TUBERCULOSIS Diagnosis & treatment - PowerPoint Presentation

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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

shadowsSlide9
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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