tuberculosis : definition, epidemology, transmission of tuberculosis, stages of tuberculosis, types of tuberculosis,etiology, pathogenesis, pathophysiology, clinical presentations, diagnosis, treatment of tuberculosis, treatment of tuberculosis in breastfeeding, pregnancy, HIV/AIDS, oral contraceptives, renal failure, liver failure conditions and multi-drug resistance tuberculosis : types , diagnosis, and treatment

1. TUBERCULOSIS
Presented by: Venu priya Boyapati

2. TUBERCULOSIS
 Chronic airborne infection caused by Mycobacterium tuberculosis.
 Mycobacterium tuberculosis is also known as acid fast bacilli.
 It can also caused by Mycobacterium avium & Mycobacterium
africanus.

3. EPIDEMOLOGY
 Tuberculosis (TB) is one of the top 10 causes of death worldwide.
 In 2016, 10.4 million people fell ill with TB, and 1.7 million died
from the disease (including 0.4 million among people with HIV).
Over 95% of TB deaths occur in low- and middle-income countries.
 Seven countries account for 64% of the total, with India leading the
count, followed by Indonesia, China, Philippines, Pakistan, Nigeria,
and South Africa.
 In 2016, an estimated 1 million children became ill with TB and 250
000 children died of TB (including children with HIV associated
TB).
 TB is a leading killer of HIV-positive people: in 2016, 40% of HIV
deaths were due to TB.

4.  Multidrug-resistant TB (MDR-TB) remains a public health crisis
and a health security threat. WHO estimates that there were 600 000
new cases with resistance to rifampicin – the most effective first-
line drug, of which 490 000 had MDR-TB. Globally, TB incidence
is falling at about 2% per year. This needs to accelerate to a 4–5%
annual decline to reach the 2020 milestones of the End TB Strategy.
 An estimated 53 million lives were saved through TB diagnosis and
treatment between 2000 and 2016.
 Ending the TB epidemic by 2030 is among the health targets of the
sustainable development goals.

5. TRANSMISSION
OF
TUBERCULOSIS
Not infected
Infected ,but
no symptoms
LATENT TB
INFECTION(
LTBI)
If not
identified &
treated ,10%
develop TB
during their
lifetime
Family ,
friends ,
workmates
etc.. exposed
Active TB
INFECTIOUS

6. TYPES
OF
TUBERCULOSIS
Pulmonary
tuberculosis
Most common
&infectious
Affects the lungs
Extra
pulmonary
tuberculosis
Bacteria spread out
side the lungs . It is
more common in
people with
HIV/AIDS
Eg. Meninges ,
lymph nodes ,
spleen, kidney ,
intestine

7. STAGES
OF
TUBERCULOSIS
Latent TB Active TB
TB lives but does not grow in the
body.
TB is active and grows in the
body.
Does not make a person feel sick
or have symptoms .
Makes a person feel sick and
have symptoms.
Cannot spread from person to
person.
Can spread from person to
person.
Can advance to TB disease. Can cause death if not treated.

8. ETIOLOGY
 Close contact. Having close contact with someone who has an
active TB.
 Low immunity. Immunocompromised status like those with HIV,
cancer, or transplanted organs increases the risk of acquiring
tuberculosis.
 Substance abuse. People who are IV/injection drug users and
alcoholics have a greater chance of acquiring tuberculosis.
 Inadequate health care. Any person without adequate health care
like the homeless, impoverished, and the minorities often develop
active TB.
 Immigration. Immigration from countries with a high prevalence of
TB could affect the patient.
 Overcrowding. Living in an overcrowded, substandard housing
increases the spreading of the infection.

9. PATHOGENESIS
Droplet nuclei
containing
tubercle bacilli
are inhaled
enter the lungs
, and travel
into alveoli
Tubercle bacilli
multiply in the alveoli
A small number
of tubercle
bacilli enter the
blood stream
and spread
throughout the
body
1
2
3
4
Macrophages form
a hard shell &
keeps bacilli under
control
5 Hard shell breaks down
and tubercle bacilli
escape and multiply

10. PATHO-
PHYSIOLOGY
 Inhalation. Tuberculosis begins when a susceptible person inhales
mycobacteria and becomes infected.
 Transmission. The bacteria are transmitted through the airways to
the alveoli, and are also transported via lymph system and
bloodstream to other parts of the body.
 Defence. The body’s immune system responds by initiating an
inflammatory reaction and phagocytes engulf many of the bacteria,
and TB-specific lymphocytes lyse the bacilli and normal tissue.
 Protection. Granulomas new tissue masses of live and dead bacilli,
are surrounded by macrophages, which form a protective wall.

11.  Ghon’s tubercle. They are then transformed to a fibrous tissue mass,
the central portion of which is called a Ghon’s tubercle.
 Scarring. The bacteria and macrophages turns into a cheesy mass
that may become calcified and form a collagenous scar.
 Dormancy. At this point, the bacteria become dormant, and there is
no further progression of active disease.
 Activation. After initial exposure and infection, active disease may
develop because of a compromised or inadequate immune system
response.

12. CLINICAL
MANIFESTATIONS
 After an incubation period of 4 to 8 weeks, TB is usually
asymptomatic in primary infection.
 Nonspecific symptoms. Nonspecific symptoms may be produced
such as fatigue, weakness, anorexia, weight loss, night sweats, and
low-grade fever, with fever and night sweats as the typical
hallmarks of tuberculosis.
 Cough. The patient may experience cough with mucopurulent
sputum.
 Hemoptysis. Occasional hemoptysis or blood on the saliva is
common in TB patients.
 Chest pain. The patient may also complain of chest pain as a part of
discomfort.

13. DIAGNOSIS
 Sputum culture: Positive for Mycobacterium tuberculosis in the active
stage of the disease.
 Ziehl-Neilsen (acid-fast stain applied to a smear of body fluid): Positive
for acid-fast bacilli (AFB).
 Skin tests (purified protein derivative [PPD] or Old tuberculin [OT]
administered by intradermal injection [Mantoux]): A positive reaction
(area of induration 10 mm or greater, occurring 48–72 hr after inter
dermal injection of the antigen) indicates past infection and the
presence of antibodies but is not necessarily indicative of active
disease. Factors associated with a decreased response to tuberculin
include underlying viral or bacterial infection, malnutrition,
lymphadenopathy, overwhelming TB infection, insufficient antigen
injection, and conscious or unconscious bias. A significant reaction in a
patient who is clinically ill means that active TB cannot be dismissed as
a diagnostic possibility. A significant reaction in healthy persons
usually signifies dormant TB or an infection caused by a different
mycobacterium.

14.  Enzyme-linked immunosorbent assay (ELISA)/Western blot: May
reveal presence of HIV.
 Chest x-ray: May show small, patchy infiltrations of early lesions in
the upper-lung field, calcium deposits of healed primary lesions, or
fluid of an effusion. Changes indicating more advanced TB may
include cavitation, scar tissue/fibrotic areas.
 CT or MRI scan: Determines degree of lung damage and may
confirm a difficult diagnosis.
 Bronchoscopy: Shows inflammation and altered lung tissue. May
also be performed to obtain sputum if patient is unable to produce
an adequate specimen.
 Histologic or tissue cultures (including gastric washings; urine and
cerebrospinal fluid [CSF]; skin biopsy): Positive for Mycobacterium
tuberculosis and may indicate extrapulmonary involvement.
 Needle biopsy of lung tissue: Positive for granulomas of TB;
presence of giant cells indicating necrosis.

15.  Electrolytes: May be abnormal depending on the location and
severity of infection; e.g., hyponatremia caused by abnormal water
retention may be found in extensive chronic pulmonary TB.
 ABGs: May be abnormal depending on location, severity, and
residual damage to the lungs.
 Pulmonary function studies: Decreased vital capacity, increased
dead space, increased ratio of residual air to total lung capacity, and
decreased oxygen saturation are secondary to parenchymal
infiltration/fibrosis, loss of lung tissue, and pleural disease
(extensive chronic pulmonary TB).

16. TREATMENT
Treatment goals
 Promote airway clearance.
 Adhere to treatment regimen.
 Promote activity and adequate nutrition.
 Prevent spread of tuberculosis infection.

17.  Pulmonary tuberculosis is treated primarily with anti tuberculosis
agents for 6 to 12 months.
 First line treatment. First-line agents for the treatment of
tuberculosis are isoniazid (INH), rifampin (RIF), ethambutol
(EMB), and pyrazinamide.
 Active TB. For most adults with active TB, the recommended
dosing includes the administration of all four drugs daily for 2
months, followed by 4 months of INH and RIF.
 Latent TB. Latent TB is usually treated daily for 9 months.

18.  Treatment guidelines. Recommended treatment guidelines for
newly diagnosed cases of pulmonary TB have two parts: an initial
treatment phase and a continuation phase.
 Initial phase. The initial phase consists of a multiple-medication
regimen of INH, rifampin, pyrazinamide, and ethambutol and lasts
for 8 weeks.
 Continuation phase. The continuation phase of treatment include
INH and rifampin or INH and rifapentine, and lasts for an additional
4 or 7 months.
 Prophylactic isoniazid. Prophylactic INH treatment involves taking
daily doses for 6 to 12 months.
 DOT. Directly observed therapy may be selected, wherein an
assigned caregiver directly observes the administration of the drug

19. PHARMA-
COLOGICAL
THERAPY
 The first line anti-tuberculosis medications include:
 Isoniazid (INH). INH is a bactericidal agent that is used as
prophylaxis for neuritis, and has side effects of peripheral neuritis,
hepatic enzyme elevation, hepatitis, and hypersensitivity.
 Rifampin (Rifadin). Rifampin is a bactericidal agent that turns the
urine and other body secretions into orange or red, and has common
side effects of hepatitis, febrile reaction, purpura, nausea, and
vomiting.
 Pyrazinamide. Pyrazinamide is a bactericidal agent which increases
the uric acid in the blood and has common side effects of
hyperuricemia, hepatotoxicity, skin rash, arthralgias, and GI
distress.
 Ethambutol (Myambutol). Ethambutol is a bacteriostatic agent that
should be used with caution with renal disease, and has common
side effects of optic neuritis and skin rash.

20. TREATMENT
OF
TUBERCULOSIS
IN
SPECIAL
CASES
 Pregnancy: Always ask a woman if she is pregnant before
commencing treatment, most of anti-TB is safe during pregnancies
except streptomycin, which causes permanent deafness in the foetus
therefore it should be avoided during pregnancy
 Breastfeeding: Full TB treatments are safe and are best way to
prevent tuberculosis in the baby mother and child can stay together
for the entire duration of treatment. In the mothers with pulmonary
tuberculosis, the baby should receive INH preventive (5mg/kg) for
6months followed BCG vaccination
 Oral contraceptives: Rifampicin interacts with oral contraceptives
and reduces the efficacy of this contraception. Women using
contraceptive should be advised to use pills with higher dose of
oestrogen (50mcg) or change to another method

21.  Liver disease: Most of anti-TB can cause liver damage. In case a
patient develops jaundice, treatment should be stopped and restarted
as soon as the jaundice resolves. In severely ill patients start
streptomycin and ethambutol only. If the patient improves follow
with a gradual step up introduction of isoniazid followed by
rifampicin until full dose. Monitor liver functions and clinical
picture. If the condition deteriorates stop the drug which was added.
Patients with established chronic liver disease should not receive
pyrazinamide
 Renal failure; Isoniazid, Rifampicin and Pyrazinamide are almost
entirely excreted by the liver and therefore safe to use. Streptomycin
and Ethambutol are excreted by the kidneys and should either be
avoided or given in a reduced dose. The safest regimen for patients
with renal failure is 2 RHZ/4 RH combined with pyridoxine to
prevent Isoniazid induced peripheral neuropathy

22.  HIV/AIDS: There is a danger of interaction between Rifampicin
and protease inhibitors in HIV positive patients receiving anti
retroviral (ARV) treatments. Rifampicin stimulates the activity of
the liver enzyme system, which metabolises protease inhibitors (PI)
and Nucleoside Reverse Transcriptase Inhibitors (NRTIs). This can
lead to decreased blood levels of PIs and NsRTIs. Of the NsRTIs
the concentration of Nevirapine is significant reduced and hence
Nevirapine and Rifampicin should not be used concomitantly. On
other hand PIs enhance the liver enzyme system which influences
the blood levels of rifampicin resulting in ineffective TB treatment
or drug toxicity. NRTIs can cause peripheral neuropathy, which can
result in an added toxicity caused by Isoniazid.

23. MDR-TB
 Multi drug resistance Tuberculosis: MDR TB is a laboratory
diagnosis confirmed after culturing
 Mycobacterium tuberculosis strains and performing drug
susceptibility tests (DST). Resistant strains will be identified
because they will be able to survive exposure to anti TB drugs
which were previously toxic to them. Four different categories of
drug resistance have been identified:
 Mono-resistance: Resistance to one anti-tuberculosis drug
 Poly-resistance: Resistance to more than one anti-tuberculosis drug,
other than both isoniazid and Rifampicin (e.g. against both
pyrazinamide and isoniazid)
 Multidrug-resistance: Resistance to at least isoniazid and
rifampicin
 Extensive drug resistance TB (XDR-TB): Multi drug resistance
with additional resistance to any fluoroquinolone, and at least one
of three injectable second-line drugs (capreomycin, kanamycin and
amikacin

24.  Diagnosis of MDR –TB: The required baseline investigations of
any DR -TB suspect include:
• Comprehensive medical history including outcomes of prior TB
treatment
• Physical examination
• Collection of 2 sputum samples (spot – morning) for smear
microscopy, culture and DST
• Provider Initiated Testing and Counselling (PITC) for HIV
• Chest X-ray examination
 DST confirmed MDR TB patients shall be referred and transported
by a special ambulance to the MDR TB Hospital where they will be
admitted

25. TREATMENT
OF
MDR-TB
 Standardized treatment: Regimens are designed according to
representative Drug Resistance Well-defined patient populations.
All patients in a patient group or category receive the same regimen
. Suspected MDR TB should be confirmed by DST whenever
possible.
 Intensive Phase (minimum 6 months, or 6 months post culture
conversion) :
 Amikacin or Kanamycin
 Ofloxacin or Levofloxacin
 Pyrazinamide
 Ethionamide
 Cycloserine
 Ethambutol

26.  Continuation Phase (minimum 12 months or 18 months post culture
conversion)
 Ofloxacin or Levofloxacin
 Ethionamide
 Pyrazinamide
 Cycloserine
 Ethambutol

27. PATIENT
EDUCATION
 Disposal of secretions. Cough and sneeze into tissues and to
dispose of all secretions in a separate trash can.
 Isolation. Wear a mask when going outside of the room.
 Activity and nutrition. Remind the patient to take a lot of rest and
to eat balanced meals to aid recovery.
 Adverse effects. Advise the patient to watch out for adverse effects
of medications and to report them to the physician immediately

28. THANK YOU