02/07/2020

1:30-4:00 Tuberculosis
TTh Preventive, Community, and Family Medicine
LDT 301 Adrian Dominic Deocadez & Krizza Isabelle Sigaya

OUTLINE  Lungs: most commonly affected organ

 Other organs (e.g. spine, brain, kidney): can also be the site of
I. Font AnatB1 should be Arial, size 9 infection  Extrapulmonary TB
II. Do not use all caps  Has the ability to remain dormant for years without causing
III. Do not forget to include References in your symptoms or spreading to other people.
outline o When the immune system of a patient with dormant TB is
weakened, either due to DM or HIV, the disease can
reactivate and cause infection
 Low-grade fever is usually manifested in the afternoon or at night
CASE SCENARIO
Who are at Risk?
Case 1

1. Persons who have been recently infected with TB bacteria

Ina Pe, a 34-year old housewife from Pavia, calls up her family  E.g. close contacts of a person with infectious TB disease,
doctor early one evening. She claims she has been having bouts of persons who have immigrated from areas of the world with
excessive coughing for the past 4 days. She noted would spit out high rates of TB
2. Persons with medical conditions that weaken the immune
blood-tinged phlegm whenever she coughs. On the day when she
system
called her doctor, she was coughing out blood and blood clots. She
 E.g. babies and young children with weak immune system,
claimed she also felt febrile. Her doctor requests that she have a
substance abuse (smoking, alcohol abuse)
chest X-ray taken that night and consult him in the morning.

Past medical history revealed she had been diagnosed with INCIDENCE
pulmonary tuberculosis in 2013. She had tested +2 on sputum AFB.
She was on 6 months of anti-TB medications. She did not return to  Incidence rate per 100,000 in the Philippines is 554. No change in
her doctor upon completing her regimen. the incidence rate is noted from the year 2016 until 2018. (WHO
Global Tuberculosis Report, 2019)
She is a mother to 3 children ages 9,7 and 5 years old. Her  Higher incidence rate is observed in males, specifically those
husband is a seaman who is presently abroad. A female household belonging in the age groups of 15-24 years old and 45-54 years
help has been living with them for the past year. That household old. (WHO Global Tuberculosis Report, 2019)
help was also having bouts of cough when she fell ill. Her last  Five risk factors to which TB cases were attributed to (WHO
menstrual period was December 2019. She claims she has a Global Tuberculosis Report, 2019):
o Undernourishment (highest incidence rate)
regular monthly period.
o Smoking
Upon seeing the woman the following morning, physical o Harmful use of alcohol
examination revealed a fair-complexioned woman, with the o Diabetes
following vital signs: BP= 80/60 mmHg, heart rate of 86 per minute, o HIV
respiratory rate of 24 per minute, temperature of 37.5 degrees
Celsius, weight of 40 kilograms, height of 1.60 meters. She had ETIOLOGY
pinkish conjunctivae, slightly hyperemic tonsillopharyngeal area,
fine crackles more on the left side as compared to the right. The Mycobacterium tuberculosis
patient is anxious about her illness
 One of the most common mycobacterial human pathogens
Case 2 worldwide
 Causes tuberculosis
Fe Pe is the 7-year-old daughter of Ina Pe. She is evaluated for  (in tissue) Thin, straight rods
prolonged fever and cough which started 7 days before her mother  Acid-fast: due to organism’s high content of mycolic acid
fell ill. A Mantoux (5 tuberculin units) test produces 22 mm of  Highly susceptible: humans, guinea pigs
induration at 72 hours. A chest x-ray is reported probably normal,  Resistant: fowl, cattle
the radiological notes poor inspiration and vessel crowding.
INCUBATION PERIOD
She had Bacille Calmette-Guerin at birth, and the mother believes
this is the likely cause of her positive test. She is hepatitis B surface
 Vary between 2 to 12 weeks
antigen negative.
 Latent infection may be many decades
INTRODUCTION
MODE OF TRANSMISSION
Tuberculosis
 Mycobacteria are emitted in the form of airborne droplets (<
25μm in diameter)
 Caused by Mycobacterium tuberculosis

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  Portal of exit: mouth and nose when infected persons cough, o Lymphadenopathy
sneeze, or speak. o Cutaneous lesions
 Portal of entry: inhaled through the nose and mouth, and droplet  Lymphadenopathy in TB
nuclei travels from either the nasal passages or the mouth → o Occurs as painless swelling of 1 or more lymph nodes
upper respiratory tract → bronchi → alveoli of the lungs o Usually bilateral
 Four factors that determine the probability of M. tuberculosis o Frequently involves the anterior and posterior cervical chain or
Transmission (CDC, 2014): supraclavicular nodes.
o Susceptibility  TB in young children
 Depends on the immune status of exposed individual o Almost invariably accompanied by hilar or paratracheal
o Infectiousness lymphadenopathy due o the spread of bacilli form the lung
 Directly related to the number of tubercle bacilli expelled parenchyma through lymphatic vessels.
in the air. The more tubercle bacilli expelled, the more  The absence of any significant physical findings does not exclude
infectious active TB
o Environment  Classic symptoms are often absent in high-risk patients,
 Factors that affect concentration of M. tuberculosis particularly those who are immunocompromised or elderly
organisms
o Exposure DIFFERENTIAL DIAGNOSIS
 Proximity, frequency, duration of exposure
Case 1:
IMMUNITY & HYPERSENSITIVITY
Differentials Rule in Rule out
 During infection, a development of cellular immunity is formed  Dyspnea
 Development of hypersensitivity occurs in primary infection, by  Fever  Recurring
providing a positive tuberculin test Lung cancer  Cough infections
o Tuberculin: extracted protein from the M. tuberculosis used to  Hemoptysis  Bone Pain
determine one’s exposure to tuberculosis  Finger clubbing
o Positive tuberculin test:
 Shortness of
 Is observed within 4-6 weeks of infection breath
 Indicates that the individual acquired the infection in the
 Lumps on the
past
 Cough neck and face
 Does not imply active disease Actinomycoses
 Fever  Draining sores on
 At risk of developing disease from reactivation of the
skin
primary infection
 Excess sinus
APPROACH TO DIAGNOSIS drainage
Bronchiectasis  Fever  Dyspnea
History  Cough  Shortness of
 Crackles breath
 Hemoptysis  Clubbing of
 Classic clinical manifestation/s fingers
o Cough at least 2 weeks duration and associated features:
 Nausea
 Weight loss  Crackles
 Shortness of
 Fever (often low-grade and intermittent)  Fever
Pneumonia breath
 Bloody sputum or hemoptysis  Cough
 Pleuritic chest
 Chest pain  Hemoptysis
pain
 Easy fatigability or malaise
 Night sweats  Slightly hyperemic  Swollen lymph
 Shortness of breath/difficulty of breathing tonsillopharyngeal nodes
Viral Pharyngitis area  Mouth ulcers
Physical Examination  Cough
 Fever
 Tachycardia
 Pallor and finger clubbing may be observed
 Foul or bloody
 Patients with pulmonary TB have abnormal breath sounds  Crackles sputum
(especially over the upper lobes or involved areas)
Lung Abscess  Fever  Bluish
o Rales in the involved areas during inspiration , especially after
 Cough discoloration of
coughing
skin
o Occasionally, rhonchi due to partial bronchial obstruction
o Classic amphoric breath sounds (low pitch bronchial breath
Tuberculosis  History of
sound with high pitch overtones) in areas with large cavities.
Tuberculosis last
 Accumulations of pleural fluid, or pleural effusions, is seen in 2013, with AFB
patient with tuberculosis sputum result of +2,
 Signs of extra pulmonary TB differ according to the tissues in which patient
involved. They may include the following: was on anti-TB
o Neurologic deficit drugs for 6 months
o Coma  May have been
o Confusion exposed to an
o Chorioretinitis undiagnosed TB
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 patient for the past  Works by having a “treatment partner” watching the patient
year (household take medicines everyday during the whole course of treatment,
help) from intensive to maintenance phase.
 Excessive cough o Staff of the health department
 Fever o Person who is respected by the patient
 Hemoptysis o BHW
 Fine crackles o Family member
 Slightly hyperemic  Success rate is 88% with case detection rate of 48% meeting
tonsillopharyngeal the global targets of 75% detection rate and 87% success rate
area
(extrapulmonary Summary of recommended treatment regimen and dose of anit-
tuberculosis) TB drugs

Impression: PTOU (Previous Treatment Outcome Unknown) of

Tuberculosis, to rule out MDR-TB
*See Appendix
CASE 2:
Legend:
H- Isoniazid
Differentials Rule in Rule out
R- Rifampicin
 Positive tuberculin
Z- Pyrazinamide
test E- Ethambutol
 Cough S- Streptomycin
Pulmonary
 Fever
Tuberculosis
 TB exposure (close *Note: For TB meningitis in adults, ethambutol should be
contact of a known replaced by streptomycin (WHO Tuberculosis Guidelines)
active TB case)
 shortness of Drug dosage per kg body weight single drug formulations (if
 Positive tuberculin breath using SDFs)
Nontuberculosis test  fatigue
mycobacteria  Cough  weight loss
*See Appendix
 fever  hemoptysis
 night sweats
Monitoring and Evaluation of Patients under Treatment
Pneumonia  Fever  shortness of
 Cough breath
 Chest pain when  Schedule of sputum follow-up and adverse drug reaction of
you breathe or patients receiving anti-TB medications must be closely
cough monitored
 Fatigue  Closer follow-up given to Category 2 - possiblity for MDR TB
 Nausea  Currently, most TB patients are treated on an out-patient basis.
 Vomiting  Patients recommended for hospitalization:
 Diarrhea o Massive hemoptysis
 Fever  runny nose o Pleural effusion obliterating more than half of the lung field
Bronchiolitis  Cough  stuffy nose o Miliary TB
o TB meningitis
o TB pneumonia
o Those requiring surgical intervention or with complications
 Once Adverse Drug Reaction has resolved, anti-TB drugs are
Impression: Pulmonary Tuberculosis, Category 1 reintroduced one by one following this schedule:

APPROACH TO MANAGEMENT OF TUBERCULOSIS *See Appendix

 TB case holding- set of procedures used by the NTP to Guideline in managing the side effects of anti-TB drugs
manage the TB disease
 Includes the following:  Minor side effects: Patient should be encouraged to continue
o Assignment of the appropriate treatment regimen based taking medicines with minor side effects
on the diagnosis and previous history of treatment
o Supervision of drug intake with support to patients  Major side effects: May necessitate withdrawal of responsible
o Monitoring of response to treatment through follow-up drug, may need to switch to SDF
sputum smear microscopy
*See Appendix for list of side effects
Directly Observed Treatment Short-course (DOTS)
Treatment outcomes for Drug-susceptible TB cases
 Strategy developed to ensure treatment compliance by
providing constant and motivational supervision to TB patients  Cured
with positive sputum

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 o Bacteriologically-confirmed patient who has smear or
culture negative test in the last month of treatment and on
at least one previous occasion in the continuation phase
 Treatment completed
o Bacteriologically-confirmed or clinically-diagnosed patient
who has completed the treatment without evidence of
treatment failure but does not have any record to show
status of sputum exam in the last month of treatment or on
at least one previous occasion
o Group includes:
 DSSM-positive patients who initially completed
the treatment without follow-up sputum
examinations during the treatment or with only
one negative sputum examination the last
month of treatment
 Sputum-negative patient who has completed
the treatment
 Died
o Died from any reason during the course of treatment
 Lost to follow-up
o Patient whose treatment was interrupted for two
consecutive months or more
 Not evaluated
o Patient for whom no treatment outcome is assigned
o Includes cases transferred to another DOTS facility and
whose treatment outcome is unknown
CONTROL AND PREVENTION MEASURES
 Avoidance of exposure and infection or reinfection- basic goal
for preventing TB disease
 For vulnerable populations- aim is preventing progression to
TB disease
o Young children (0-4 years old)
o People living with HIV (PLHIV)
A. Occupational/ Household control measures
 Administrative control 
o Constitutes measures that will reduce the risk of TB
transmission by preventing the generation of droplet
nuclei or reducing exposure to droplet nuclei
o Type of control that has the greatest impact on preventing
the spread of TB
o Examples include:
 Promptly identifying people with TB
symptoms
 Separating or isolating infectious patients
 Controlling spread of pathogens through
cough etiquette
 Reducing diagnostic delays
 Minimizing the time spent by patients in
the health facility
 Initiating early treatment for TB patients
 Providing a package of prevention,
treatment, and care interventions for staff,
including HIV prevention
 Environmental control
o Measure that will reduce the concentration of infectious
droplets in the air especially in areas where air
contamination is likely
o Examples include:
 Opening windows and doors to improve
natural ventilation
 Placing or rearranging furniture and
seating such staff- patient interaction
occurs with airflow passing from staff to
patient rather than from patient to staff
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 Ensuring that fans are clean and working
properly
 Respiratory protection controls
o Measures that involve selection and proper use of
respirators to protect one from inhaling droplet nuclei
o Respirators that meet or exceed the NIOSH-certified N95,
CE-certified FFP2 standards shall be used
 Household measures
o Measures that healthcare workers advise to TB patients
o Examples include:
 Importance of early detection and
treatment of TB with prompt screening of
household contacts
 Cough etiquette
 Minimizing time spent by infectious TB
patients in crowded public places
 Opening windows and removing any
obstruction to ventilation in rooms where
TB patient sleeps or spends much time
B. In the Philippines, the universal use of BCG at the birth of a child
was also included in the Expanded Program of Immunization
C. Isoniazid preventive therapy (IPT)
 Children qualified for IPT could be identified through
household contacts with positive TB disease
 Given for 6 months and is indicated for the following conditions:
o Children 0-4 years old 
 Without signs and symptoms of TB and
without radiographic findings suggestive
of TB
 Household contacts of bacteriologically-
confirmed TB case regardless of TST
results and a clinically-diagnosed TB case
o PLHIV with no signs and symptoms of TB regardless of
age
 IPT Instructions:
o After ruling out any signs and symptoms suggestive of TB,
INH should be started at 10 mg/kg. 
o If the child gains weight during the follow-up visits, the
dosage of INH must be adjusted accordingly
o Child should be assessed at least every 2 months and
checked for presence of signs and symptoms of TB 
o If the child develops any signs or symptoms, the physician
should evaluate for TB disease using the aforementioned
procedure. 
o If assessed positive, IPT should be stopped, and regular
treatment started.
Special Issues and Concerns
 TB and Diabetes Mellitus
o Two to three times higher risk of TB compared with those
without diabetes
o Rifampicin- adversely alters glycemic control by lowering
the concentrations of most oral anti-diabetic drugs
o Poor glycemic control is an important contributing factor to
tuberculosis case fatality and relapse
 TB and HIV 
o People newly diagnosed with HIV should be tested for TB
infection as soon as possible
o People living with HIV and at ongoing risk for TB exposure
should be tested annually
o People with HIV and latent TB infection are at much higher
risk of progressing to active TB disease than people with
latent TB infection alone
Page 4 of
  Identify the nearest DOTS center on the locality
CASE RESOLUTION  Layman’s forum on the early consultation for prolonged history
of cough in a member of the family
Case 1  Barangay leaders must emphasize the importance of
environmental of environment sanitation and wearing personal
Patient is classified as a Category 2 because she has been protective equipment for those workers handling garbage
previously treated as drug susceptible Pulmonary Tuberculosis and  Clean air act and no smoking law must be enforced
was given 2 month HRZES then 1 month HRZE for Internsive
phase and 5 months HRE for Continuation phase. She was given
SOURCES
health teaching on the different adverse effects she could possibly
have and to seek consult if major problems arise. She was advised
 Centers for Disease Control and Prevention website
to avoid alcohol and have a well balanced diet as well as adequate
 Centers for Disease Control and Prevention. (2014). Chapter 2:
sleep to strengthen her immune system. Direct sputum smear
Transmission and Pathogenesis of Tuberculosis. Core
microscopy must be followed-up to monitor the treatment of patient.
Curriculum on Tuberculosis: What the Clinician Should Know.
 Jawetz, Melnick, & Adelberg’s Medical Microbiology, 28e
Case 2
 Textbook of family medicine, vol 2, leopando et al
World Health Organization website
FP is classified as a Category 1 new case. She is advised to go on
an intensive phase for treatment that is 2 months HRZE. The
number of tables to be taken will vary depending on the weight of
FP. These anti-TB drugs elicit particular side effects; thus, FP must
be encouraged to continue on taking here medication even with the
side effects.

SUMMARY OF CARE AND APPROACHES

Patient-centered

 Focused history and PE

 Appropriate medical management- DOTS- to the patient
 Supportive management
o Rest
o Monitoring of anti TB-treatment
o Diet intake 
 Increase patient’s knowledge and awareness regarding the
natural history of the disease
 Alert patient on the signs and symptoms that will require
immediate admission to the hospital
 Remind patient regarding sputum follow-up and regular consult
to the DOTS center
 Immunization for influenza and pneumococcal vaccines must
be encouraged
 Teach patient on the proper handling of sputum and cough
etiquette
 Encourage ventilation of feeling of patient that will alleviate the
patient’s stress including fear of the possible complications and
stigma of the disease and the possibility of infecting others

Family-focused

 Family health education 

 Signs and symptoms that will alert the family to bring the sick
member to the physician
 Preventive measures
 Advice against self-medication of anti-TB drugs to all members
 BCG vaccination for newborn influenza and pneumococcal
immunization
 Advice against smoking
 MD must seek the help of the family member close to the
patient to act as treatment partner

Community-oriented to community-based

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 02/07/2020
1:30-4:00 Tuberculosis
TTh Preventive, Community, and Family Medicine
LDT 301 Adrian Dominic Deocadez & Krizza Isabelle Sigaya

APPENDIX
AnatB1
Summary of recommended treatment regimen and dose of anti-TB drugs

Regimen(FDC) Type of TB patient Drugs and Weight Number of

duration of of tablets during
treatment patient the intensive
and
continuation
phase

Category 1 New cases of Intensive phase: 30-37 2 tablets 

bacteriologically- 2 months HRZE kg 3 tablets
confirmed or clinically- 38-54 4 tablets
diagnosed PTB Continuation kg 5 tablets
phase: 55-70
New case of 4 months HR kg
bacteriologically- >70 kg
confirmed or clinically-
diagnosed EPTB
except CNS/bones or
joints

Category 1A New case of EPTB in Intensive phase: 30-37 2 tablets 

CNS/bones or joints 2 months HRZE kg 3 tablets
38-54 4 tablets
Continuation kg 5 tablets
phase: 55-70
10 months HR kg 1 gm/day for at
>70 kg least 56 vials IM
ANST

Category 2 Previously treated drug Intensive phase: 30-37 2 tablets 

susceptible PTB or 2 months HRZES kg 3 tablets
EPTB except CNS then  38-54 4 tablets
bones or joints 1 month HRZE kg 5 tablets
55-70
Continuation kg 1 gm/day at least
phase: >70 kg 56 vials
5 months HRE

Streptomycin vial

Category 2A Previously treated drug Intensive phase: 30-37 2 tablets 

susceptible EPTB- 2 months HRZES kg 3 tablets
CNS/bones or joints then  38-54 4 tablets
1 month HRZE kg 5 tablets

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 55-70
Continuation kg 1 gm/day at least
phase: >70 kg 56 vials
9 months HRE

Streptomycin

Standard Confirmed cases of Standard regimen

Regimen Drug- rifampicin-resistant or DR
Resistant (SRDR) multidrug-resistant TB
Individualized
once DST(drug
susceptibility
testing) result is
available

Treatment
duration for at
least 18 months

Refer to DOTS
facility with
PMDT services

XDR TB Extensively drug- Individualized

Regimen resistant TB based on DST
result and history
of previous
treatment

Refer to DOTS
facility with
PMDT services

Drug dosage per kg body weight single drug formulation (if using SDFs)

Drug Adults Children

Isoniazid (H) 5 (4-6) mg/kg, not to exceed 300 10 (10-15) mg/kg, not to exceed 300
mg daily mg daily

Rifampicin (R) 10 (8-12) mg/kg, not to exceed 600 15 (10-20) mg/kg, not to exceed 600
mg daily mg daily

Pyrazinamide 25 (20-30) mg/kg, not to exceed 2 g 35 (30-40) mg/kg, not to exceed 2 g

(Z) daily daily

Ethambutol (E) 15 (15-20) mg/kg, not to exceed 1.2 20 (15-25) mg/kg, not to exceed 1.2 g
g daily daily

Streptomycin 15 (12-18) mg/kg, not to exceed 1 g 30 (20-40) mg/kg, not to exceed 1 g

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 (S) daily daily

Once Adverse Drug Reaction has resolved, anti-TB drugs are reintroduced one by one following this
schedule:

Drug Likelihood of causing a reaction Challenge doses

Day 1 Day 2  Day 3

Isoniazid Least likely 50 mg 300 mg Full dose

Rifampicin 75 mg 300 mg Full dose

Pyrazinamide 250 mg 100 mg Full dose

Ethambutol 100 mg 500 mg Full dose

Streptomycin Most likely 125 mg 500 mg Full dose

Minor side effects: Patient should be encouraged to continue taking medicines with minor side effects
Side effects Drug(s) primarily responsible What to do?

Gastrointestinal Rifampicin/Isoniazid/Pyrazinamid Give medication at bedtime or

intolerance e with small meals

Mild or localized skin Any drug Give antihistamine

reactions

Orange/ Red colored Rifampicin Reassure the patient

urine

Pain at the injection site Streptomycin Apply warm compress and

rotate the site of injection

Burning sensation of Isoniazid Take pyridoxine (Vitamin B6)

the feet due to 50-100 mg daily for treatment;
peripheral neuropathy 10 mg daily for prevention

Arthralgia due to Pyrazinamide Give aspirin or NSAID; if

hyperuricemia symptoms persist, consider
gout and give
allopurinol/febuxostat

Flu-like symptoms Rifampicin Give antipyretics

(fever, muscle pains,
inflammation of the
respiratory tract)

Major side effects: May necessitate withdrawal of responsible drug, may need to switch to SDF

Side effects Drug(s) primarily responsible What to do?

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 Severe skin rash due to allergy Any drugs especially Discontinue drugs and
streptomycin refer to specialist

Jaundice due to hepatitis Any drugs especially Isoniazid, Discontinue; if symptoms

Rifampicin, Pyrazinamide subside continue
treatment and monitor

Impairment in visual acuity and Ethambutol Discontinue Ethambutol

color vision due to optic neuritis and refer to
Opthalmologist

Hearing impairment, tinnitus, Streptomycin Discontinue Streptomycin

dizziness due to damage of the and refer to specialist
eighth cranial nerve

Oliguria, albuminuria due to Streptomycin/Rifampicin Discontinue the drugs and

renal problem refer to nephrologist

Psychosis and convulsion Isoniazid Discontinue Isoniazid and

refer to specialist

Thrombocytopenia, anemia and Rifampicin Discontinue Rifampicin

shock and refer to specialist

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