Brief idea- tuberculosis, causative agent, epidemiology of disease in world and India, burden in HIV patients, Burden on Indian Economy, disease symptoms, control programmes implemented by government

1. TUBERCULOSIS IN
IMMUNOSUPPRESSED
Presented by: Rashmi Sharma

2. • Suppression of the body’s immune system and its
ability to fight infections and other disease.
• Deliberately induced – organ transplantation
• Disease induced- AIDS, SCID, Lymphoma.

3. • A specific infectious disease-
Mycobacterium tuberculosis
(human)
Mycobacterium bovis
(bovines)
• Mainly affecting lungs-
pulmonary tuberculosis (Most
important form)
• Infects- intestine, lymph node
and Skin.
• Disease chronic in nature

4. OTHER CAUSATIVE AGENT
• Mycobacterium africanum
• Mycobacterium microti
• Mycobacterium pseudotuberculosis
• M. tuberculosis complex
– M. africanum
– M. bovis
– M. carnetti
– M. microti

5. CAUSATIVE AGENT
• Gram positive
• Aerobic,
• non motile
• non spore forming.
• Acid fast- high mycolic acid content in wall.
• On staining have a beaded appearance.

6. • Tuberculosis called as “phthisis” in
ancient Greece
• In 1700, TB termed as “white plague”
due to paleness of patients.
• In 1800, termed as “consumption or
captain of all these men of death”.
• Dr. Robert Koch discovered the bacilli
Mycobacterium tuberculosis- 1832.
• Johann Schonlein named it- 1834

7. • Top 10 causes of death worldwide.
• 2017-
– 10 million people fell ill with TB
– 1.6 million deaths.
– 0.3 million in HIV patients (lead killer of HIV positive
patient).
– Globally, incidence is falling 2%/Year
– Ending TB epidemic by 2030 is among the health target of
Sustainable Development Goal

8. CONTD….
• 5-15% people have lifetime risk of TB
• People with TB can infect 10-15 people through close
contact in a year
• Without treatment- 45% of of HIV- negative and
100% of HIV positive patient die.

11. COUNTRIES HIGH BURDEN LIST

13. REGIONAL TRENDS IN ESTIMATED TB CASE
INCIDENCE

16. M. tuberculosis enters macrophage by endocytosis mediated by several macrophage receptors
Inside the macrophage, M. tuberculosis replicates within the phagosomes by blocking
phagolysosomes formation.

17. DISEASE IN ANIMALS
• Transmission primary source
– Inhalation
– Ingestion of contaminated pasture
– Communal drinking water
and trough
• Intrauterine infection
• Intramammary infection
– Contaminated teat siphon
– Cups of milking machine

18. • Progressive emaciation
• Capricious appetite and low grade fever
• Cough
– once or twice at a time
– Frequency increases in morning and cold weather
– Dyspnea due to bronchial node involvement
– Dysphagia in intestine involvement

19. • Infertility
• Abortion or a live calf dies
immediately due to generalized
TB
• Tuberculous mastitis- a major
public health concern.
– Characterized by marked
indurations
– Hypertrophy of the gland.

20. • M. bovis causes a relatively small
proportion, less than 2%, of the total
number of cases of TB
•
• Eating or drinking contaminated,
unpasteurized dairy products.
• M. bovis are similar to the symptoms of TB
caused by M. tuberculosis; this can include
fever, night sweats, and weight loss.

21. • A bacteriologically confirmed TB case is one from whom a
biological specimen is positive by smear microscopy, culture
or WRD (such as Xpert MTB/RIF). All such cases should be
notified, regardless of whether TB treatment has started.
• A clinically diagnosed TB case is one who does not fulfill the
criteria for bacteriological confirmation but has been
diagnosed with active TB by a clinician or other medical
practitioner who has decided to give the patient a full course of
TB treatment.

22. •M. tuberculosis – carried
in droplet nuclei (1-5
micron meter)
• Ingestion of unpasturized
milk (M. bovis)
• Inoculation (skin
tuberculosis)
• Transplacental route
(rare) TB is spread from person to person through
the air. The dots in the air represent droplet
nuclei containing tubercle bacilli.

23. FACTORS AFFECTING TRANSMISSION

24. Contd…
Adults are more infectious than young children

25. 1. Anatomical site of disease
2. History of previous treatment
3. Drug resistance
4. HIV status

26. • Pulmonary
– Primary
– Secondary
• Extra pulmonary
• Lymphnode TB
• Pleural TB
• TB of upper airways
• Skeletal TB
• Genitourinary TB
• Miliary TB
• Pericardial TB
• Gasterointestinal TB
• Tuberculous meningitis

27. • 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 1 month or more of anti-TB
drugs in the past. They are further classified by the outcome of their most recent
course of treatment as follows:
a. Relapse patients have previously been treated for TB, were declared cured or
treatment completed at the end of their most recent course of treatment, and are
now diagnosed with a recurrent episode of TB
b. Treatment after failure patients are those who have previously been treated for TB
and whose treatment failed at the end of their most recent course of treatment.
c. Treatment after loss to follow-up patients have previously been treated for TB and
were declared lost to follow up at the end of their most recent course of treatment.
d. Other previously treated patients are those who have previously been treated for TB
but whose outcome after their most recent course of treatment is unknown.
e. Patients with unknown previous· TB treatment history do not fit into any of the
categories listed above..

28. a. Monoresistance: resistance to one first-line anti-TB drug only.
b. Polydrug resistance: resistance to more than one firstline anti-
TB drug (other than both isoniazid and rifampicin).
c. Multidrug resistance: resistance to at least both isoniazid and
rifampicin.
d. Extensive drug resistance: resistance to any fluoroquinolone
and at least one of three second-line injectable drugs
(capreomycin, kanamycin and amikacin), in addition to
multidrug resistance.

29. • Latent infections- 5-10% develop into active ones.
• Active infection- further categorized as
– Primary infections
– Secondary infections

30. • Develops in previously
unexposed individual.
• Begins in lungs essentially
• 1-1.5cm area of grey white
inflammation with
consolidation develops
called as Ghon focus –
caseates.
• Can progress to miliary TB

31. Granuloma Skin tuberculosis

32. • Upper part of lungs show
softening and cavitations.
• Lesions normally heal with
fibrous scarring and
calcification
• Lesions may coalesce together
to form large Tuberculous
pneumonia- pulmonary and
extra pulmonary tb

33. • Extensive infection through
hematogenous spread
• Lungs- 2mm small foci of
yellow white consolidation
throughout parenchyma.
• Result in- pleural effusion,
tuberculous empyema
• Extrapulmonary tuberculosis-
most prominent in liver,
spleen, bone marrow, kidney
etc.

34. • Weight loss
• Fatigue
• Fever
• productive cough
• night sweats.
•
• IN CHEST RADIOGRAPH-
– Patchy or nodular infiltrates in upper lobes.

35. • HIV serves as the most important risk factor
for active TB
• CD4+ cells multiply in response to TB
infection, HIV replicates in these cells with
essentially destroying them
• HIV infected patients are at substantial higher
risk of mortality compared to HIV negative.

36. • HIV most important risk factor
for active TB- decreased immune
response prevents patients from
containing infection.
• Disease usually takes weeks to
months in progressing.
• 25% of HIV deaths are attributed
to TB as the two diseases seem
to speed each other

39. • Individuals with both Tb and
HIV- TB therapy is started
earlier followed by HIV
therapy after 2-8 weeks.
• Proportion of HIV positive TB
person receiving ARTs is 78%
globally
• 90% among them belong to –
India, kenya, Malawi,
Moambique, Nambia and
Swaziland
An HIV/TB-co-infected patient in Rwanda
before (left ) and after (right ) 6 months of
treatment.

40. •A triage to identify TB
suspects
•Separate patients with
suspected or confirmed
TB
•Spend most time
outside.
•Cough etiquette
•Sleep alone while smear
positive
•Avoid congregate
settings and public
transport while smear
positive.

41. GOVERNMENT INTIATIVES
• RNTCP (2012-17) - Revised national TB control program-
ensures free availability of drugs to all affected individuals.
• JOINT TB Monitoring Mission – India has screened 80
million cases and treated more than 15 million people.
• National Strategic plan 2017-2025- elimination of TB by
2025.
• Targets- private sector engagement
• Plugging leak from TB care cascade
• Active case finding among key population
• Preventing the development of latent infection to active

42. THANK YOU