TB

Case 1

55 years old lady, referred to resp clinic tro TB

Has underlying 1) SLE since 1995. last relapse 2004. last immunosuppressant
nov 2014. 2) hypertension . 3) bilateral knee OA

She denies cough or any symptoms. Her husband just being diagnosed with
smear positive PTB on 25 March 2016. She is non smoker.
Routine contact screening done.
ESR 28, Mantoux 10mm , CXR as attached
Smear ve for AFB x 1
cxr
Diagnosis ?

A) Latent PTB
B) Active PTB
C) I DONT KNOW
MANAGEMENT

Unable to rule out active PTB in this case.

Need for further investigations.
It is not latent TB. Despite she doesnt has any symptoms , her mantoux is
10mm AND CXR is not perfectly clear.

Plan :
Bronchoscopy (BAL AFB, BAL MTB C+S, MTB PCR , BAL C+S, GENE EXPERT)
If all ve , to treat as latent TB if pt agreeable.
LATENT TB
 Is defined as infection with mycobacterium tuberculosis complex, where the
bacteria may be alive but in the state of dormancy and not currently causing
any active disease/symptoms.

Diagnosis
1) No sx to suggest of active TB
2) Normal CXR /static CXR findings
3) Smear ve /c+s ve on sputum or BAL for MTB ve
4) +ve mantoux test
TRUE / FALSE?

If abnormal findings are found on CXR, there should be no changes seen on

repeat CXR over a period of at least 6/12.
Most patients with LTBI have a normal CXR
Repeat sputum induction or BAL for AFB smear and culture should be
considered with abnormal CXR, even though there are no changes seen on
repeat CXR.
Healed lesions are often characterised by nodules and fibrotic lesions that are
well demarcated.
Calcified nodular lesions (calcified granulomas) and apical or basal pleural
thickening pose a lower risk for future progression to active TB.
MANTOUX TEST

Reagent (tuberculin) used in the test cross reacts with BCG and NTM. This
gives rise to false +ve results in some individual.

+ve mantoux test for LTBI

5mm or more : HIV, organ transplant recipients, immunosupp person (t pred >
15mg/day > 1/12 or taking TNF-alpha antagonist)

15mm or more : individuals from countries with low incidence of TB

10mm or more : all other high risk individuals

HIGH RISK OF ACQUIRING LTBI

HIV
Organ transplant
Immunosuppressant
Recent close contact (< 2 years)
Recent immigrant (<2 years ) from high prevalence countries
IVDU
Residents and employees of high risk congregate settings (nursing home,
homeless shelters, hospital)
Person with fibrotic changes on CXR consistent with old TB
 TREATMENT LTBI

DRUGS DURATION INTERVAL COMPLETION CRITERIA

INH 6-9/12 OD 180 doses in 9/12 (6/12 regimen)
270 doses in 12/12 (9/12 regimens)
INH + 4/12 OD 120 doses in 6/12
RIF
RIF 4/12 OD 120 doses in 6/12
INH +RIFAPENTINE 3/12 Once 12 doses
weekly
Not recommended for children < 2y,
HIV, presumed INH or RIF-resistant
MTB, Pregnant.
WHATS TREATMENT OF CONTACTS WITH
INDEX CASE OF MDR-TB?
 No RCT
Immunocompetent people exposed to MDR-TB be followed up for 6/12,
whether they are being treated or not.

If Rx is administered (for high risk of TB reactivation) , PZA and ETH or PZA

and guinolones x 6-12/12 recommended.
2nd CASE
LIVER IMPAIRMENT
RENAL IMPAIRMENT

If renal failure or Egfr <30,

2/12 : EHRZ followed by
4/12 : HR

HOWEVER, dose adjustment needed for Ethambutol and PZA.

PZA 3 x a week (25-30mg/kg)
Ethambutool 3 x a week (25-30 mg/kg)

All 4 anti TB should be administered after HD to facilitate DOTS

PZA should be administered after HD to avoid premature drug removal.
Streptomycin should be avoided in renal failure pt as it increased risk of nephrotoxicity and
ototoxicity. If streptomycin need to be used, the dosage is 15mg/kg , 2-3 x a week, to a max 1g per
dose. Serum levels of the drugs should be monitored.