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tuberculosis 2
History
Its a disease of great antiquity. Found in the vertebra of Neolithic man in
Europe and on Egyptian mummies from asearly as 3700 BC.
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Tubercle Bacillus
It is a acid-fast, alcohol-fast, aerobic ormicroaerophilic, non-spore-forming, non-motile
bacilli. Only M. Tuberculosis, M. Bovis and M. Africanumare recognized as Tubercle Bacilli.
Optimal temperature for growth is 33-39 degreeCelsius at pH 6.5-6.8 in an atmosphere of 5-10% CO2.
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Transmission
Transmitted by the airborne route. The unit of infection is a small particle
called a droplet nucleus.
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Epidemiology
Most common infectious disease in theworld.
One third of the world population isinfected. 2.5 million death annually.
The incidence of the disease has beenincreasing both in developed anddeveloping countries.
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Pathology
Deposition of Tubercle Bacilli in the alveoliof the lungs is followed by vasodilatation
and influx of polymorphonuclearleucocytes and macrophage.
Macrophages crowed together as
epitheloid cells to form the tubercle.
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Pathology (contd..)
Some mononuclear cells fuse to form themultinucleated or Langerhans giant cells.
Lymphocytes surround the outer margin ofthe tubercle.
In the centre of the lesion a zone of
caseous necrosis may appear that maysubsequently calcify.
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Tuberculin test:
Mantoux test:1. Intradermal inj of .1 ml of 5 TU PPD on
the volar surface of forearm.2. Test is read after 48-72 hours.3. Positive: > 10 mm.
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Tuberculin test:
Heaf test:1. Done with a gun which has 6 needle.
2. The needle puncture the skin through athin film of PPD3. Test is read after 3-7 days.
4. Grade: 1-45. Gr. 3 and 4: past or present infection.
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False negative tuberculin test
patient related factor Tuberculin related factor
Method of administration factor Reading and recording factor
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BCG vaccination
Bovine strain of M. tuberculosis. 230 passage through media.
Freeze-dried vaccine can be stored forlonger period.
In developing countries the vaccine shouldbe given to neonates or as early aspossible to children.
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Chemoprophylaxis
Administration of chemotherapy to preventtuberculosis.
A. Primary: usually not given.
B. secondary:1. Close contact of newly diagnosed patient.2. Positive tuberculin test reactors with anabnormal but inactive X-ray.
3. Positive tuberculin test reactor with specialclinical situations.
Drug: INH-300 mg/day for 01 year.
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Congenital tuberculosis
Very rare.
Three possible modes of transmission:Haematogenous, aspiration, inhalation.
C/F: wide spread disease i.e. respiratorydistress, fever, hepatosplenomegaly, jaundiceetc.
Treatment: 3 drugs. Steroid may be added.
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Primary pulmonary tuberculosis
The first infection with tubercle bacilli . It includes: pulmonary focus plus
involvement of draining lymph node. Primary complex. C/F: may be asymptomatic. Few may be
symptomatic i. e. fever, cough, failure togain wt, wheeze or features of collapse.
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Diagnosis:
X-ray chest Tuberculin test
Gastric washing and sputum for AFB and AFBC/S.
Complications: Collapse/ consolidation,bronchiectasis, obstructive emphysema,broncholith, erythema nodosum, phlyctenularconjuntivits, pleural effusion etc.
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Miliary tuberculosis
Produced by acute dissemination oftubercle bacilli by blood stream.
Seeding of bacilli in the vessel wall causecaseous vasculitis with subsequentdischarge of bacilli in the blood stream.
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pathology
The millet seed sized lesions consists ofepithelioid cells, Langhans giant cells with
or with out central caseation. AFB may bepresent.
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Clinical features:
Acute or classical miliary tuberculosis:common in children. May have anorexia,
nausea, vomiting, fever, cough, dyspnoea,haemotysis etc.
Clinically: creps, HSM, neck rigidity,
choroidal tubercle etc.
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Cryptic miliary tuberculosis
Common in elderly. Difficult to diagnose.
Onset is with malaise,anorexia, weightloss, fever.
Variety of blood dyscrasias may be seen.
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diagnosis
Radiology Gastric lavage, sputum, transtracheal
aspirate, FOB with washing for AFB andAFB C/S.
BM, spleen and liver biopsy.
Blood: TC, DC, ESR. Tuberculin test.
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Complications
ARDS Immune complex nephritis.
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Post primary pulmonarytuberculosis
Most common type of pulmonarytuberculosis.
Pathogenesis- arise in one of the threeways:1.direct progression of primarylesion. 2. reactivation 3. reinfection.
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Risk factors
Nutrition Homelessness
OccupationAlcoholism HIV infection Immunosuppressive drugs Immunosuppressive diseases
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Clinical features
Disease of middle aged and elderly Symptom free - discovered on routine CXR.
Persistent cough with or without sputum. General malaise. Recurrent colds
Pneumonia. Haemoptysis.
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Signs
No physical signs. Fever, wt loss.
Post tussive creps. Signs of consolidation. Evidence of fibrosis. Evidence cavity
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Newer diagnostic technique
TB serology PCR
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Complications (contd..)
Pulmonary tuberculoma Poncets disease
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Treatment
Before 1950s mainstay of Rx was: bedrest, open air and sunshine.
Surgical resection and collapse therapywere also practiced. Presently short course chemotherapy is
the mainstay of Rx.
Short course combination chemotherapy isusually given for 6 months.
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First line drugs
Rifampicin. INH.
PZA. Ethambutol. Streptomycin.
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Second line drugs
Thiacetazone. PAS.
Ethionamide, prothionamide, cycloserine Kanamycin, capreomycin, viomycin.
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Newer drugs
Quinolons:1. Ciproflxacin
2. Ofloxacin Rifabutin Macrolides.
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Thrice weekly regimen
Rifampicin, INH, PZA plus EMB/ SM dailyfor 02 months followed by
Rifampicin and INH thrice/week.
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Rx of MDR TB
At least 03 drugs to which the organismsaresensitive.
The drugs should be continued for 6-12months after sputum become culturenegative.
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Thank You