Dr Fazli Wahab FCPSMed FCPS Pulmonology Assisstant Prof Peshawar Medical College Diagnostic Tools Microscopy AFB smear Histology AFB Culture Radiology Tuberculin skin test ID: 736182
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TUBERCULOSIS
Diagnosis & treatment
Dr.
Fazli
Wahab
FCPS(Med), FCPS(
Pulmonology
)
Assisstant
Prof Peshawar Medical CollegeSlide3
Diagnostic Tools
Microscopy
AFB smear
Histology
AFB Culture
Radiology
Tuberculin skin test
Serological TestsSlide4
AFB smear
Rapid and inexpensiveSlide5
GranulomaSlide6
Mycobacterial
Culture
Definitive diagnosis
Growth detected after 4–8 weeks.Slide7
Radiographic Procedures
The "classic" picture is that of upper-lobe disease with infiltrates and cavities,Slide8
X-ray chest appearance can be any of the following
Infiltration
Cavitations
Fibrosis with traction
Enlargement of
hilar
and
mediastinal
lymph node
Pleural
effusion/
empyema
Nodular/
Miliary
shadowsSlide9Slide10Slide11
Slide12Slide13
Mantoux
Tuberculin Test (MT)/ Tuberculin Skin Test (TST)
Test TB infection in adults and children
Patient status
Positive Result
Healthy individuals with no exposure history
>15mm
Healthy individuals with exposure history or risk factors
>10mm
HIV +
ve
>5mmSlide14
Serological Tests
Not routinely used
Polymerase Chain Reaction (PCR)
Interferon Gamma release assays (IGRS)
Enzyme Assays & Chromatographic assays:
Unreliable & Ineffective methods
No role in diagnosis in any form of TB
Mycodot
assay
ICT TB Slide15
TreatmentSlide16
Two aims
Interrupt transmission
Prevent morbidity and death. Slide17
Anti-tuberculosis Drugs
1
ST
LINE DRUGS:
Isoniazid
(H)
Rifampicin
(R)
Pyrazinamide
(Z)
Ethambutol
(E)
Streptomycin (S)Slide18
1
st
line ATT
Mode of Action
Daily
Dose (mg/kg)
Isoniazid
(H)
Bactericidal
5 (4-6)
Rifampicin
(R)
Bactericidal
10 (8-12)
Pyrazinamide
(Z)
Bactericidal
25 (20-30)
Streptomycin (S)
Bactericidal
15 (12-18)
Ethambutol
(E)
Bacteriostatic
15 (15-20)Slide19
Regimens
Standard short course regimens 6-8 months.
An initial, intensive or bactericidal, phase and
A continuation, or sterilizing, phase. Slide20
DOTS
DOTS
(directly observed treatment, short-course), the WHO-recommended TB control strategy.Slide21
New Cases
Sputum smear positive pulmonary TB
Sputum smear negative pulmonary TB
Extra-pulmonary tuberculosis
Initial Intensive Phase
HRZE : 2 Months
Continuation Phase
HR: 4months OR
HE: 6
Months
WHO Category I:
New SS +VE Pulmonary TB
Severe Extra-Pulmonary
Severe SS –VE Pulmonary TB
WHO Category III:
New SS-VE Pulmonary TB
Extra-Pulmonary (less severe)Slide22
RE-TREATMENT
CASES/ WHO
Category II:
Relapse
Treatment Failures
Smear positive patients who have taken ATT for more than one month and defaulted
INITIAL INTENSIVE PHASE (3months)
HRZES: 2MONTHS
Then HRZE:1 Month
CONTINUATION PHASE
HRE: 5 Months Slide23
No Treatment is better than Poor Treatment
Drug-resistant TB is caused by:
Inconsistent or partial treatment, when patients do not take all their medicines regularly for the required period.
Doctors and health workers prescribe the wrong treatment regimens, or because
The drug supply is unreliable. Slide24
The ultimate result is the multidrug-resistant TB (MDR-TB) or extensively-drug resistant TB (XDR-TB)
In MDR-TB the Mycobacterium Tuberculosis is resistant to Rifampacin and INH with or without resistance to other 1
st
ATT.
Treatment is difficult and expensive.Slide25
Prevention
The best way to prevent tuberculosis is to Treat.
Additional strategies include
BCG vaccination and
Treatment of persons with latent tuberculosis infection who are at high risk of developing active disease.Slide26
ATT in Special situations
Pregnancy
Infants of T.B. mothers & Breast Feeding
Women on O.C.P
Renal Impairment
ATT Induced Hepatitis
HIV - Infected or AIDSSlide27
Pregnancy
H, R, Z, E : Safe
Streptomycin:
Ototoxic
May cause deafness in babies
ContraindicatedSlide28
Infants of T.B. mothers & Breast Feeding
Mothers must continue A.T.T during feeding
Child should not be separated
Mother should cover her mouth during cough particularly if smear +
ve
INH prophylaxis : 5 mg/Kg 2 monthsSlide29
Infants of T.B. mothers & Breast Feeding
Do T.T:
If –
ve
Stop INH, give BCG
If +
ve
Continue INH 4 months
Then BCG
Do not give BCG while on INH
INH resistant BCG
Rifampicin
+ INH – 3 months Slide30
Women on O.C.P
Rifampicin
:
Hepatic enzyme inducer
O.C.P may become ineffective Slide31
Renal Impairment
General principle:
Standard chemotherapy
Standard duration
Dose interval modification
Rifampicin
and INH
Safe and use normal dose
Pyrazinamide
Needs dose interval adjustmentSlide32
Renal Impairment
Ethambutol
Nephrotoxic
, Renal excretion - 80% unchanged
Ocular toxicity – dose dependent
Serum monitoring required
Amino glycosides – Streptomycin
Nephrotoxic
, renal excretion- 80% unchanged
Needs dose interval adjustment in all stages
New
recomandations
Avoid
AminoglycosidesSlide33
ATT Induced Hepatitis
Usually present early but may present any time
Mild / transient derangement in LFTs is normal (15 – 20 %)
TYPES:
Hepatocellular
:
Cholestatic
MixedSlide34
ATT Induced Hepatitis
RISK FACTOR
Age >35 years
Female sex
Oriental race (EAST ASIAN)
Pre-existing liver disease
Extensive tuberculosis
High alcohol consumption
Malnutrition and hypo
Albuminemia
Other
hepatotoxic drugs
Slow
Acetylator
status
High dosage in relation to body weightSlide35
Management
↑ ALT/AST (< Twice normal)
Continue ATT
Check after 2 weeks
↑ ALT/AST (>Twice normal)
Continue ATT
Check LFTs weekly for 2 weeks
Then every 2 weeks until normalSlide36
Management
↑ ALT/AST (>Thrice normal) + Symptoms
Anorexia, Nausea, Vomiting, Abdominal Pain , Jaundice
STOP ATT
↑ ALT/AST (>5 time normal) OR ↑
Bilirubin
Even If Patient Asymptomatic
Stop ATT
If patient is smear –
ve
/ Clinically stable
Wait until LFTs are normalNo need for alternate drugs
If patient is smear +
ve
/ Clinically unstable
Start
Ethambutol
, Streptomycin and one of the reserve drugs until LFT‘s are normal
Continue safe drugs until LFTs are normalSlide37
Management
When LFT’s are normal
Reintroduce ATT to detect offending drugs
Start with least
hepatotoxic
one by one
INH > RIF > PZA
If no reaction
Continue ATT
Stop alternate drugs
If reaction has developed
Stop offending drugContinue remaining drugsEnsure adequate regimen and durationSlide38
HIV - Infected or AIDS
Standard regimen – usually good response
Drug reactions more common
Thiacetazone
should be avoided
Prolonged treatment Slide39
Thanks