tuberculosis diagnosis & treatment
DESCRIPTION
TUBERCULOSIS Diagnosis & treatment. Dr. Fazli Wahab FCPS(Med), FCPS( Pulmonology ) Assisstant Prof Peshawar Medical College. Diagnostic Tools. Microscopy AFB smear Histology AFB Culture Radiology Tuberculin skin test Serological Tests. AFB smear. Rapid and inexpensive. Granuloma. - PowerPoint PPT PresentationTRANSCRIPT
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TUBERCULOSISDiagnosis & treatment
Dr. Fazli WahabFCPS(Med), FCPS(Pulmonology)
Assisstant Prof Peshawar Medical College
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Diagnostic ToolsMicroscopy
◦AFB smear◦Histology
AFB Culture
Radiology
Tuberculin skin test
Serological Tests
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AFB smearRapid and inexpensive
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Granuloma
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Mycobacterial Culture
Definitive diagnosis
Growth detected after 4–8 weeks.
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Radiographic Procedures
The "classic" picture is that of upper-lobe disease with infiltrates and cavities,
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X-ray chest appearance can be any of the followingInfiltrationCavitationsFibrosis with tractionEnlargement of hilar and mediastinal lymph node Pleural effusion/empyemaNodular/ Miliary shadows
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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 >5mm
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Serological TestsNot 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
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Treatment
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Two aims
◦Interrupt transmission
◦Prevent morbidity and death.
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Anti-tuberculosis Drugs 1ST LINE DRUGS:
• Isoniazid (H) • Rifampicin (R)
• Pyrazinamide (Z) • Ethambutol (E) • Streptomycin (S)
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1st line ATT Mode of Action
DailyDose (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)
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Regimens
Standard short course regimens 6-8 months.
An initial, intensive or bactericidal, phase and
A continuation, or sterilizing, phase.
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DOTS
DOTS (directly observed treatment, short-course), the WHO-recommended TB control strategy.
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New Cases•Sputum smear positive pulmonary TB•Sputum smear negative pulmonary TB•Extra-pulmonary tuberculosis
Initial Intensive Phase
HRZE : 2 MonthsContinuation Phase
HR: 4months OR HE: 6 Months
WHO Category I:• New SS +VE Pulmonary
TB• Severe Extra-Pulmonary• Severe SS –VE
Pulmonary TBWHO Category III:New SS-VE Pulmonary TBExtra-Pulmonary (less severe)
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RE-TREATMENT CASES/ WHOCategory 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 PHASEHRE: 5 Months
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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.
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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 1st ATT.
Treatment is difficult and expensive.
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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.
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ATT in Special situationsPregnancy
Infants of T.B. mothers & Breast Feeding
Women on O.C.P
Renal Impairment
ATT Induced Hepatitis
HIV - Infected or AIDS
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PregnancyH, R, Z, E : Safe
Streptomycin: OtotoxicMay cause deafness in babiesContraindicated
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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 months
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Infants of T.B. mothers & Breast Feeding
Do T.T:If –ve
◦Stop INH, give BCGIf +ve
◦Continue INH 4 months◦Then BCG
Do not give BCG while on INH◦ INH resistant BCG
Rifampicin + INH – 3 months
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Women on O.C.PRifampicin:
◦Hepatic enzyme inducer
◦O.C.P may become ineffective
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Renal ImpairmentGeneral principle:
◦Standard chemotherapy◦Standard duration ◦Dose interval modification
Rifampicin and INH◦Safe and use normal dose
Pyrazinamide◦Needs dose interval adjustment
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Renal ImpairmentEthambutol
◦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 Aminoglycosides
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ATT Induced HepatitisUsually present early but may
present any time
Mild / transient derangement in LFTs is normal (15 – 20 %)
TYPES:◦Hepatocellular:◦Cholestatic◦Mixed
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ATT Induced HepatitisRISK FACTOR
Age >35 years Female sex Oriental race (EAST ASIAN)Pre-existing liver disease Extensive tuberculosisHigh alcohol consumption Malnutrition and hypo AlbuminemiaOther hepatotoxic drugsSlow Acetylator statusHigh dosage in relation to body weight
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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 normal
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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 normal◦ No 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 normal
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ManagementWhen LFT’s are normal
◦Reintroduce ATT to detect offending drugs◦Start with least hepatotoxic one by one
INH > RIF > PZAIf no reaction
◦Continue ATT◦Stop alternate drugs
If reaction has developed◦Stop offending drug◦Continue remaining drugs
Ensure adequate regimen and duration
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HIV - Infected or AIDSStandard regimen – usually good
response ◦Drug reactions more common ◦Thiacetazone should be avoided ◦Prolonged treatment
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Thanks