CASE 6: PULMONARY TUBERCULOSIS 1. Groups at high risk for developing PTB A.

Persons who have

been Recently Infected with TB Bacteria

This includes:

• Close contacts of a person with infectious TB disease

• Persons who have immigrated from areas of the world with high rates of TB

• Children less than 5 years of age who have a positive TB test

• Groups with high rates of TB transmission, such as homeless persons, injection drug users, and
persons with HIV infection

• Persons who work or reside with people who are at high risk for TB in facilities or institutions such as
hospitals, homeless shelters, correctional facilities, nursing homes, and residential homes for those with
HIV

B. Persons with Medical Conditions that Weaken the Immune System

Babies and young children often have weak immune systems. Other people can have weak immune
systems, too, especially people with any of these conditions:

• HIV infection (the virus that causes AIDS)

• Substance abuse

• Silicosis

• Diabetes mellitus

• Severe kidney disease

• Low body weight

• Organ transplants

• Head and neck cancer

• Medical treatments such as corticosteroids or organ transplant

How does vaccination with BCG affect TST and

IGRA?

1. Í GRA measures how strong a person’s immune system reacts

to TB bacteria by testing the person’s blood in a laboratory. 2. T́ ST measures the response to antigenic
stimulation by T cells

that resides in the skin rather than the response of re circulating memory T cells. 3. Í GRA is more
specific than TST as a result of less cross-

reactivity due to BCG vaccination and sensitization

Importance of Liver Function Tests in TB infection

A. Liver disease can occur due to hepatic tuberculosis or the

treatment with various anti-tubercular drugs may precipitate hepatic injury or patients with chronic liver
disease may develop tuberculosis and pose special management problems. B. C. Currently
recommended first line treatment for TB includes regimen of isoniazid (INH), rifampicin (RMP),
pyrazinamide (PZA) and ethambutol (EMB) for initial 2 months followed by 4 months of INH and RMP
and/or EMB D. E. Among the first line quadruple therapy drugs (INH, RMP, PZA,

EMB), first three are metabolized mainly by the liver and are potentially hepatotoxic. F. A fair fraction of
TB patients on chemotherapy with isoniazid

and rifampicin exhibit elevations in serum levels of liver

enzymes, alanine aminotransferase (ALT, earlier called SGPT) and aspartate aminotransferase (AST,
earlier SGOT) activities.

2. Treatment if patient is HIV Positive

• Rifampicin can be change to rifabutin to prevent its effect on anti-retroviral drugs.

• T́ he continuation phase can be extend to 7 months if the sputum smear is still positive after the
intensive phase therapy.

GUIDELINES IN TREATMENT OF PULMONARY TUBERCULOSIS DIAGNOSIS OF TUBERCULOSIS CPG 2016

• Presumptive TB – A patient who presents with symptoms or signs (radiologic findings) suggestive of TB
(replaces the term TB suspect or TB symptomatic).

• Bacteriologically confirmed case of TB – A patient from whom a biological specimen is positive by

smear microscopy, culture or WHO- approved rapid diagnostic test (such as Xpert® MTB/RIF). All such
cases should be notified, regardless of whether TB treatment is started.

• Clinically diagnosed case of TB – A patient who does not fulfill the criteria for bacteriologically
confirmed TB but has been diagnosed with active TB by a clinician or other medical practitioner who has
decided to give the patient a full course of TB treatment (based on imaging studies, suggestive histology
and extra-pulmonary cases without laboratory confirmation). Clinically diagnosed cases subsequently
found to be bacteriologically positive (before or after starting treatment) should be reclassified as
bacteriologically confirmed.

• Case of pulmonary TB – Any bacteriologically confirmed or clinically diagnosed case of TB involving the
lung parenchyma or the tracheobronchial tree. A patient with both pulmonary and extra- pulmonary TB
should be classified as a case of pulmonary TB.

• Case of extra-pulmonary TB – Any bacteriologically confirmed or clinically diagnosed case of TB

involving organs other than the lungs, e.g. abdomen, genitourinary tract, joints and bones, lymph nodes,
meninges, pleura, skin.

For purposes of standardized reporting across countries, this document adopts the WHO cut off of 15
years old and above to refer to adults.
Extensive literature search, retrieval and appraisal were performed to provide evidence-based
recommendations in the diagnosis of susceptible

TB among immunocompetent adults, harmonized with international standards and policies for easier
application for the clinician.

TREATMENT OF PTB CPG 2016

To prevent the development of complications of high LDL

Lifestyle modification

Smoking cessation

Alcohol avoidance

Diet modification

NON- PHARMACOLOGIC REGIMEN