.() 11,

Robert Koch - ..2425 - Schatz Wakesman Streptomycin .. 2486Koch Schatz Nobel Prize 1950s, 1960s 1970s

Tuberculosis 100 1. 24232. TT 24433. 2513

WHO Global TB Control Report 20109.4 million new TB case (1.1 million case with HIV)1.7 million people die from TB (4700 death/d.)TB / HIV :- 26% of TB case have HIV (2009)MDR :- 440,000 of MDR-TB : estimated (2008) :- 250,000 of MDR-TB : should be reported :- 30,000 of MDR-TB : actually reported (only 10%) :- 150,000 of MDR-TB : death :- 3.3% of all new TB cases had MDR-TBXDR :- confirmed in 58 countries( WHO Global TB Control 2010 )

(1)..2547 80,000 35,000 ()30-40% 15-44 13-14% HIV

1 22 WHO high-burden TB - - , . (2)

( IEIP 5th Annual Scitific Meeting , Aug 25-26, 2010 , Bangkok )Result :-7,984 pneumoniaage > 15 yo.4273 (54%) examinesputum > 1 sputumAFB +ve (sputum)N = 364AFB veN = 3920 (92%)Newly detected AFB +veN = 353 (8.3% of clinical pneumonia)Excluded 11known/ / registeredTBTB in Pneumonia Surveillance ( Sakaeo, NakornPhanom :- Oct. 2008 Jan.2010 ) (2)

TB in Pneumonia Surveillance ( Sakaeo, NakornPhanom :- Oct. 2008 Jan.2010 ) (3)8.3% 15 clinical diagnosis Pneumonia TB AFB positive 1 TB AFB Negative :- 15% Pneumonia TB ( IEIP 5th Annual Scitific Meeting , Aug 25-26, 2010 , Bangkok )

- 15-20% ( 40% ) WHO smear +ve WHO 0-4 5-14 ( Pediatr Respir Rev 2011; 12: 1-2. )

rare disease ????- Not rare :- ~ 15-20% Cape Town, SA :- 407 / 100,000 / :- 845 / 100,000 / (Marais. IJTLD 2006; 10:259-63)- () (Marais. IJTLD 2006; 10:259-63)- Not limited disease :- Autopsy Zambia acute pneumonia ( Chintu. Lancet 2002; 360: 985-90. )

TB 50% TB 25% 20% (TB)

() (smear ) 10-14 /1. ( > )2. ()3. ()4. ()5. ( )

1. 2. 3. 4. ()5. 6. MDR-TB XDR-TB7. (compliance)(JAMA 1995; 273:220)

Index case :- 1. 2. smear positive for AFB 3.

LTBI 1. ( )2. (Index case)- AFB - - -

LTBI TB 1-2 host- < 5 (

Mycobacteriology

MycobacteriologyFamily MycobacteriaceaeGenus Mycobacterium60 species Human Mycobacterias :- 3 groups1. Tuberculosis complex eg. M.tb, M.africanum, M.bovis2. Non Tuberculosis Mycobacteria or Atypical Mycobacteria, M.avium complex (MAC)3. M.leprae

Tuberculosis ComplexM. tuberculosisM. bovisM. africanum

M. tuberculosis1. Glycolipids Lipid (Acid-fast bacilli)2. ( 20-24 .)3. latent granuloma 4. spores M. tuberculosis

( Oxford Textbook of Medicine; Fifth edition 2010 : P812. )

BCG Vaccine Strain M. bovis 231 bileM.bovis BCG strain - Pathogenicity - glycerol- TB CMI- 5 x 106 20 x 106

M. tuberculosis 1. > 95% 2. 3. airborne transmission < 5

Pathogenesis

Pathogenesis of Tuberculosisinhaling of M.tbimplantation at alveolimultiplication of M.tbSPREADINGLympho-hematogenousUnfavorable to growth Favorable to growtheg. BM, liver, spleen eg. Upper lung, renal epiphysis, cerebral cortex4-8 wk. DTH TT+CMIadequate(Tuberculous inf.)inadequate(Tuberculosis)

M. tuberculosis 4 primary TB diseases Latent TB , LTBI () ()( Jones C. Pediatr Respir Rev 2011; 12 : 3-8. )

Inhalation of M.tbLungLympho-hematogenousComplete resolutionPrimary TB(rare)eg. pulmonarydisseminatedhealing granuloma(distant organ)Post primary TBeg.pulmonary (adult type)extrapulmonarySTABLEyears

Kochs PhenomenonRobert Koch - 10-14 - 4-6 2

(1) granulomaGranuloma macrophage Granuloma macrophages, CD4, CD8 lymphocytes, fibroblast, giant cell and epithelioid cellCalcified granuloma Ghon complexGhon complex + Calcified LN Rankes complex( Oxford Textbook of Medicine; Fifth edition 2010 : P815. )

BCGLymphocyteM. TuberculosisAtypicalMycobacteriaTActivatedT-LymTuberculoprotein (TT reagent)LYMPHOKINES (eg.MIP, SRF)Redness, Induration of skin(DTH)

Role of Different Lymphocyte in TB (2)B cell and AntibodyHave long been considered to be of secondary important in M.tb immunologyImmunomodulating through antigen presentation, co-stimulation and cytokine production

( Jones C. Pediatr Respir Rev 2011; 12 : 3-8. )

3 1. Exposure (contact TB)2. Infection (LTBI)3. Disease (TB)

() (M. tuberculosis) ( ~ 50-60% ) (40-50%) (infection)( ~ 40% ) (disease)( ~ 5% ) INH 6-9 TB disease (4 drugs)

()1-2 < 1 40-50% 10% ( 1 ) 10-15% 10% 5% 5% HIV 5% (Nelson LJ. Wells CD, Int J Tuberc Lung Dis 2004;8:636-47.)

TB Diagnosis Major portion : to identify any untreated TB infection (recent or past, primary or reinfection).Minor portion : to identify symptomatic TB disease as early as possible.( Marais BJ. Int J Tuberc Lung Dis 2004; 8: 392-402. )

:- :- :- (Immunodiagnostic test) :- WHOIGRA TT LTBI TB HIV, ( Pediatr Respir Rev 2011; 12: 1-2. )

:- -1. 2000 ()2. 3. (airborne transmission) 4. - ()- ()- 5. 6. MDR , XDR-TB () 7. HIV

**