Introduction to TBCP

A primary care guide project

by Dr Gerard Loh
MO
KK Bandar Miri

Acknowledgements:
Dr Wong Yong Kai, MO, TBCP KK Miri
TBCP Staff, KK MIRI

Note: These guides serve as introductory notes to the new MO in TBCP setting, always refer to CPG for more precise
guidelines.
The Primary Care Guide Project 2013
www.myhow.wordpress.com

TUBERCULOSIS
Cases:
1) New cases PTB Never treated for TB
2) Follow up Intensive phase / Maintenance / Surveillance
3) Relapse
- D/S +ve relapse : after cured, came back with smear +ve
- D/S ve relapse : after cured, came back with symptoms or CXR features
4) Chronic case remain smear +ve despite re-treatment
5) Treament failure after 5/12 treatment remain smear +ve
6) Treatment after interruption defaulter > 2/12 with smear +ve
7) Contact Tracing
Tuberculosis
- Pulmonary
Clinical:
Cough > 2/52, with sputum +/- blood stained
LOW/ LOA
Fever with chills, night sweats

- Extra-pulmonary
TB Lympadenitis
Ix: FNAC / excisional biopsy

Radiological:
- Lesions or hazinesss in upper lobe, +/- cavities
Bacteriological
Sputum AFB +ve or C&S MTB +ve
Immunological:
Mantoux > 10mm
ESR up to 100+

TB Genitourinary
Ix: Urine AFB
TB Meningitis
Ix: CSF AFB
TB bone/joints

TB Pleura
Ix: thoracocentesis/pleural tapping for AFB

Miliary TB

Radiological Features

Image source : Institue of Tropical Medicine, Antwerp

I. Minimal slight lesions without cavitations
II. Moderately advanced disemminated lesions, not exceeding total volume of 1 lung, cavitations < 4mm
III. Far Advanced extensive changes

Management of confirmed TB
PLAN:
- Notify
- Contact Tracing
- Home Isolation 2/52
- Check Visual Acuity
- MC 2/52
- TCA 2/52 to review investigations , rpt SAFB, LFT
- DOTS

Ix:
FBC/ESR
FBS/FLP/BUSE/CREAT/LFT
HIV/Hep B-C / VDRL
SAFB x 3 / Sputum TB C&S

Monthly SAFB
2 Monthly CXR + ESR
* monthly SAFB only in Sarawak due to high rate of false negative results
* CPG recommends SAFB and CXR at 2 months and 6 months, 4 months if no clinical improvement
Treatment of TB
1. Intensive Phase - 2 months of EHRZ / SHRZ
* may extend 1 month if 1st / 2nd month SAFB remain +ve
2. Maintenance Phase 4-10 months of HR
TB
Pulmonary TB
TB Lymph Node
TB Pleural effusion and/or Pericarditis
Bone / Joint
TB Meningitis

Recommended Regimes
2EHRZ / 4 HR
2EHRZ / 4HR
2EHRZ / 7HR
2SHRZ / 10HR

Anti TB drugs
First Line Drugs: Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), Ethambutol (E), Streptomycin (S)
Recommended Tx : 2EHRZ + 4HR + Pyridoxine
- For improved compliance, FORECOX a fixed dose combination anti TB is recommended
FORECOX
WEIGHT (KG)
(Adult Dose)

INTENSIVE PHASE
Duration : 2 MONTHS

30-39

2 tab

40-54

3 tab

55-70

4 tab

> 70

5 tab

Weight
Till 20 kg
25
30
35
40
45
50
55
60
65
70
>70

INH
100mg
125
150
200
225
250
300

RIF
300mg

ETH
400mg

450

500
600

PZA
500mg
625
750
1000

800

1250

900
1000

1500

600

1200

TB in Children

Peds dosage ( recommended regime 2 HRZ / 4HR )

Isoniazid
Rifampicin
Ethambutol
Pyrazinamide
+ Pyridoxine

Dose (mg/kg)
10 ( 10 15)
15 (10 20)
20 (15 25)
35 (30 40)
5-10mg

* For prophylaxis INH 10mg/kg (6H or 3 HR)

Maximum
300mg
600mg
1g
2g

Adverse Drug Reactions

Signs and symptoms
Organs affected
Paraesthesia hands or feet
Liver, peripheral nerves
Orange-reddish urine, easy bruising
Blood (Plt ), GIT, Kidney
loss of colour vision, arthralgia
Eyes, Liver
Dyspepsia, gout, arthralgia
GIT, Liver, Joint
Ringing in the ears, ataxia, vertigo and deafness
CN8 neuritis, Kidney
Adverse Reactions
Minor No need to interrupt treatment
Severe stop immediately
Sx: Nausea, lethargy, pruritus
Stevenson-Johnson Syndrome (SJS)
Tx: Symptomatic relief
Toxic Epidermal Necrolysis (TEN)
Drug rash+eosinophilia+systemic syndrome (DRESS)
Drug Induced Hepatitis (DIH)
Isoniazid
Rifampicin
Ethambutol
Pyrazinamide
Streptomycin

SJS / TEN immune-complex hypersensitivity involving skin and mucous membranes

Sx: necrolysis of skin, eyelid, tongue

DIH When serum transaminase level >3 fold upper limit , symptomatic

*If baseline LFTs are abnormal, do investigate the underlying cause (U/S Abdo, Hep B/C)
do not start antiTB first, refer to specialist

Drug Desensitisation / rechallenge

Drug rechallenge Done by re-starting drugs once symptoms abated, gradually increasing dose and adding drugs
1. Determine maximum dose
2. Begin day 1 with Isoniazid, low dose
3. Gradually increase till maximum
4. Move on to the next anti TB, until adverse reaction to drug and dose is determined
eg:

Drug
Isoniazid
(INH)
Rifampicin
(RIF)
Pyrazinamide
(PZA)
Ethambutol
(ETM)
Streptomycin
(SM)

Dose
Date
Dose
Date
Dose
Date
Dose
Date
Dose
Date

Day 1
50
1/3/14
75
5/3/14
250
8/3/14
200

Challenge Dose (mg)

Day 2
Day 3
100
300
2/3/14
3/4/14
300
450
6/3/14
7/3/14
500
1000
9/3/14
400
800

250

500

1000

Adverse Reactions

Day 4
NIL
NIL
1500
1200

Joint pain + rashes

Contact Tracing

Latent TB (LTBI) infected by MTB, but bacteria in dormancy, not causing any active symptoms
Diagnosis:
Close contact with Mantoux test > 10mm
- no active symptoms
- normal CXR
- SAFB negative
Mx:
- allow home with advise and surveillance for 6mo, 12mo, 18mo
Criteria for Tx:
- HIV / immunocompromised
- Child < 5 years with close PTB contact prophylaxis INH 10mg/kg for 6/12 (6H or 3 HR)
* before starting prophylaxis , rule out active TB ( FBC/ESR/CXR)
* if in doubt refer to paediatrician (for admission and gastric lavage for AFB)

AntiTB regime for LTBI in Children

6H
Isoniazid 10mg/kg
3 HR
Isoniazid 10mg/kg + Rifampicin 15mg/kg
+ Pyridoxine 5 10mg OD

Weight
Till 20 kg
25
30
35
40
45
50
55
60
65
70
>70

INH
100mg
125
150
200
225
250
300

RIF
300mg

ETH
400mg
500
600

PZA
500mg
625
750
1000

WEIGHT (KG)

INTENSIVE PHASE

450

30-39

2 tab

800

1250

40-54

3 tab

900
1000

1500

55-70

4 tab

> 70

5 tab

600

FORECOX (FDC)

1200

AntiTB regime for LTBI in Children

6H
Isoniazid 10mg/kg
3 HR
Isoniazid 10mg/kg + Rifampicin 15mg/kg
+ Pyridoxine 5 10mg OD

Timeline of TB management and follow up

Timeline
Day 0

Day 14
1/12
2/12

3/12
4/12

5/12
6/12

+6/12

Start Anti TB : INTENSIVE PHASE : 2 EHRZ

Notify, Home isolation, MC 2/52
Check Visual Acuity
Ix: HIV/Hep B/c / VDRL + FBC/ESR + FBS/FLP/BUSE/Creat/LFT
Sputum MTB C&S
Monthly SAFB, 2 monthly CXR/ESR
Review Ix taken earlier and reponse to tx (ADR), rpt LFT and SAFB
INTENSIVE PHASE 1/12
SAFB x 3
INTENSIVE PHASE 2/12
CXR / ESR
SAFB x 3 : positive extend Intensive phase 1/12 + Ix: LPA, C&S MTB
(* if after 3/12 still +ve refer Physician for MDR TB)
negative proceed to MAINTENANCE PHASE : 4 HR
MAINTENANCE PHASE 1/12
SAFB
MAINTENANCE PHASE 2/12
CXR/ESR
SAFB
MAINTENANCE PHASE 3/12
SAFB
MAINTENANCE PHASE 4/12
CXR/ESR
SAFB
COMPLETE TREATMENT
If SAFB ve , CXR no changes, cough reduced, good weight gain and appetite
FOLLOW UP TB SURVEILANCE
Surveilance 6 months
CXR / SAFB
< DISCHARGE > With advise

TB
Pulmonary TB
TB Lymph Node
TB Pleural effusion and/or Pericarditis
Bone / Joint
TB Meningitis

Recommended Regimes
2EHRZ / 4 HR
2EHRZ / 4HR
2EHRZ / 7HR
2SHRZ / 10HR

Adverse Drug Reactions

Signs and symptoms
Organs affected
Paraesthesia hands or feet
Liver, peripheral nerves
Orange-reddish urine, easy bruising
Blood (Plt ), GIT, Kidney
loss of colour vision, arthralgia
Eyes, Liver
Dyspepsia, gout, arthralgia
GIT, Liver, Joint
Ringing in the ears, ataxia, vertigo and deafness
CN8 neuritis, Kidney
Adverse Reactions
Minor No need to interrupt treatment
Severe stop immediately
Sx: Nausea, lethargy, pruritus
Stevenson-Johnson Syndrome (SJS)
Tx: Symptomatic relief
Toxic Epidermal Necrolysis (TEN)
Drug rash+eosinophilia+systemic syndrome (DRESS)
Drug Induced Hepatitis (DIH)
Isoniazid
Rifampicin
Ethambutol
Pyrazinamide
Streptomycin

Introduction to LEPROSY
By Dr Gerard Loh
Leprosy Chronic granulomatous infection, primarily affects skin and peripheral nerves
Three cardinal signs:
1. Hypopigmented / erythematous skin lesions with sensory impairment
2. Enlarged peripheral nerves with signs of nerve damage e.g. pain, tenderness, sensory/motor deficit
3. Presence of acid-fast bacilli in skin smear or biopsy

Leprosy patches
- skin patch with definite loss of sensation (heat/touch/pain)
- flat/raised
- reddish/copper coloured
- non- pruritic
- non tender

Ripley-Jopling Classification

WHO Classification
Paucibacillary (I, TT, BT)
< 5 skin lesions
No bacilli on skin smear

Multibacillary: BB, BL, LL

> 5 skin lesions
Skin Smear Positive

Investigations:
- Slit Skin Smear (SSS)
- Skin Biopsy
- PCR
SSS
- Done every 6/12
- 6 sites : 2 earlobes + 4 active lesions
* if less than 4 sites, 2 earlobes + all active lesions
Bacteriologic Index (BI)
BI = Sum of all index
no of sites taken

Density of leprosy bacilli

Include both living (solid) and dead (fragmented)

BI < 4 : 1 year Tx ( within 1 year 6 months)

BI > 4 : 2 years Tx (within 2years 6months)

Morphological Index (MI)

MI =

Total no of solid bacilli

X 100%
Total no of bacilli (solid + fragmented)

Percentage of living bacilli

Valuable indicator of response to treatment
MI reduced from +6 +2 if compliant

Management:
Notify, contact tracing
start MDT regimen
6 monthly SSS (for MBL)
Ix: G6PD, FBC/BUSE/Creat/LFT/UFEME/RBS
3 monthly BUSE/CREAT/LFT
Paucibacillary
Monthly treatment
Daily treatment
Duration

Rifampicin 600 mg
Dapsone 100 mg
6 months

Completion

Surveillance: 5 years
6 doses within 9 months

Multibacillary
Monthly treatment
Daily treatment
Duration

Completion

Rifampicin 600 mg
Clofazimine 300 mg
Dapsone 100 mg
Clofazimine 50 mg
1 year (BI < 4)
2 years (BI 4)
Surveillance: 15 years
12 doses within 18 months (BI < 4)
24 doses within 36 months (BI 4)

Leprosy Rx in Children
Paucibacillary
10 14 yo
< 10 yo

Rifampicin 450 mg daily

Dapsone 50mg daily
Rifampicin 10 mg/kg
Dapsone 2 mg/kg

Duration

6 months

Surveillance

5 years

Multibacillary
10 14 yo

Rifampicin 450 mg monthly

Dapsone 50 mg daily
Clofazimine 150 mg monthly
50 mg EOD

< 10 yo

Rifampicin 10 mg/kg
Dapsone 2 mg/kg
Clofazimine 6 mg/kg monthly
1 mg/kg EOD

Duration

1 year (BI < 4)

2 years (BI 4)
Surveillance
15 ears
* G6PD deff Replace dapsone with orfloxacin/minocycline
Once completed treatment SSS both ears + maximum 6 other sites
Follow up:
- PBL = 3 years; no need SSS / MBL = 15 years;

- First 5 years = SSS yearly

- MBL contacts = examine yearly for 3 years
Adverse Drug Reactions
Dapsone Hemolysis, hepatitis, photosensitive dermatitis, pruritus, Dapsone Hypersensitivity Syndrome,
methaemoglobinaemia
Clofazimine Darkening of skin, GI complaints, dryness of the skin and eyes, pruritus
Rifampicin Reddish discoloration of urine, urticaria, GI complaints, leucopenia, eosinophilia, thrombocytopenia, liver
& renal dysfunction, flu-like syndrome, pruritus, Stevens Johnson Syndrome

Type 1 Lepra Reaction (Reversal Reaction)

- mostly in BB, BT and BL (may occur in LL, TT on Rx)
- Type IV hypersensitivity reaction, alteration in cell mediated immunity
- Upgrading reaction : erythematous and swelling over existing lesions
- Downgrading reaction : new lesions, progress to LL

Type II Lepra Reaction ( Erythema Nodosum Leprosum)

- Mostly occur in LL
- Type III hypersensitivity reaction
- precipitation of immune complexes in tissues and blood vessels
- Sudden appearance of erythematous tender subcutaneous nodules
- may become vesicular, pustular, bullous, and may ulcerate
a/w
- Fever, malaise, may be toxic. Oedema of hands, feet, face.
- Acute neuritis, iritis, arthritis, dactylitis, lymphadenitis, orchitis, nephritis
* may be life-threatening if untreated

Treatment of adverse reactions

- Rest + MC
- Symptomatic relief analgesia
- Suggested course of Prednisolone:
40 mg (8 tablets) every morning for 14
days
30 mg (6 tablets) every morning for 14
days
20 mg (4 tablets) every morning for 14
days
15 mg (3 tablets) every morning for 14
days
10 mg (2 tablets) every morning for 14
days
5 mg (1 tablets) every morning for 14 days

* Follow up every 14 days before reducing dose

* if not clinical improvement refer hospital

References

Guide to Eliminate Leprosy as a Public Health Problem, WHO, 2000

Leprosy 2013, by Dr Maurice Steve Utap, Family Medicine Specialist, KK Tudan

Institute of Tropical Medicine, Antwerp

http://itg.content-e.eu/Generated/pubx/173/tuberculosis/clinical_aspects.htm

Tables, algoritms and management recommendations from

CPG Malaysia, Managment of TB (3 rd edition)

Acknowledgements:
Dr Maurice Steve Utap, FMS, KK Tudan
Dr Wong Yong Kai, Medical Officer, TBCP, KK Miri
TBCP staff KK Miri