Pulmonary Tuberculosis

http://crisbertcualteros.page.tl

Pulmonary Tuberculosis
Etiology: 1.1 Mycobacterium tuberculosis 1.2 Mycobacterium bovis, rarely bovis,

Epidemiology
Philippine Statistics: FHSIS DOH 2001 o Respiratory TB, 6th leading cause of morbidity with 110,841 cases and rate of 142.2/100,000 population o TB meningitis with 466 cases or rate of 0.6/100,000 population o Other forms of TB, 11,494 cases with a rate of 14.7/100,000 population

Epidemiology
Source: o Usually sputum form an infected adult; occasionally exudate from draining sinuses and urine Mode of transmission: o Inhalation of droplet nuclei as a rule o Occasionally, by ingestion of contaminated milk (M. bovis) o Direct contamination of open wounds (pathologist and lab personnel)

Epidemiology
Period of communicability: o Only if associated with open lesions of PTB, draining sinuses or renal involvement; as long as tubercle bacilli are found in sputum, exudate or urine, respectively o Children with active PTB are rarely contagious because of the nature of pulmonary lesion, the low baterial output and because sputum is often swallowed. o A patient is non-infectious within 2-4 weeks of non2starting adequate therapy

Risk Factors
1. 2. 3. Age: infants and adolescents are at highest risk of disease Close contact with an untreated sputum positive patient Impaired host defenses: immunodeficiency states, particularly that associated with HIV infection; immunosuppression related to accompanying viral infection, or drug induced; malnutrition. Other disease staes: Hodgkins lymphomas, diabetes mellitus, leukemia, malignancy (head and neck) severe kidney disease, silicosis, prolonged treatment with corticosteroids

4.

Risk Factors
5. Persons whose tuberculin skin test results converted to (+) in the past 1-2 1years 6. Persons who have CXR suggestive of old TB

Portal of Entry
o Usually respiratory tract (inhalation of aerosolized particles containing 1-3 1tubercle bacilli); rarely, skin, gastrointestinaltract, mucous membrane, transplacentally from mother to fetus or via infected amniotic fluid

Incubation Period
o From 3 to 8 weeks

CLASSIFICATION
 Class I (TB exposure)
 (+) exposure  (-) Mantoux tuberculin test  (-) signs and symptoms suggestive of TB  (-) chest radiograph

CLASSIFICATION
 Class II (TB infection)
 ( ) exposure  (+) Mantoux tuberculin test  (-) signs and symptoms suggestive of TB  (-) chest radiograph

CLASSIFICATION
 Class III (TB disease)
 Has three or more of the ff. criteria
 (+) history of exposure to an adult/adolescent with active TB disease  (+) Mantoux tuberculin test  (+) signs and symptoms suggestive of TB
 Cough/wheezing > 2 weeks; fever > 2 weeks  Painless cervical and/or other lymphadenopathy  Poor weight gain; failure to make a quick return to normal after an infection (measles, tonsillitis, whooping cough) or failure to respond to approriate antibiotic therapy (pneumonia, otitis media)

 Abnormal Chest radiograph  Laboratory findings suggestive of TB (histological, cytological, biochemical, immunological or molecular)

CLASSIFICATION
 Class IV (TB inactive)
 A child/adolescent with or without history of previous TB and any of the ff:
 ( ) previous chemotherapy  (+) radiographic evidence of healed/calcified TB  (+) Mantoux tuberculin test  (-) signs and symptoms suggestive of TB  (-) smear/culture for M. tuberculosis

Clinical Forms of Tuberculosis

 Pulmonary/endothoracic
 Asymptomatic or Latent TB infection  Primary TB/primary complex
 Primary focus, lymphangitis and regional lymphadenitis  Most common clinical symptoms
 Non-productive cough Non Mild dyspnea  Cervical lymphadenopathies

Clinical Forms of Tuberculosis

 Pleurisy with effusion
 Accompanies primary focus  Considered a component of the primary complex  Onset is usually abrupt  Fever, chest pain, shortness of breath  Dullness to flatness and diminished breath sounds  Obliteration of costophrenic sulcus on CXR (minimal)  Layering of fluid density (moderate effusion)  Occupy one hemithorax (massive effusion)

Clinical Forms of Tuberculosis

 Progressive primary tuberculosis
 More severe fever, malaise, cough, weight loss  Classical signs of cavitation  Crepitant rales, diminished breath sounds, lymphadenopathy

 Endobronchial TB
 Bronchial obstruction due to enlargement of peribronchial lymph nodes
 Sudden death by asphyxia  Emphysema  Atelectasis

Clinical Forms of Tuberculosis

 Miliary TB
 Generalized hematogenous tuberculosis due to massive invasion of the blood stream by the tubercle bacilli  Arises from a discharge of a caseous focus often from a lymph node into the blood vessel (pulmonary vein)  High fever, cough, dyspnea  Crepitant rales, splenomagly, hepatomegaly, signs of menigeal irritation

Clinical Forms of Tuberculosis

 Chronic TB
 Reinfection or adult TB  Apical or infraclavicular infiltrates often with cavitation and no hilar lymphadenopathy  Persistent cough, prlonged fever, chest pain, hemoptysis and supraclavicular adenitis

 Tuberculoma  Pericardial TB

Clinical Forms of Tuberculosis

 Extrapulmonary TB
 TB of the cervical lymph nodes/Scrofula
 Involved LN are painless, firm, discrete, movable becoming adherent to each other and anchored to the surrounding tissues and skin as they enlarge  Scofuloderma (when left untreated and ruptures resulting in a draining sinus tract

 TB of the CNS
 TB meningitis  TB abscess

Clinical Forms of Tuberculosis  Skeletal TB

 TB of the bones and joints  TB of the spine or Potts

 GI TB
 TB enteritis  TB peritonitis  Hepatobiliary TB  TB of the pancreas

   

Cutaneous TB Ocular TB GUT TB TB of the Middle Ear

Diagnostic Tests
 Mantoux Testing/Tuberculin skin test
 Most widely used method to determine latent TB infection  Standard method for screening  positive if 8 mm induration size  A dose of 0.1 ml of 2-TU PPD-RT23 or 0.1 ml 2PPDof 5-TU PPD-S 5PPD Provides a general measure of a persons cellular response

Diagnostic Tests
 Mantoux Testing/Tuberculin skin test
 Features of reaction
 Delayed course reaching a peak of more than 24h after injection of antigen  Indurated character  Occasional vesiculation and necrosis

 A pale wheal of 6 to 10mm in diameter should be evident after injection  Read within 48-72hrs from the time of 48administration

Diagnostic Tests
 Mantoux Testing/Tuberculin skin test
 False positive
 Nontuberculous mycobacteria  BCG vaccination
 Reaction develops 6-12 weeks after vaccination 6 Wanes after 5 years from immunization

 False negative
 Anergy  Very young age (< 6 months)  Recent TB infection or overwhelming TB disease  Live-virus vaccination Live postpone for at least 4 6 weeks after immunization or do it on the same day of vaccination

Diagnostic Tests
 AFB smears (microscopic examination)
 Provides presumptive diagnosis of active TB  Gives a quantitative estimation of the number of bacilli on the smear  Implies infectiousness of the patient  Low sensitivity (51.8 53.1%)  High specificity (97.5 99.8%)  104 bacilli per ml of sputum : lowest concentration that can be detected

Diagnostic Tests
 Culture : gold std.
 Solid media: 4-6 weeks for isolation and another 2424 weeks for susceptibility testing
 Middlebrook 7H-11 7H-10 (agar-based) 7H- 7H(agar Lowenstein-Jensen (egg-based) Lowenstein(egg-

 Liquid media
 Bactec : as few as 7 to 10 days; carbon-14 (marker of carbonbacterial growth)  Middlebrook broth  Septi-check AFB Septi BBL mycobacteria growth incubator tube

Diagnostic Tests
 Sputum

 Specimens collected for demonstration of tubercle bacilli

 for older children able to expectorate  Series of three early morning specimens on different days before starting chemotherapy  Make sure brought up from the lungs

Diagnostic Tests
 Gastric aspirate

 Specimens collected for demonstration of tubercle bacilli

 For infants and children who cannot expectorate even with aerosol inhalation  5-10 ml of gastric contents aspirated early in the morning after the person has fasted for at least 8 10 hours preferably before the child arises and peristalsis empties the stomach of respiratory secretions swallowed overnight

Diagnostic Tests
 Bronchial washings  Urine

 Specimens collected for demonstration of tubercle bacilli

 First morning-voided midstream specimen morning-

 Other body fluids and tissues

 Bone marrow, lung and liver biopsy in patients with hematogenous spread/disseminated disease must be considered

Diagnostic Tests
 Radiographic Findings
 No pathognomonic findings in childhood TB  Lateral projections are important wherein partially calcified mediastinal nodes may be visible  Most common cause of calcification in children  Uniform stippling of both lungs found in miliary tuberculosis  Lobar or lobular consolidations  Common findings: Enlarged retrocardiac lymphadenopathy (70%), hilar adenopathy

Initial Empiric Therapy of Tuberculosis in Infants, Children and Adolescents

Category Class I TB Exposure  <5 years  5 years Regimen 3 months INH Remarks Immediately prophylaxis controversial for those 5 years, but is recommended by some experts specially if with risk factors e.g. malnutrition, immunocomimmunocompromised states

Initial Empiric Therapy of Tuberculosis in Infants, Children and Adolescents


(a) Extrapulmonary Severe, lifelifethreatening disease: disseminated/ miliary, meningitis, bone/joint disease Other extrapulmonary sites 2 months HRZ + E or S ffd by 10 months HR E/S given once daily or as DOT 3x weekly Same regimen as pulmonary disease

 Corticosteroids
(usually prednisone at 1 mkday for 6-8 weeks 6with gradual tapering) beneficial for the following: meningitis, pericarditis, pleuritis, endobronchial TB, miliary TB

(b)

Initial Empiric Therapy of Tuberculosis in Infants, Children and Adolescents

Class II TB infection  PPD conversion within past 1-2 years, (-) CXR 1( PPD (+) not due to BCG,(BCG,(-)CXR, (-) (previous treatment  PPD (+) with stable/ healed lesion, (-) (previous treatment 9 months INH 9 months INH 9 months INH

In the presence of primary INH resistance, use Rifampicin

Initial Empiric Therapy of Tuberculosis in Infants, Children and Adolescents

Class II TB infection  PPD (+) with stable / healed lesion, (+) previous treatment, at risk of reactivation due to: Measles, pertussis, etc Conditions/drugs inducing immunosuppression (IDDM leukemia chronicdialysis) HIV infection/ persons at risk for infection but HIV status unknown

a) b)

1-2 mos For the duration of immunosupimmunosuppression 12 Months INH

c)

Initial Empiric Therapy of Tuberculosis in Infants, Children and Adolescents

Class IIIB TB Disease  Pulmonary (a) Fully susceptible: based on culture results of index case, (-) previous treatment, <10% local prevalence of primary INH resistance (b) Susceptibility unknown or initial drug resistance suspected because of big bacillary population, previous treatment (1 month), close contact with resistant source case, residence in area with >10% primary INH resistance 2 months HRZ once daily, ffd by 4 months HR given once daily or as DOT 3x weekly Streptomycin preferred in children < 6 years of age, where visual acuity/color perception cannot be monitored reliably

2 months HRZ plus E or S once daily, ffd by 4 months HR E/S given once daily or as DOT 3x weekly

 In immunocompromised patients, continuation phase extended to 7 months (total duration of therapy:9 months) or for at least 6 months after sputum conversion (if applicable) whichever is longer. If susceptibility results anavailable, continue E/S for the entire duration of therapy

Algorithm for Preventive Therapy of Childhood Tuberculosis

TB Exposure Class I yes <5years old Start INH for 3 months No Repeat Mantoux test Yes Radiologic findings Yes TB Disease After 3 months(+) and /or, signs/symptoms (Class III) No No suggestive of TB Multiple drug tx If no Discontinue INH No BCG scar, If no BCG scar, TB Infection Give BCG give BCG (Class II) Continue u 6 INH