Tuberculosis
Divya Mathew
Mr. X, 20 years old, presented to the
medicine OPD with symptoms of fever for
the last one month. He also complained of
generalised tiredness and loss of
appetite. He was surprised to note that in
the last 1 month he had lost 5 kgs of
weight. For the last 2 weeks he had also
developed a productive cough that had
not subsided despite antibiotics given to
him by his treating physician.
On examination he was found to be
afebrile, thinly built. General
examination was otherwise
unremarkable however auscultation
of the chest revealed bronchial
breath sounds in the right upper
lobe.
Sputum AFB
positive
Diagnosis???
Objectives
Causative organism
Pathophysiology
Pulmonary tuberculosis
Extra pulmonary tuberculosis
MDR, XDR Tuberculosis
Drugs first line, second line
Causative organism
Mycobacterium tuberculosis
Genus mycobacterium
Acid fast bacillus mycolic acid
resistant to gram staining
Resists destaining by acid alcohol
Slow growth rate generation time of
20- 24 hours
Robert Koch
discovered M.Tb in
1882
Estimated TB incidence rate, 2007
:Source:
WHO Geneva; WHO Report 2009: Global Tuberculosis Control; Surveillance, Planning and
Financing
Pathophysiology
Transmission airborne
1-5 microns droplets
Pathogenesis
MTB into lungs (or to cervical nodes or abdo.
nodes)
Replication of organisms
Primary complex (lung and mediastinal lymph
nodes) Ghon complex
Mycobacteraemia with potential for seeding
Consequence of tuberculous infection
Symptomatic illness disease (minority)
immunological control (majority) with Ghon focus on Xray.
Infection is contained by granuloma but not eliminated
Pathogenesis
Tuberculous disease is a consequence of:
Primary infection e.g. in children
Reactivation
natural
Associated with immunosupression
Re infection
Pulmonary tuberculosis
Lungs major site for primary infection
and disease
Primary tb Fever
Pleuritic chest pain- pleural effusion
Myalgia, arthralgia, fatigue, weight
loss
ReactivationFever, night sweats
Anorexia
Cough productive or non productive
Apical posterior segment of upper
lobe and superior segment of lower
lobe.
Clinical manifestations
Clinical manifestations
Physical examination:
Thinly built
Pallor
Lymphadenopathy
Bronchial breath sounds/ decreased
breath sounds (pleural effusion)
Fever +/-
Complications
Hemoptysis
Pneumothorax
Extensive pulmonary destruction
Miliary tuberculosis
Wide dissemination
1-5 mm millet seed size of lesions
Hematogenous spread
Multiorgan involvement
Adrenal shock
Extra pulmonary
tuberculosis
Skin and soft tissue
Lymph nodes
Bones and joints
Intra abdominal structures including
Peritoneum
Kidneys
Adrenals
Lymph nodes
Central nervous system
Tuberculoma
meningitis
tuberculous lymphadenitis
Potts spine
Renal tuberculosis
Tuberculomas
Skeletal tuberculosis
TB involvement of the
bonesand/orjoints
10 to 35 percent of cases of
extrapulmonary tuberculosis, 2
percent of TB cases overall
Potts spine
Tuberculous arthritis
Tuberculous spondylitis (Pott's disease)
most common form of skeletal TB
lower thoracic and upper lumbar region
Initially involving the anterior aspect of
the intervertebral joint.
Spreads behind the anterior ligament to
involve the adjacent vertebral body
Eventually spreads into the
intervertebral space
Avascular disc dies
Vertebral collapse
Gibbus deformity
Risk of paraplegia
Cold abscess
Subacute course progressively
worsening pain, muscle spasm,
characteristic aldermans gait (short
deliberate steps)
Arthritis
Usually monoarticular
Typically hip (most common) or knee
Swelling, pain, loss of joint function over
weeks to months.
Cold joint
Constitutional symptoms not common.
Synovial proliferation, joint effusion,
erosion of cartilage and joint destruction.
diagnosis microscopy, culture of infected
material
Medical treatment ATT duration uncertain
Indications for surgery
Spinal disease and advanced neurological
deficits
Worsening neurological deficits while on ATT
Spinal disease and kyphosis > 40 degrees at
presentation
Chest wall cold abscess
Antituberculous agents
First line
isoniazid,
rifampicin,
ethambutol,
pyrazinamide
Drug resistant tuberculosis
The term "drug-resistant TB" refers
to cases of TB caused by an isolate
ofM. tuberculosisthat is resistant to
one of the first-line anti-TB drugs:
isoniazid,rifampin,pyrazinamide,
ethambutol, or streptomycin.
The term "multidrug-resistant TB" (MDR-TB)
refers to an isolate ofM. tuberculosisthat is
resistant to at leastisoniazid
andrifampinand possibly additional agents.
The term "extensively drug-resistant TB"
(XDR-TB) refers to an isolate ofM.
tuberculosisthat is resistant to at
leastisoniazid,rifampin, and
fluoroquinolones, as well as either
aminoglycosides (amikacin,kanamycin)
orcapreomycinor both
The term "totally drug-resistant TB"
(TDR-TB) refers to an isolate ofM.
tuberculosisresistant to all locally
tested medications
Primary drug resistance
Secondary drug resistance
Summary
Mycobacterium tuberculosis
Airborne transmission
Primary infection, latent disease,
reactivation, reinfection
Pulmonary, extraulmonary tuberculosis
Potts spine/ tuberculous arthritis
1st line and second line drugs
Drug resistant tuberculosis
Thankyou
