Tuberculosis

DR .Aswani Chaudhary

MD,Clinical Pharmacology
Tuberculosis:
Case-Scenario:

Q. A 35 years old male, bus conductor by occupation came to Primary Health Care center with
complaints of productive cough and low grade fever for 3 weeks. He noticed a small amount
of blood in the sputum one day ago. On examination BMI was found to be 18 kg/m 2. Sputum
was sent for microscopy which revealed AFB.

a. Give your probable diagnosis and list other symptoms of the disease. (1+1 =2)

b. Write about the other investigations used to diagnose the disease. (2)

c. Categorize the patient according to DOTS and write the treatment for this case.(3)

d. Discuss the prevention and control of the disease in the community (3)
Case-Scenario:

Q. A “Defaulter” case of tuberculosis had presented in the clinic with the

history of fever and cough. On sputum microscopy he was found to be positive
for AFB. He was diagnosed as sputum smear positive case and put under one
of the categories of DOTS and treatment was started.

a. Define a defaulter case. (2)

b. Discuss the epidemiological impact of HIV/AIDS on tuberculosis patient. (2)

c. Explain the case finding tools of tuberculosis. (2)

d. Discuss on prevention and control of tuberculosis in community. (4)

Case-Scenario:

Q. 35 years old driver presented with the history of cough with fever since last 2 weeks and
he also complained of anorexia and weight loss. His sputum was sent for AFB and was
found positive.

a. What is the probable diagnosis of this case? How can you find out the prevalence of this
disease in a community?
b. Discuss the epidemiology of TB.
c. Make a note on DOTS Regimen.
d. Define following terminology:
Relapse
Return after default
New case
Treatment failure
Tuberculosis:
Tuberculosis is a specific infectious disease caused by M. tuberculosis.

The disease primarily affects lungs and causes pulmonary tuberculosis (PTB).

It can also affect intestine, meninges, bones and joints, lymph glands, skin

and other tissues of the body (Extra Pulmonary TB).

TB is curable and preventable.

TB has also been described as a barometer of social welfare.

Anti TB day: 24 march

Epidemiology of TB:
 TB is present in all countries and age group.

World: A/C to WHO, in 2021 an estimated 10.6 million people fell ill with
TB worldwide and 1.6 million people died from TB.
Nepal: WHO estimates that around 45,000 people develop active TB
every year in Nepal.
Country with highest TB burden in world: India
 Natural history of tuberculosis: Determinants of TB:

Agent factors: Host factors: Environmental and Social

factors:

AGENT: M. tuberculosis AGE: TB affects all ages.

Lack of education,
Lack of awareness of causes
SOURCE OF INFECTION: SEX: Male > Female of illness,
Overcrowding ,population
Cases (Human and bovine). NUTRITION:
Malnutrition explosion,
is widely believed to Large families, early
predispose to tuberculosis. marriages
Undernutrition/malnutrition
on
Smoking, alcohol,
Poor quality of life,
Poor housing.
 Mode of transmission of TB: Tuberculosis is a RESPIRATORY DISEASE,

transmitted mainly by Air droplets (droplet infection and droplet nuclei)

generated by sputum-positive patients with pulmonary tuberculosis.

 Incubation period of TB: Weeks- months- years.

Period of communicability: As long as the patient is not treated.

Clinical finding suggestive of
Tuberculosis:
1. Fever ≥ 2 weeks

( Evening rise of temperature associated with sweating)

2. Persistent cough ≥ 2 weeks

3. Hemoptysis (blood in the sputum)

4. Chest pain

5. Weight loss
Q. Who is a presumptive pulmonary
TB case?
 Any person with cough ≥ 2 weeks

Any individual having FEVER or night sweat or appreciable weight loss for ≥
2 weeks
Contact of a smear positive TB patients having cough of any duration.

Suspected/ confirmed extra pulmonary TB having cough of any duration.

HIV positive patient having cough of any duration.

 Classification of TB:

1. Anatomical site of disease: Pulmonary tuberculosis (PTB) and

Extrapulmonary tuberculosis (EPTB)

2. History of previous treatment: New patient and Previously treated patient.

3. Drug resistance: Monodrug resistance TB, Polydrug resistance TB, Rifampicin

resistant TB, MDR TB, XDR TB.

4. HIV status.
Classification of TB based on history of previous
TB treatment:
 New patients: Patients who have never been treated for TB or have taken anti-
TB drugs for less than 1 month.
 Previously treated patients: Patients who received anti-TB drugs for ≥ 1 month
in the past:

1. Recurrent TB (Relapse): A TB Patients who had completed course of treatment

for TB or declared cured and are now diagnosed with a recurrent episode of TB.

2. Treatment after failure: Patients who had been treated for TB and their
treatment failed at the end of most recent course of treatment.
3. Treatment after loss to follow-up (treatment after default patients): A

patient who had been treated TB for > 1 month and registered as lost of follow

up and now presenting as microbiologically confirmed case of TB.

Treatment after loss to follow-up were previously known as treatment after

default patients.
Classification of TB based on on drug resistance:

1. Monodrug resistance TB: Bacteria is resistance to any one first-line anti-

TB drug except rifampicin.
2. Polydrug resistance TB: Bacteria is resistance to > 1 first line anti-TB drug
except rifampicin.
3. Rifampicin resistant TB: Bacteria is resistance to rifampicin only.
4. Multidrug resistance TB (MDR TB): Bacteria is resistance to both
Isoniazid(H) and Rifampicin (R).
5. Extensive drug resistance TB (XDR TB): Bacteria is resistance to minimum
Isoniazid(H) and Rifampicin (R) + Minimum One of the fluoroquinolone +
Minimum one of the injectable drugs.
Q .Write about the investigations used to diagnose the disease:

Lab and Radiological investigations:

1. Chest X-ray

2.Sputum examination (Sputum AFB): 2 samples

3. GeneXpert

4. Mantoux test (IMMUNITY STATUS TEST)

5. HIV ( As relevant)
Q. Explain the case finding tools of tuberculosis.
Q. How can you find out the Incidence and prevalence of this disease in a community?

CASE-FINDING TOOLS: Sputum AFB

Sputum smear examination (Sputum AFB) by direct microscopy is now considered
the method of choice.
A pulmonary tuberculosis suspect should submit 2 sputum samples for microscopy.

Early morning sputum sample is more likely to contain TB bacilli than one taken
later in the day.
The chances of finding TB bacilli are greater with two samples than with one
sample.
Q. Mantoux Test:
AKA: Tuberculin skin test:

This is an IMMUNITY STATUS TEST.

Antigen: PPD (Purified Protein Derivative)
Dose: 1 TU (0.1 ml) injected intradermally on the flexor surface of forearm
Reading: After 72 hrs (3d)
Only induration is measured:
Induration >9 mm: Positive
Induration 6-9 mm: Doubtful
Induration <6 mm: Negative

Mantoux Test cannot differentiate between current infection and past infection.
Mantoux Test (AKA: Tuberculin skin test): cont.…
Mantoux test may also report false positive or false negative result:

False positive result: False negative result:

Prior BCG vaccination HIV/AIDS
Infection with atypical mycobacterium
Immunosuppressive therapy
Severe malnutrition
Repeated tuberculin test
Pertussis
Faulty injection technique
Measles
Too deep injection Chickenpox
PPD (Purified Protein Derivative):
Treatment of TB:
DOTS: Directly Observed Therapy, short course.
Cat 1: New Patients
Cat 2: Old patients

DOTS IP ( Intensive phase) CP(Continuation phage)

Cat 1 (New Patients) 2 HRZE 4 HRE

Cat 2 (Old patients) 2 HRZES 5 HRE

+ 1 HRZE
Treatment of TB (New guideline
2018):
DOTS IP ( Intensive phase) CP(Continuation phage)

Cat 1 (New Patients) 2 HRZE 4 HRE

Or
Cat 2 (Old patients)
 MDR TB and Treatment of MDR TB:
MDR TB: Bacteria is resistance to both Isoniazid(H) and Rifampicin (R)

Treatment of MDR:
IP ( Intensive phase) CP(Continuation phage)

 Minimum 6 drugs x 6 months  Minimum 4 drugs x 18 months

Avoid combining cross resistance drugs: 2 FQs, Km with Am or
Protionamide, Ethionamide or Cycloserine.
Include: From group one to four: Group one ( Z,E), 1 injectable drug
(group 2), 1 FQ (group 3) and 2 from Group 4 drugs
XDR TB and Treatment of XDR TB:
XDR TB: Bacteria is resistance to minimum Isoniazid(H) and Rifampicin (R) +
Minimum One of the fluoroquinolone + Minimum one of the injectable drugs.

 Treatment of XDR TB:

IP ( Intensive phase) CP(Continuation phage)

Minimum 7 drugs x 6 months Minimum 6 drugs x 18 months

Prevention and control of tuberculosis in community:

1. Health education: Through Information Education and Communication(IEC)

about causes, cure, treatment and arability of services.
2. Nutritional education:
3. Quit smoking
4. BCG immunization for children.
5. Early detection of sputum-positive cases.
6. For patient:
Motivate to take drug regularly and completely, going for periodic
examination.
Cover the mouth with cloth while coughing.
Hygienic disposal of sputum.
7. Removal of stigma
Immunization for TB:
BCG VACCINATION:

Tuberculin syringe
BCG VACCINATION: Bacilli Calmette Guerin

Type: Live attenuated vaccine

Diluent: Normal Saline

Strain: DANISH-1331

Schedule: Given at Birth

Dose/ Site: 0.05 ml or 0.1 ml, Left deltoid (Intradermally)/R deltoid in Nepal

Efficacy: 0 -80%

Duration: 20 years
Tuberculin syringe
BCG VACCINATION: Cont.…
Protective efficacy:
 Does not protect Pulmonary TB: 0% Suppurative
 Protect Severe form of TB: 50% Lymphadenitis
 Leprosy: 30%
 BCG immunotherapy is given in superficial Bladder cancer.

Phenomenon after vaccination:

 2-3 weeks: Papule
 6-8 weeks: Ulcer covered with crust
 6-12 weeks: Permanent tiny round Scar
 8-14 weeks: Mantoux test become positive
The End TB Strategy 2016-2035:

 Vision: A world free from TB.

Target for 2035:

1. Reduction in TB incidence rate: > 90% (< 10 TB cases per 100,000

population)

2. Reduction in TB death: >95% (Compared with 2015)

3. TB affected families facing catastrophic cost: Zero

Q. Explain the epidemiological impact of HIV and TB
combination.
Most common opportunistic infection of HIV: TB

HIV is the most potent risk factor for TB.

HIV-infection increases the risk of TB 20-fold compared with person

without HIV.
World: 10-15% of PLHIV are infected with TB.

World: More than 1 million people have HIV/ TB co-infection.

Early detection and effective treatment (DOTS): Reduce mortality

 QQQQQ
Q. Write the short note on MDR TB and XDR TB.

Q. Write the short on:

New patients, Recurrent TB (Relapse),

Treatment after failure,

Treatment after loss to follow-up (treatment after default

patients).