Paradigma baru pemeriksaan

Tuberkulosis Paru

Ida Parwati
Tropical and Infectious Diseases/Clinical Microbiology Division
Department of Clinical Pathology and Laboratory Medicine
Dr. Hasan Sadikin Hospital–Faculty of Medicine Universitas Padjadjaran
BANDUNG
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Outline
TB Epidemiology
TB transmission
Recent advance of TB Diagnostic
WHO recommendations for TB Diagnostic tools

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 Epidemiology
• TB is one of the top ten leading causes of death worldwide and the leading cause
from a single infectious agent, ranking above HIV/AIDS.
• In 2017 there were a total of 1,600,000 TB related deaths.
• Also an estimated 234,000 children died of TB in 2017 including children with HIV
associated TB.
• There were an estimated 10.0 million new cases of TB disease (also known as active
TB) in 2017. Two thirds were in eight countries India (27%), China (9%), Indonesia
(8%), the Philippines (6%), Pakistan (5%), Nigeria (4%) and South Africa (3%).

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 Transmisi TB: airborne melalui droplet nuclei

Droplet nuclei:
Batuk: 3000 d.n
Bersin: 10.000 d.n

Droplet nuclei:
<5µ, berisi 1-3 BTA

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 Transmission & ~70-80%
Natural History of Exposure
(1)
M. tuberculosis Airborne Infection
Control
Uninfected
~20-30%
~5-10%
 Airborne transmission Infection

 20-30% of exposed will

become infected Active TB
~90-95% (2)
 5-10% of infected will Latent TB Containment
Case finding and
treatment of TB

develop active TB (3)

Diagnosis and
~10% healthy adults
~20% children <5 yrs
treatment of LTBI
 90-95% of infected will ~30% HIV+ patients
~40% children <2 yrs
develop latent TB Other high risk
clinical settings
 Those infected with
Post primary pulmonary/
LTBI may reactivate! Extra pulmonary/
Reactivation Miliary TB
Host immunity (2)
Mycobacterial virulence Case finding and
treatment of TB
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Adapted from: Chest. 2012;142(3):761-773. doi:10.1378/chest.12-0142
What is the best TB diagnostic tools?

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 WHO’s recommended techniques for
diagnosing TB
• Microscopy • Molecular testing
Conventional light microscopy LPA (first and second-line)
Light-emitting diode fluorescent TB-LAMP
microscopy Xpert MTB/RIF assay (Ultra)
• Culture • LF-LAM Urine test for PLHIV
Culture on solid media
Commercial liquid culture systems
and rapid speciation
• Drug-susceptibility testing
DST first-line anti-TB agents
DST for second-line anti-TB agents
Non-commercial methods Christopher Gilpin, Global TB Programme WHO Geneva 2017

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20190309 DIAGNOSTIK TUBERKULOSIS_PEKANBARU www.thelancet.com/infection Vol 18 July 2018
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www.thelancet.com/infection Vol 18 July 2018
 Berlin, March 24, 1882 The development
Robert Koch (1843-1910) of TB Microscopy
“Die Aetiologie der Tuberculose”
& its problem

Franz Ziehl (1859-1926), bacteriologist

Friedrich Neelsen (1854-1894), pathologist
Alkaline methylen blue
& bismark brown

• Fast, cheap, quantify AFB, for Ziehl Neelsen

diagnosis and prognosis,
transmission
• Need 2 sputums, low sensitivity; Auramine fluorescens
<50%, 20% for pediatric & PLHIV staining (40x)

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 Permasalahan pada Diagnostik TB
Kultur
Keuntungan Keterbatasan
 Gold standard walaupun imperfect  Dibutuhkan fasilitas
 Menambah jumlah penemuan kasus biosafety
 Dapat mendeteksi kasus pada BTA neg
 Membuktikan viabilitas bakteri  Waktunya lama:
 Membedakan spesies Mycobacterial 4-8 minggu
 Dapat dilanjutkan pemeriksaan DST (uji
kepekaan obat)
 Membantu diagnosis pada kasus gagal
terapi

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LAMPIRAN
PERATURAN MENTERI KESEHATAN
REPUBLIK INDONESIA NOMOR 67
TAHUN 2016TENTANG
PENANGGULANGAN TUBERKULOSIS

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 Pemeriksaan Tes Cepat Molekuler (TCM) TB

• Pemeriksaan tes cepat molekuler dengan metode Xpert MTB/RIF. TCM merupakan
sarana untuk penegakan diagnosis, namun tidak dapat dimanfaatkan untuk evaluasi
hasil pengobatan.
• Pemeriksaan biakan dapat dilakukan dengan media padat (Lowenstein-Jensen) &
Ogawa dan media cair MGIT (Mycobacteria Growth Indicator Tube)

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 Spesimen dahak
• Pemeriksaan dahak untuk penegakan diagnosis dilakukan dengan
mengumpulkan 2 contoh uji dahak yang dikumpulkan berupa dahak
Sewaktu-Pagi (SP):
• S (Sewaktu): dahak ditampung di fasyankes.
• P (Pagi): dahak ditampung pada pagi segera setelah bangun tidur. Dapat
dilakukan di rumah pasien atau di bangsal rawat inap bilamana pasien
menjalani rawat inap.

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Xpert MTB/RIF assay & GeneXpert instrument

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 TARGET DETEKSI GeneXpert

Target deteksi: rpoB Mtb wild type dengan memakai 5 probe (A-E)
Tidak ada mutasi → 5 probe terdeteksi → Rifampisin sensitif
Ada mutasi → > 1 probe tidak terdeteksi → Rifampisin resisten

Kodon 523-529
Kodon 507-511 Kodon 518-523

Kodon 512-518 Kodon 529-533

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Visualizing the test results

Information about test

Interpretation of results

Real-Time PCR curves

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Gambaran Hasil Pemeriksaan GeneXpert

El-Hajj H H et al. J. Clin. Microbiol. 2001;39:4131-4137

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 Keterbatasan metode TCM
• Gen yang menjadi target deteksi masih terbatas
• Tidak semua mutasi berhubungan dengan phenotypic resistance
→ Silent mutations: tidak ada perubahan protein
• Umur catridge hanya 18 bulan
• Membutuhkan asupan listrik yang stabil
• Instrumen harus direkalibrasi setiap tahun
• Temperatur sekitar harus memadai
• Harga masih mahal
• Tidak dapat digunakan untuk monitoring/follow up Th/

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Line-Probe Assays

GenoType MTBDRsl Ver2.0;

Genes for Second line TB drug: FQ

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Deteksi Antigen yang disekresi M. tuberculosis

Positivity rate; AFB 52/141 (36.9%),

culture 50/141 (35.5%), urinary Mtb
antigens cocktail 95/141 (67.4%).

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Determine TB LAM Ag

Advantages;
• Antigen detection
• In urine specimen
• Assist TB D/ in CD4 cell count ≤100
cells/μL or HIV + seriously ill

Disadvantages;
• Do not differentiate species in
MTBc

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 Latent TB should be treated?
If so, what is the diagnostic tool?

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 TST
IGRA

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 Immunology of TB
• Activation by CD4+ TDTH cells
enable the macrophages to
destroy bacilli
• TH1 cells produce the cytokines
IFN-gg and IL-2
• IFN-gg specifically activates
macrophages and stimulates
them to ingest and kill
mycobacteria
• IFN-g Basis of the QFT-TB test

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 Tuberculin Skin Test (TST)
• Indirect test for detection of M. tuberculosis – in vivo
– Type IV cell-mediated immune response to M. tuberculosis
• Requires trained and experienced personnel1
• Intradermal injection of tuberculin (PPD), with assessment for
presence of skin induration in 2-3 days

1. AAP IGRA technical report by Jeff Starke 2014 Dec

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 TST Limitations: False Results
False positive results due to: False negative results due to:
• BCG vaccination  Improper intradermal
• Immune reactivity to non- injection of PPD
tuberculosis mycobacteria  Improper storage
(NTMs)  Reading error
• In US-born individuals, up to  Malnourishment
50% of TST responses can be  Infections
due to NTM infections1  Steroids
 Renal Failure
 Burns
 Age
 Immunocompromised

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1. von Reyn CF et al. (2001) Int J Tuberc Lung Dis 5 (12), 1122-1128.
 IGRAs
• Blood tests for tuberculosis (TB) – ex vivo
– QuantiFERON®-TB Gold (QFT®) → ELISA-based
– T-SPOT®.TB → ELISPOT-based IGRA
• Indirect detection of TB bacterial infection
– Measure secretion of cytokine interferon-gamma
(IFN-γ) by lymphocytes stimulated in vitro with TB-
specific antigens
• Like the TST, IGRAs do not specify active or latent TB

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 T-SPOT®.TB

Nil Control

Infection

Infection

Positive Control

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Oxford Immunotec
 Is There a Role For IGRAs in Diagnosing Active TB or
Predicting Progression to Active TB?
 A positive IGRA does not distinguish latent TB infection from active TB disease

However…
 In patients with extrapulmonary TB,
 Patients who test negative for AFB in sputum or by culture
 In children,
 or in the differential diagnosis of NTM,

IGRAs may provide useful supplementary information.

Overwhelming active TB infection may suppress the cellular immune response and
cause a negative IGRA or TST result.

MMWR. CDC 2010 20190309 DIAGNOSTIK TUBERKULOSIS_PEKANBARU

VISI TB DIAGNOSTIK pada Tahun 2020

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• we need simpler, non-sputum-based, biomarker tests
that can rapidly detect TB at the point-of-care,
especially in children

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It’s time!

Terimakasih
20190309 DIAGNOSTIK TUBERKULOSIS_PEKANBARU