TUBERCULOSIS

Infectious Disease Series

Minci © 2007
• Image credit : http://sitemaker.umich.edu/medchem13/files/tb.htm
Mycobacterium tuberculosis
• Also known as Koch’s
bacillus
• Obligate aerobe; Gram +ve
• Withstand weak disinfectants
• Survive dry states in weeks
• AFB : acid-fast bacilli
 • Primary TB
– Pulmonary (droplet spread)
– Ghon focus  Ghon
TB
complex
– Asymptomatic OR
– Fever, lassitude, sweats,
anorexia, cough, sputum,
erythema nodosum, or
phlyctenular conjunctivitis
– SPUTUM : AFB
– CXR
Primary TB Post-primary TB
– GI : ileocaecal junction and
associated lymph nodes
• How would you describe this skin lesion?
Post primary TB : state of immunocompromise
 reactivation
• Pulmonary : Silent or
Pulmonary
Pericarditis
Effusion & Miliary
symptomatic
Constrictive
– Cough, sputum
– Haemoptysis
Acute TB
pericarditis
Meningeal (massive)
TB
– Malaise
– Night sweats
Peritoneal GU
– Weight loss
Skin
(lupus
Bone
– Pleurisy
vulgaris)
– Pleural effusion
• Miliary TB
– Haematogenous
dissemination
– Non-specific
presentation
– CXR : reticulonodular
shadowing
– Look for retinal TB
– Biopsy : lung, liver, LN,
marrow may yield AFB
or granulomata.
• Meningeal TB :
– Fever, headache, nausea, vomiting, neck
stiffness, photophobia.
• GU TB :
– Frequency, dysuria, loin/back pain,
haematuria, sterile pyuria.
– 3 EMU for AFB
– Renal USS
– May spread to bladder, seminal vesicles,
epididymis, fallopian tubes
– (endometrial TB)
• Bone TB:
– Vertebral collapse
adjacent to
paravertebral abscess
– Pott’s vertebra
– XRay + biopsies (for
AFB stains and
culture)
• Lupus Vulgaris – jelly-like nodules
• May progress to be ulcers
• Peritoneal TB :
– Abdo pain + GI upset
– AFB in ascites; need laparatomy
• Acute TB pericarditis : primary exudative
allergic lesion
• Chronic pericardial effusion and
constrictive pericarditis:
– Chronic granulomata
– Manage by giving steroids for 11 weeks +
anti-TB meds to reduce need for
pericardiectomy.
Diagnosis
• Culture from relevant clinical samples.
– Send multiple sputum for MC+S for AFB
– Effusion : pleural aspiration/ biopsy
– Negative sputum? Bronchoscopy + biopsy +
lavage
• TB PCR : to identify resistance to
rifampicin (or multi-drug)
• Histology : caseating granuloma
CXR

• Consolidation, cavitation, fibrosis and calcification

Diagnosis continued..
• Immunological evidence:
– Tuberculin skin test : TB Ag injected intradermally
and cell-mediated response at 48-72hrs recorded.
• Positive : has immunity, previous exposure/BCG, active
infection
• False negative : immunosupression, including miliary TB,
sarcoid, AIDS, lymphoma.
– Mantoux test : serial dilutions of TB Ag to give 1,10
and 100 TU)
• Positive if produce ≥ 10mm induration
• Negative <5mm
– Heaf and Tine tests : screening. Consist of a circle of
primed needles which inject the tuberculin.
Treatment
• Before:
– Stress importance of compliance
– Check FBC, liver & renal function
– Test colour vision and acuity. Ethambutol
cause reversible ocular toxicity.
 Initial Phase (8 weeks on 3-4 drugs)

Drugs Dose Side effects

Rifampicin 600-900 mg , PO Hepatitis, orange urine and

tears, pill inactive, flu-like
(child:15mg/kg) 3x week syndrome

Isoniazid 15mg/kg PO 3x/ week Hepatitis, neuropathy,

+ pyridoxine 10mg/24h pyridoxine deficit,
agranulocytosis.
2.5g PO 3x/ week Hepatitis, arthralgia
Pyrazinamide
(2g if < 50kg) (Contraindication :
Child : 50mg/kg gout)

Ethambutol 30mg/kg PO 3x/ week Optic neuritis (colour

*0.75-1g/24h IM vision deteriorate)
*Streptomycin Child : 15mg/kg/24h
Continuation Phase ( 4 months on 2 drugs)

• Rifampicin + Isoniazid at same dose

• If possible resistance, use ethambutol
15mg/kg/24h PO
• Give pyridoxine throughout
• Steroids may be indicated in meningeal
and pericardial disease
Additional Points
• Advise HIV testing
• Notify consultant in CCDC to arrange contact
tracing and screening
• Explain prolonged Rx is necessary
• Explain taking the tablets is important. LFTS are
monitored. Explain that DOT may be needed.
• Explain need for respiratory isolation procedures
while infectious
• Check regularly for drug compliance and toxicity.