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Pulmonary Tuberculosis

Muhammad Omar Warsame Adam Elmi Adam

Presentation outline
In our presentation we will go through

Definition II. Epidemiology III. Aetiology IV. Pathology V. Fate of pulmonary TB VI. Clinical manifestations VII. Investigations VIII.Management.

I. Definition
Tuberculosis is a communicable, chronic,

granulomatous disease, caused by mycobacterium tuberculosis. It usually involves the lungs( Pulmonary Tuberculosis) but may affect any organ or tissue of the body .

Roughly one-third of the world's population has

been infected with M. tuberculosis new infections occur at a rate of one per second on a global scale. However, most infections with M. tuberculosis do not cause TB disease. Tuberculosis is the second most common cause of death from infectious disease (after those due to HIV/AIDS) It is more common in developing countries.

III. Aetiology
A. Causative Organism:

Mycobacterium tuberculosis - Aerobe organism - Acid-fast bacilli - Intracellular pathogen Types - Human type: 98% - Bovine type: 2% Sources of infection - Inhalation: droplets of patients - Ingestion: milk of infected animals - Inoculation: Skin inoculations by the laboratory specimens.

B. Predisposing Factors: o Sex: equal in both males and females o Age: - Above 15 years: high susceptibility to develop disease - Between (5-15): low susceptibility to develop disease - Below 5 years: high susceptibility to disease and spread but a low incidence of exposure except from tuberculous patient. o Race: black races common o Place: low socio-economic classes and developing countries due to poor nutrition. o Occupation: doctors and nurses are more exposed to infection o Underlying diseases: - Pulmonary diseases: as viral infection or silicosis - Decreased immunity: in DM, malignancy or immunosuppressives.

IV. Pathology
A. Pulmonary component: Gohns focus It is an area of consolidation in the lung

formed of tubercles aggregation. It is more common in - Upper part of the middle and lower lobes - Lower lobes of the upper lobe - Right lung and sub pleural areas.

B. Lymphatic component:
Regional lymph nodes: Regional lymphadenitis glandular component
- it is more common in the mediastinal lymph nodes.

- it usually appears as unilateral hilar lymphadenopathy .

Lymphatic vessels: Lymphagitis of the intervening lymphatic vessels.

V. Fate of pulmonary tuberculosis

Healing 90% It occurs by fibrosis, calcification or dormant

foci may be formed. Progression of pulmonary component local spread It may lead to; - Tuberculous pneumonia - Pleural effusion - Primary cavitation

Progression of glandular component lymphatic

spread It may lead to - Bronchial ulceration bronchopneumonia occurs - Pressure on the bronchus - Pressure on other mediastinal structures Haematogenous spread: it usually heals by forming dormant foci which may lead to miliary tuberculosis or a single organ involvement.

VI. Clinical manifestations

Systemic symptoms: low grade intermittent

fever usually in the morning, night sweats, Weight loss, anorexia, malaise and weakness. i. Chronic cough, often with haemoptysis ii. Pyrexia of unknown origin iii. Unresolved pneumonia iv. Exudative pleural effusion v. Asymptomatic (diagnosis on chest X-ray) vi. Spontaneous pneumothorax

VII. Investigations
1) Tuberculin test
Definition: its a delayed hypersensitivity cell mediated hypersensitivity

type (VI) used to discover the sensitivity of the human body to the tuberculo-protein antigen. Values: - Positive: * in children less than 3 years :indicates active tuberculous infection * in adult: indicates active infection, old T.B or BCG Negative: * chest lesions with ve test are not probably T.B infection * Tuberculin ve adults prone to infection need BCG False negative: *old pnts, vaccination with live . *corticosteroids and immunosuppressive - False positive: *Atypical mycobacteria and post-BCG vaccination

2) Radiological findings -it depends on the nature of the lesion as Fibrocaseous TB: - Apical cavity which is surrounded by fluffy opacities Miliary TB: - Multiple shadows of equal shape and size in the different lung zones Tuberculous bronchopneumonia: - Multiple irregular patches scattered in the lung zones Other findings: - Pleural effusion, pneumothorax, and pulmonary fibrosis - Calcification and enlarged hilar lymph nodes.

3) Laboratory findings - C-reactive protein and ESR: markedly elevated - Blood culture: * Normocytic normochromic anaemia * Leukopenia with relative lymphocytosis 4) Bacteriological investigations - Sputum examination - Gastric, bronchoalveolar lavage and laryngeal swab. 5) New investigations: - PCR: for the detection of mycobacterium, DNA - ELIZA: for detection of serum IgG against mycobacterium antigens

VIII. Management
i. Therapeutic treatment
A. Medical treatment
Symptomatic treatment Fever: antipyretics Productive cough: mucolytics General care: Proper nutrition, fresh air

B. Surgical treatment
Indications Uncontrolled haemoptysis

Uncontrolled empyema
Tuberculous bronchitis Tuberculoma Open cavity

inhalation Bed rest in acute phase then ambulatory treatment later Specific treatment Combined antituberculous drugs Steroid and immunotherapy

VIII. Mngt..cont
ii. Prophylactic treatment
A. Chemo prophylaxis
Indications In immunocompromised

B. immunoprophylaxis
Indications At birth

patient with radiological changes in CXR Using Isoniazide INH

In high risk groups;

-Immunosuppressive therapy for long periods. -Health professionals -Contact of tuberculous patients In countries with high incidence of tuberculous infection.

Characteristics of anti-tuberculous drugs

Drug Most common sideeffect
Peripheral neuritis Hepatitis Hypersensitivity Hepatitis Thrombocytopenia Fever Reversible optic neuritis Hypersensitivity rash Hepatitis Gout 8th nerve damage Neurotoxicity

isoniazid Rifampicin Ethambutol


WHO Recommendations for TB Rx

Special clinical cases

Pregnancy: Streptomycin is contra-indicated. Pyrazinamide is usually avoided.

Breast feeding is not contraindication to ATT therapy

Renal failure: Avoid aminoglycosides For mild to moderate renal failure INH, Rifampicin and Pyrazinamide

may be given, and in sever RF dose should be reduced. Liver failure: In mild to moderate liver disease, ATT may be given with monitoring In severe liver disease, TB should be treated with SHE THERAPY

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