PULMONARY

TUBERCULOSIS

Prof.dr.Tamsil Syafiuddin,SpP(K)
Pulmonary Department
Faculty of Medicine
Universitas Islam Sumatera Utara
 Levels of competence

Standar Kompetensi Dokter , Konsil Kedokteran Indonesia, 2006

 Level of competence 4:

Mampu membuat diagnosis klinik berdasarkan

pemeriksaan fisik dan pemeriksaan tambahan
yang diminta oleh dokter (misalnya: pemeriksaan
laboratorum sederhana atau X-ray).
Dokter dapat memutuskan dan mampu menangani
problem itu secara mandiri hingga tuntas.

Standar Kompetensi Dokter , Konsil Kedokteran Indonesia, 2006

 PROBLEMS
Medical Education as a System

OUT PUT
IN PUT System/Faculty of Medicine
(Dokter) TB
Definition
Tuberculosis infection means that
Mycobacterium tuberculosis has infected a
host but is not causing disease

Tuberculosis disease or tuberculosis

means the disease caused by M.
tuberculosis
Epidemiology
WHO estimates >8 million new cases of
tuberculosis per year
Estimated that 19-43% of the worlds
population is infected with M. tuberculosis
Infected persons serve as reservoirs for
activated disease to occur
Among infectious diseases, TB remains
the second leading killer of adults in the world

More than 2 million TB-related deaths each year

 Pulmonary TB (Indonesia)

Tuberculosis (TB) is The Ancient Killer The Great

Imitator The Giant Poverty Producing Mechanism
( Guzman et al 1999 )

Indonesia : 3rd in the World MDR-TB 12 20% / year ,

mortality 175.000 / year , 500 / day
( WHO Report 2000 )
 Source

reservoirs
Child

Young adult

DM Adult
NATURAL HISTORY HIV
The scientific thinking Data:
Batuk
Umur muda
Batuk darah
Riwayat demam
Napsu makan

Analysis
TB ?

Foto
toraks Planning
The scientific thinking Data:
Batuk
Umur tua
Batuk darah
Riwayat demam
Napsu makan

Analysis
TB ?

DM,HIV AIDS ?
Planning
Foto Toraks
 Tuberculosis
History
Evidence dating back to 2400 BC
Called pthisis: Greek for consumption
Herman Brehmer: botany student from
Poland with TB, returned from Himalayans
cured; doctoral dissertation in 1854 entitled
Tuberculosis is a Curable Disease
1882: Robert Koch identified organism with
newly developed staining technique
Advent of x-ray technology in 1895 allowed for
assessment of severity and progression of
disease
 Tuberculosis
History
Early 20th century: French bacteriologists
Calumet and Guerin developed technique that
led to BCG vaccine
Advent of anti-TB chemotherapy
1940 actinomycin
1943 streptomycin
1950s combination therapy
2003 - fix dosed combination
2008 UISU students
Pathogenesis
M. tb ingested by macrophages in alveoli
May survive and multiply
Spread by lymphatics to hilar nodes
Cellular immunity develops 2-12 wks after
infection and usually limits M. tb growth in
granulomas which are small, inapparent
Active disease seen in 10%, with half
within the first 2 years
 Source

reservoirs
Child

Young adult

DM Adult
NATURAL HISTORY HIV
Pulmonary Disease
Symptoms of cough which starts non-
productive and becomes sputum
Other symptoms include pleuritic pain,
hemoptysis
Physical exam is usually not helpful
Chest X ray findings are important
primary disease with middle, lower lung infiltrates
with hilar adenopathy
reactivation with upper lobe disease and
cavitation
Diagnosis of Tuberculosis
Clinical finding
Requires positive PPD skin test and/or
Chest X ray findings consistent with TB
With confirmation by positive direct and
culture AFB from specimen
pulmonary disease with sputum collection (3
single specimens) or gastric aspirates in child or
bronchoscopy in rare instances
specimens from urine, nodes, etc. if extra
pulmonary site is suspected
 Reason for treatment cessation
(Syafiuddin T et al, 2003)

4%
4%
4%

filling good
money
51 % doctors
36 % advers drug
others

TSY, World TB Day 2003.

 Pattern of Myc. tbc resistance
(Basic theory of multiple drugs adm.)
106
Rise & fall phenomena

+ + + + +
Time
Lag phase :
Cessation of microbial metabolism
in period of time

Myc. tbc (72 hours )

Drug administration

Once a day Once for three day

 Pulmonary TB (Indonesia)

SYMPTOMS

DIAGNOSIS

TREATMENT

OUT COME

PROBLEMS and NATURAL HISTORY

 Delays of diagnosis:
Patients delays : 4.78 Moths
Doctors delays : 3.64 Moths
Clinical Manifestations
Systemic-fever, malaise, night sweats, wt
loss
Extrapulmonary- disseminated (HIV and
immune compromise) with multiorgan
involvement
lymph node, pleura, GU, bone, CNS, GI,
pericardial
Diagnosis of Tuberculosis
Use of skin test of 5 U tuberculin PPD given
intradermal
>5 mm induration is positive for infection for
contacts of TB cases, HIV, Xray fibrosis (old
disease), immune suppression
>10 mm induration is positive for persons in
high prevalence countries, IDU, prisons and
jails, medical conditions, children < 4 y/o
exposed to adults in high risk categories
> 15 mm induration with no risk factors for TB
 National Mortality Rate
( SKRT DepKes RI 1992)

Cardiovascular diseases
( 1 st rank )
Tuberculosis
( 2 nd rank )
Pneumonie
( 3 rd rank )
Asthma, bronchitis chronic
and emphysema
( 6th rank )
Pulmonary TB (Indonesia)

3rd rank in the world

2 nd rank cause of death
lost of cases
Multi drug resistance cases
Pulmonary remodelling cases
 Pulmonary TB (Indonesia)

* One new TB case / minute

* One new infectious TB case / 2 minutes

* One TB died / 4 minutes

 Perkiraan kecenderungan jumlah kematian akibat TB
di seluruh dunia menjelang abad 21
Int J Tuberc Lung Dis 1998; 2(9): 696-703.

5 juta

4 juta

3 juta

2 juta

Deklarasi WHO:
1 juta Penemuan Mulai adanya Penemuan TB merupakan
basil TB sanatorium OAT I kedaruratan global
(1882) (1900) (1945) (1993)
1850 1900 1950 2000 2050

World TB Day 2003 Rozaimah Zain-Hamid

 PREVALENSI TB TIDAK DAN
ANGKA KEMATIAN YANG TINGGI

MERUPAKAN MASALAH NASIONAL

bahkan GLOBAL EMERGENCIES

World TB Day 2003 Rozaimah Zain-Hamid

 Duration of symptoms
(Syafiuddin T et al, 2003)

11 %

35 % <1 month
1-2 month
25 %
3-5 month
>6 month

29 %

TSY, World TB Day 2003.

 Source

reservoirs
Child

Young adult

DM Adult
NATURAL HISTORY HIV
Duration of treatment (Syafiuddin T et al, 2003)

11 %
24 %
< 1 bulan
2 month
39 % 3 month
26 % 4-5 mnth

TSY, World TB Day 2003.

 TENAGA MEDIS YANG PERTAMA KALI
MEMBERIKAN PENGOBATAN KEPADA
PENDERITA TB PARU
Syafiuddin T dkk, 2003

6%
8%
Bidan/perawat/
mantri
Dokter Umum
35 %
Spesialis/PPDS
51 % Paru
Spesialis lain

World TB Day 2003 Rozaimah Zain-Hamid

 Pulmonary tuberculosis
(Indonesia)

3Rd rank in the world

2 nd rank cause of deads
Higher on lost of cases
Pulmonary remodelling cases
Multi drug resistance cases

Perception
Diagnosis
Tuberculosis
( MHLC 96 - 97 )

Insurance Private

Lost of cases 65 % 68 %
Tuberculosis
Treatment
Requires multidrug regimen
Susceptibility testing of initial isolates
critical
The American Thoracic Society and CDC
recommend initial therapy be given with
four drugs:
isoniazid, rifampin, pyrazinamide and
ethambutol or streptomycin
 Pulmonary
tuberculosis

Clinical examination
Radiologic examination
Laboratoric examinatioon
History
 Pulmonary
tuberculosis

Clinical examination
Age
Respiratory problems
 Pulmonary
tuberculosis

Radiologic examination
Cloudy swelling
Multiform
Pleural effusion
 Pulmonary
tuberculosis

Laboratory examination
Direct smear
Culture
Mantoux test
DNA test
 Pulmonary
tuberculosis

Suspected pulmonary Tb
Pulmonary Tb
Post pulmonary Tb
 Clinically (+)
History (-)
Radiology (+)
1 st Category Laboratory (-)

Suspected pulmonary Tb

Clinically (+)
History (+)
Radiology(+)
Laboratory(-) 1 st Category
 Clinically (+)
Radiology (+)
History (+)
2 nd Category Laboratory (+)

Pulmonary Tb

Clinically (+)
Radiology (+)
History ( - )
1 st Category
Laboratory (+)
 Clinically (-)
Radiology (-) or (+)
History (+)
No treatment Laboratory (-)

Post pulmonaryTb

Clinically ( +)
Radiology (+)
History (+) Symptomatic
Laboratory (-)
 Guideline of anti tb drugs
(tb control program in Indonesia,
based on WHO recommendation)

1 st Category : ( 2 HRZE/ 4 H3R3 )

(New cases, AFB + , ( 2 HRZE/ 4 HR )
AFB , Ro +, severe illness)

2 nd Category : ( 2 HRZES + HRZE/ 5 H3R3E3 )

(Relapse, failure, AFB + ) ( 2 RHZES/ 5 RHE )

3 rd Category : ( 2 HRZ/ 4 H3R3 )

(New cases, AFB - ) ( 2 HRZ/ 4 HR)

4 th Category : ( H long-life ? )
(Chronic tb)
Treatment Principles
Regiment must contain multiple drugs to
which the TB is susceptible

Drugs must be taken regularly

Drugs must be continued for sufficient time

 Doses of anti tb drugs
(tb control program in Indonesia,
based on WHO recommendation)
1 st Category

Intensive : H 300 mg , R 450 mg, Z 1500 mg, E 750 mg

phase
Intermittent : H 600 mg , R 450 mg
phase
2 nd Category

Intensive : H 300 mg , R 450 mg, Z 1500 mg, E 750 mg

phase S 750 mg

Intermittent : H 600 mg , R 450 mg

phase
 Doses of anti tb drugs
(tb control program in Indonesia,
based on WHO recommendation)

3 rd Category

Intensive : H 300 mg , R 450 mg, Z 1500 mg,

phase

Intermittent : H 600 mg , R 450 mg

phase