Tuberculosis

TB Transmission

Transmission is defined as the spread of an organism, such as M. tuberculosis, from one person to another.

Tuberculosis
Second most common cause of death from infectious disease In US, higher prevalence in areas with large population of Native Americans Health care workers are considered to be at high risk. Resurgence
High rates of TB with HIV infection Multidrug-resistant strains of M. tuberculosis

TB Transmission

Types of Mycobacteria
M. tuberculosis causes most TB cases in U.S. Mycobacteria that cause TB:
M. tuberculosis M. bovis M. africanum M. microti M. canetti
M. tuberculosis

Mycobacteria that do not cause TB

M. avium complex

TB Transmission
TB is spread person to person through the air via droplet nuclei M. tuberculosis may be expelled when an infectious person:
Coughs Sneezes Speaks Sings

Transmission occurs when another person inhales droplet nuclei

TB Transmission

Dots in air represent droplet nuclei containing M. tuberculosis

TB Transmission
Probability that TB will be transmitted depends on:
Infectiousness of person with TB disease
Environment in which exposure occurred Length of exposure

Virulence (strength) of the tubercle bacilli

The best way to stop transmission is to:

Isolate infectious persons Provide effective treatment to infectious persons as soon as possible

TB Pathogenesis

Pathogenesis is defined as how an infection or disease develops in the body.

TB Pathogenesis

Latent TB Infection (LTBI)

Occurs when tubercle bacilli are in the body, but the immune system is keeping them under control Detected by the Mantoux tuberculin skin test (TST) or by blood tests such as interferon-gamma release assays (IGRAs) which include:
QuantiFERON-TB Gold test (QFT-G) QuantiFERON-TB Gold In-Tube (QFT-GIT) T-Spot.TB test (T-SPOT)

People with LTBI are NOT infectious

TB Pathogenesis
TB Disease
Develops when immune system cannot keep tubercle bacilli under control
May develop very soon after infection or many years after infection

About 10% of all people with normal immune systems who have LTBI will develop TB disease at some point in their lives People with TB disease are often infectious

TB Pathogenesis

Droplet nuclei containing tubercle bacilli are inhaled, enter the lungs, and travel to small air sacs (alveoli)

TB Pathogenesis
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bronchiole blood vessel tubercle bacilli

alveoli

Tubercle bacilli multiply in alveoli, where infection begins

TB Pathogenesis
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brain bone lung

kidney

A small number of tubercle bacilli enter bloodstream and spread throughout body

TB Pathogenesis
LTBI

special immune cells form a barrier shell (in this example, bacilli are in the lungs)

Within 2 to 8 weeks the immune system produces special immune cells called macrophages that surround the tubercle bacilli These cells form a barrier shell that keeps the bacilli contained and under control (LTBI)

TB Pathogenesis
TB Disease

shell breaks down and tubercle bacilli escape and multiply (in this example, TB disease develops in the lungs)

If the immune system CANNOT keep tubercle bacilli under control, bacilli begin to multiply rapidly and cause TB disease This process can occur in different places in the body

LTBI vs. TB Disease

Latent TB Infection (LTBI)
Inactive, contained tubercle bacilli in the body
TST or blood test results usually positive Chest x-ray usually normal Sputum smears and cultures negative No symptoms Not infectious Not a case of TB

TB Disease (in the lungs)

Active, multiplying tubercle bacilli in the body
TST or blood test results usually positive Chest x-ray usually abnormal Sputum smears and cultures may be positive Symptoms such as cough, fever, weight loss Often infectious before treatment A case of TB

Progression to TB Disease
Risk of developing TB disease is highest the first 2 years after infection People with LTBI can be given treatment to prevent them from developing TB disease Detecting TB infection early and providing treatment helps prevent new cases of TB disease

Progression to TB Disease
Some conditions increase probability of LTBI progressing to TB disease
Infection with HIV
Chest x-ray findings suggestive of previous TB Substance abuse Recent TB infection

Organ transplant
Silicosis Diabetes mellitus Severe kidney disease Certain types of cancer Certain intestinal conditions Low body weight

Prolonged therapy with corticosteroids and other immunosuppressive therapy, such as prednisone and tumor necrosis factor-alpha [TNF-] antagonists

Progression to TB Disease
People Exposed to TB

Not TB Infected

Latent TB Infection (LTBI)

Not Infectious
Negative TST or QFT-G test result No TB Infection
Figure 1.5

Not Infectious
Positive TST or QFT-G test result

Latent TB Infection

May go on to develop TB disease

Progression to TB Disease
TB and HIV
In an HIV-infected person, TB can develop in one of two ways:
Person with LTBI becomes infected with HIV and then develops TB disease as the immune system is weakened Person with HIV infection becomes infected with M. tuberculosis and then rapidly develops TB disease
Image credit: Mississippi State Department of Health

Progression to TB Disease
TB and HIV
People who are infected with both M. tuberculosis and HIV are much more likely to develop TB disease TB infection and NO risk factors

TB infection and HIV infection

(pre-Highly Active Antiretroviral Treatment [HAART])

Risk is about 5% in the first 2 years after infection and about 10% over a lifetime

Risk is about 7% to 10% PER YEAR, a very high risk over a lifetime

Sites of TB Disease
Bacilli may reach any part of the body, but common sites include:
Brain Larynx Bone Kidney Lymph node Pleura Lung Spine

Sites of TB Disease
Location Pulmonary TB Extrapulmonary TB
Lungs Places other than lungs such as: Larynx Lymph nodes Pleura Brain Kidneys Bones and joints Carried to all parts of body, through bloodstream

Frequency
Most TB cases are pulmonary Found more often in: HIV-infected or other immunosuppressed persons Young children Rare

Miliary TB

TB Classification System
Based on pathogenesis of TB
Class 0 Type No TB exposure Not infected Description No history of TB exposure Negative result to a TST or IGRA

TB exposure No evidence of infection

TB infection No TB disease

History of TB exposure Negative result to a TST (given at least 810 weeks after exposure) or IGRA
Positive result to a TST or IGRA Negative smears and cultures (if done) No clinical or x-ray evidence of active TB disease

TB Classification System
Based on pathogenesis of TB
Class 3 Type TB, clinically active Previous TB disease (not clinically active) Description Positive culture (if done) for M. tuberculosis Positive result to a TST or IGRA, and clinical, bacteriological, or x-ray evidence of TB disease Medical history of TB disease Abnormal but stable x-ray findings Positive result to a TST or IGRA Negative smears and cultures (if done) No clinical or x-ray evidence of active TB disease

TB suspected

Signs and symptoms of TB disease, but evaluation not complete

Clinical Manifestations
Early stages are usually free of symptoms.

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Clinical Manifestations
Fatigue Weight loss

Malaise
Anorexia

Low-grade fevers
Night sweats

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Clinical Manifestations
Cough becomes frequent.
Hemoptysis is not common and is usually associated with advanced disease. Dyspnea is unusual.

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Clinical Manifestations
Acute symptoms (generalized flu symptoms)
High fever Chills Pleuritic pain Productive cough

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Complications
Miliary TB
Large numbers of organisms invade the bloodstream and spread to all organs.
Acute or chronic symptoms

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Complications
Pleural effusion Empyema
Caused by bacteria in pleural space Inflammatory reaction with plural exudates of protein-rich fluid

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Complications
TB pneumonia
Large amounts of bacilli discharging from granulomas into lung or lymph nodes

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Complications
Other organ involvement
CNSMeninges Bone and joint tissue Kidneys

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Complications
Other organ involvement
Adrenal glands Lymph nodes Genital tracts

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Diagnostic Studies
Skin testing
Intradermal administration of tuberculin
Induration at injection site indicates exposure. Sensitivity remains for life, and individual should not be tested again.

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Diagnostic Studies
Skin testing
Response in immune compromised patients
Reactions 5 mm considered positive

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Diagnostic Studies
Skin testing
Two-step testing recommended for health care workers getting repeated testing and those with decreased response to allergens.

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Diagnostic Studies
Chest x-ray
Cannot make diagnosis solely on x-ray Upper lobe infiltrates, cavitary infiltrates, and lymph node involvement suggest TB.

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Diagnostic Studies
Bacteriologic studies
Stained sputum smears examined for acid-fast bacilli Required for diagnosis

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Diagnostic Studies
Bacteriologic studies
On different days, three consecutive sputum samples Could also be collected from
Gastric washings CSF Fluid from an abscess or effusion

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Collaborative Care
Hospitalization not necessary for most patients Drug therapy used to prevent or treat active disease

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Drug Therapy
Active disease
Four drugs are used in initial phase for maximum effectiveness.
Treatment is aggressive to combat resistant strains of TB.

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Drug Therapy
Directly observed therapy (DOT)
Noncompliance is major factor in multidrug resistance and treatment failures. Requires watching patient swallow drugs Preferred to ensure adherence

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Drug Therapy
Active disease
Patients should be taught about side effects and when to seek medical attention. Liver function should be monitored.

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Drug Therapy
Latent TB infection
Usually treated with INH for 6 to 9 months HIV patients should take INH for 9 months.

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Drug Therapy
Vaccine
Bacille Calmette-Gurin (BCG) vaccine to prevent TB is currently in use in many parts of the world. In United States, not recommended Can result in positive PPD reaction

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Nursing Assessment
Assess for
Productive cough Night sweats Afternoon temperature elevation Weight loss Pleuritic chest pain Crackles over apices of lungs

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Nursing Diagnoses
Ineffective breathing pattern Imbalanced nutrition: Less than body requirements Noncompliance

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Nursing Diagnoses
Ineffective health maintenance Activity intolerance

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Planning
Goals
Comply with therapeutic regimen. Have no recurrence of disease. Have normal pulmonary function. Take appropriate measures to prevent spread of disease.

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Nursing Implementation
Ultimate goal in the United States is eradication.
Selective screening programs in high-risk groups to detect TB Identify contacts of patient with TB.

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Nursing Implementation
Acute intervention
Airborne isolation Appropriate drug therapy Immediate medical workup

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Nursing Implementation
Teach patient
Cover nose and mouth with tissue when coughing, sneezing, or producing sputum Hand washing after handling sputum-soiled tissues

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Nursing Implementation
Ambulatory and home care
Ensure that patient can adhere to treatment. Teach symptoms of recurrence.

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Evaluation
Expected outcomes
Complete resolution of disease Normal pulmonary function Absence of any complications No transmission of TB

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