek help in renal-, hepatic-, and pregnancy TBin renal-, hepatic-, and pregnancy TB RFM:RFM: cholestatsis, inactivate OCP, ‘flu’-like syn.cholestatsis, inactivate OCP, ‘flu’-like syn. INH:INH: hepatitis,hepatitis, neuropathy, agranulocytosis, B6 defi.,neuropathy, agranulocytosis, B6 defi., Ethambutol:Ethambutol: optic neuritisoptic neuritis PZA:PZA: arthralgia, hepatitis (arthralgia, hepatitis (gout is a CIgout is a CI)) Streptomycin:Streptomycin: ototoxicity, nephrotoxicityototoxicity, nephrotoxicity
  81. 81. 89 Standard ATD TherapyStandard ATD Therapy Initial/intensive PhaseInitial/intensive Phase 3-4 drugs (2 mo)3-4 drugs (2 mo) RifampicinRifampicin INH, PZAINH, PZA EthambutolEthambutol StreptomycinStreptomycin Continuation PhaseContinuation Phase 2 drugs (4 mo):2 drugs (4 mo): RifampicinRifampicin INHINH Standard drug regimen: earlier bacterial clearance (non-infectious: 2Standard drug regimen: earlier bacterial clearance (non-infectious: 2 weeks), less resistance, better monitoring, low costweeks), less resistance, better monitoring, low cost
  82. 82. Categories of Standard RxCategories of Standard Rx CategoriesCategories Pt. categoriesPt. categories InitialInitial phasephase Cont. phaseCont. phase Cat. ICat. I New smear +veNew smear +ve New ,, -veNew ,, -ve New extra-PTBNew extra-PTB New HIV-TBNew HIV-TB 2mo2mo (HRZE)(HRZE) HR: 4moHR: 4mo Cat. IICat. II Smear +ve despite RxSmear +ve despite Rx ≥1 mo no Rx≥1 mo no Rx RelapseRelapse Rx failure Cat. IRx failure Cat. I Rx after defaultRx after default OthersOthers 2 (HRZES)-2 (HRZES)- 1 (HRZE)1 (HRZE) HRE: 6moHRE: 6mo
  83. 83. 91 Drug Resistance in BDDrug Resistance in BD  StreptomycinStreptomycin 59.3%59.3%  INHINH 17.4%17.4%  RFMRFM 3.5%3.5%  EthambutolEthambutol 3.5%3.5%  INH+RFMINH+RFM 3.5%3.5%
  84. 84. MDR TBMDR TB. FU over. FU over 8y:8y: 1981: widespread1981: widespread destruction,destruction, 1985: cavity in RLL,1985: cavity in RLL, 1986: retraction of1986: retraction of cavity, but new cavitycavity, but new cavity in RULin RUL 1989: cavities in RUL1989: cavities in RUL with air-fluid-levelwith air-fluid-level
  85. 85. 93 Supportive RxSupportive Rx  Treatment of symptomsTreatment of symptoms  Correction of malnutritionCorrection of malnutrition  Balanced foodBalanced food  Adequate exerciseAdequate exercise  RehabilitationRehabilitation
  86. 86. 94 Treatment FailureTreatment Failure  Commonest:Commonest: noncompliancenoncompliance  MDR/XDR-TBMDR/XDR-TB  Inadequate number/dose/duration of drugsInadequate number/dose/duration of drugs  Incorrect DxIncorrect Dx
  87. 87. 95 Coricosteroids in TBCoricosteroids in TB In PE, TBM, pericarditis, HIV-TB, endobronchial TB, TBIn PE, TBM, pericarditis, HIV-TB, endobronchial TB, TB adrenal atrophy, MTB, compressing TBadrenal atrophy, MTB, compressing TB lymphadenitislymphadenitis Prednisolone is the DoCPrednisolone is the DoC Does not shorten duration of RxDoes not shorten duration of Rx 1-2 mg/kg/d. 6w in TBM1-2 mg/kg/d. 6w in TBM 4-6w with tapering4-6w with tapering TBM:TBM: ⇓⇓ MM.MM. MTB:MTB: improves GCimproves GC dramatically.dramatically. Pericardial E.:Pericardial E.: preventsprevents constriction.constriction. Pl. effusion:Pl. effusion: early relief.early relief. Endobronchial TB:Endobronchial TB: relievesrelieves distressdistress
  88. 88. Congenital TBCongenital TB  RareRare  Primary complex usually lies in the liverPrimary complex usually lies in the liver  Dx can beDx can be difficultdifficult  50% die within 3-4 w50% die within 3-4 w  CXR may shows MTB or primary TBCXR may shows MTB or primary TB  May be born with primary skin TBMay be born with primary skin TB  Mother may have no evidenceMother may have no evidence
  89. 89. PreventionPrevention  Contact tracing and Rx are primary goals (13% un-Contact tracing and Rx are primary goals (13% un- identified)identified)  BCG vaccinationBCG vaccination  Raising living standard, nutrition and health educationRaising living standard, nutrition and health education  Cough etiquette and hand washingCough etiquette and hand washing
  90. 90. WHO responseWHO response toto control TB.control TB. Stop TB StrategyStop TB Strategy  Global leadershipGlobal leadership  Policies, strategies, standards for Px, Rx, care and control.Policies, strategies, standards for Px, Rx, care and control. Monitor theseMonitor these  FinancingFinancing  Provide technical supportProvide technical support  Research and dissemination of knowledgeResearch and dissemination of knowledge  Facilitate and engage in partnerships for TBFacilitate and engage in partnerships for TB
  91. 91. Stop TB (WHO)  Vision:Vision: A TB-FREE WORLDA TB-FREE WORLD  Goal:Goal: to dramatically reduce TB by ‘15 (MDG6)to dramatically reduce TB by ‘15 (MDG6)  Objectives:Objectives: universal access to HQ care for alluniversal access to HQ care for all – Reduce suffering and SE burden of TBReduce suffering and SE burden of TB – Protect vulnerable popn. from TB, TB-HIV, MDR-TBProtect vulnerable popn. from TB, TB-HIV, MDR-TB  Targets:Targets: – by 2015: reduce cases and deaths by 50%by 2015: reduce cases and deaths by 50% – by 2050: eliminate TB as a PH problemby 2050: eliminate TB as a PH problem
  92. 92. Components of the Stop TB strategyComponents of the Stop TB strategy 1. HQ DOT1. HQ DOT expansion:expansion: political will, detection andpolitical will, detection and Dx, standard Rx and support, drug supply,Dx, standard Rx and support, drug supply, monitoring and evaluationmonitoring and evaluation 2. TB-HIV, MDR-TB,2. TB-HIV, MDR-TB, and the needs of poor popn.:and the needs of poor popn.: sscale-up collaborative TB/HIV activities, scale-upcale-up collaborative TB/HIV activities, scale-up prevention and management of MDR-TB, addressprevention and management of MDR-TB, address TB contacts, and needs of poor and vulnerableTB contacts, and needs of poor and vulnerable peoplepeople
  93. 93. 3. Strengthening primary HC:3. Strengthening primary HC: improve policies,improve policies, develop HW, effective running; infx. control, labdevelop HW, effective running; infx. control, lab networksnetworks 4. Engage all care providers:4. Engage all care providers: involve all; promoteinvolve all; promote International Standards for TB CareInternational Standards for TB Care 5. Empower people with TB5. Empower people with TB:: communication andcommunication and social mobilization; community participationsocial mobilization; community participation 6. Research:6. Research: operational research; research tooperational research; research to develop Dx, drugs, Vaxdevelop Dx, drugs, Vax
  94. 94. SummarySummary  TB occurs everywhereTB occurs everywhere  Mostly PTBMostly PTB  It is curable and preventableIt is curable and preventable  Spreads by droplets; only a few bacteria can infectSpreads by droplets; only a few bacteria can infect  1/31/3rdrd world popn. infected: 10% lifetime risk of active TBworld popn. infected: 10% lifetime risk of active TB  Immunocompromised has a much higher riskImmunocompromised has a much higher risk  One can infect 15 close contacts/yOne can infect 15 close contacts/y  Untreated: 2/3Untreated: 2/3rdrd diedie
  95. 95. Who is most at risk?Who is most at risk? All ages!All ages!  Mostly young adults in their most productive yearsMostly young adults in their most productive years  HIV: x30 riskHIV: x30 risk  Tobacco: >20% TB attributable to smokingTobacco: >20% TB attributable to smoking Global impact of TBGlobal impact of TB  The largest burden is in SEA and W. Pacific (56%). AfricaThe largest burden is in SEA and W. Pacific (56%). Africa has the largest new cases (280/100k)has the largest new cases (280/100k)  Some countries have a major decline in cases (Brazil ,Some countries have a major decline in cases (Brazil , China, Cambodia), while in others it is v. slowChina, Cambodia), while in others it is v. slow
  96. 96. Dx:Dx: Many countries still rely on smear: misses numerousMany countries still rely on smear: misses numerous casescases  Dx of MDR-TB and HIV-TB can be complexDx of MDR-TB and HIV-TB can be complex  Xene expert: 2h test; highly effective in Dx and DR. It isXene expert: 2h test; highly effective in Dx and DR. It is now used in many countriesnow used in many countries  TB Dx. v difficult in childrenTB Dx. v difficult in children Rx:Rx: Active, drug-sensitive TB: 6mo x 4 drugsActive, drug-sensitive TB: 6mo x 4 drugs  Info., supervision and support to pt. is v. imp. (adherenceInfo., supervision and support to pt. is v. imp. (adherence can be difficult: MDR-TB, spread)can be difficult: MDR-TB, spread) TB and HIV:TB and HIV: 1/31/3rdrd HIV has active TB (a lethal combo.)HIV has active TB (a lethal combo.) (78% in Africa). 25% of HIV deaths are due to TB(78% in Africa). 25% of HIV deaths are due to TB
  97. 97. MDR-TBMDR-TB do not respond to INH and rifampicin (2 most powerful)do not respond to INH and rifampicin (2 most powerful)  The primary cause is inappropriate RxThe primary cause is inappropriate Rx  2013: globally 480k had MDR-TB: >50% in India, China,2013: globally 480k had MDR-TB: >50% in India, China, Russia. 9% MDR-TB are XDR-TBRussia. 9% MDR-TB are XDR-TB  Curable by 2Curable by 2ndnd -line drugs x2y: are limited, not plenty and v-line drugs x2y: are limited, not plenty and v expensive: ~severe SEexpensive: ~severe SE  XDR-TB: responds to fewer drugsXDR-TB: responds to fewer drugs
  98. 98. 107 Points to PonderPoints to Ponder  TB may mimic any S/S; oTB may mimic any S/S; oftenften under-diagnosedunder-diagnosed  Most primaries are asymptomaticMost primaries are asymptomatic  More prevalent in AIDSMore prevalent in AIDS  MDR-TB is almost aMDR-TB is almost a ‘death sentence’‘death sentence’  Treating open cases controls spreadTreating open cases controls spread Contd.Contd.
  99. 99. 108  Infection necessarily is not a diseaseInfection necessarily is not a disease  Adult PTB is mostly open, child PTB is closedAdult PTB is mostly open, child PTB is closed  Normal CXR, CBC do not exclude PTBNormal CXR, CBC do not exclude PTB  TB is an important c/of PUOTB is an important c/of PUO  BCG does not prevent TBBCG does not prevent TB contdcontd Points to PonderPoints to Ponder
  100. 100. 109  ComplianceCompliance is essential:is essential: – prevents spreadprevents spread – less drug resistanceless drug resistance – full recoveryfull recovery  Monitoring: DOT, urine colorMonitoring: DOT, urine color  Vision check in ethambutol useVision check in ethambutol use Points to PonderPoints to Ponder
  101. 101. Extra Pulmonary TB: CNS Disseminated TB Lymphatics, pleura, bones and joints Urogenital Skin
  102. 102. scrofulascrofula
  103. 103. Phlyctenular conjunctivitisPhlyctenular conjunctivitis
  104. 104. OSPEOSPE Look at the CXR of a child whose mother hasLook at the CXR of a child whose mother has persistent cough, irregular F, and wt losspersistent cough, irregular F, and wt loss 1.1. What abnormalities you find?What abnormalities you find? 2.2. How do you confirm your Dx?How do you confirm your Dx? 3.3. What are the complications of the primary infx.?What are the complications of the primary infx.? 4.4. How do you treat?How do you treat?
  105. 105. 118
  106. 106. Answer KeysAnswer Keys  Miliary mottling in both lung fieldsMiliary mottling in both lung fields  MT, gastric aspirate for CS, PCR, ALSMT, gastric aspirate for CS, PCR, ALS  Complications from primary focus …., enlarged LNComplications from primary focus …., enlarged LN ….. and from caseous material …..….. and from caseous material …..  4 drug Rx for minimum 6mo4 drug Rx for minimum 6mo
  107. 107. MCQMCQ  BCG vax. prevents TBBCG vax. prevents TB  Childhood TB is mostly contagiousChildhood TB is mostly contagious  Normal CXR excludes PTBNormal CXR excludes PTB  Normal CBC excludes TBNormal CBC excludes TB  Commonest c/of pseudo-negative MT is faultyCommonest c/of pseudo-negative MT is faulty techniquetechnique  TB is an important c/of female infertilityTB is an important c/of female infertility
  108. 108. MCQMCQ  TB can mimic any sign or any symptomTB can mimic any sign or any symptom  Most primary infx. healsMost primary infx. heals  Use of steroid reduces Rx durationUse of steroid reduces Rx duration  Non-compliance is the commonest c/of Rx failureNon-compliance is the commonest c/of Rx failure  inadequate Rx is the main c/of MDR-TBinadequate Rx is the main c/of MDR-TB  Most TB infx. leads to diseaseMost TB infx. leads to disease
  109. 109. Next Lec.Next Lec. EPI TargetEPI Target DiseasesDiseases
  110. 110. 123THANK YOU

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Lecture for MBBS students at Bangladesh Medical College, Dhaka

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