Introduction:

Infects one third of world population..! responsible for 8 to 12 million cases of active tuberculosis each year, 3 million deaths due to TB every year Under privileged population Crowding, Poverty, malnutrition, single male..! economic burden. Since 1985 incidence is increasing in west AIDS, Diabetes, Immunosuppressed patients, Drug resistance.

TB in the United States

From 1953 to 1984, reported cases decreased by approximately 5.6% each year From 1985 to 1992, reported cases increased by 20% 25,313 cases reported in 1993 Since 1993, cases are steadily declining
2

Factors Contributing to the Increase in TB Cases

HIV epidemic Increased immigration from highprevalence countries Transmission of TB in congregate settings (e.g., correctional facilities, long term care) Deterioration of the public health care infrastructure
3

Sites of TB Disease
Pulmonary TB occurs in the lungs
85% of all TB cases are pulmonary

Extrapulmonary TB occurs in places other than the lungs, including the:

Larynx Lymph nodes Brain and spine Kidneys Bones and joints

Miliary TB occurs when tubercle bacilli enter the bloodstream and are carried to all parts of the body
4

Not Everyone Exposed Becomes Infected

Probability of transmission depends
on:
Infectiousness Type of environment Length of exposure

10% of infected persons will develop TB disease

5

Persons at Risk for Developing TB Disease

Persons at high risk for developing TB disease fall into 2 categories
Those who have been recently infected Those with clinical conditions that increase their risk of progressing from LTBI to TB disease

Recent Infection as a Risk Factor

Persons more likely to have been recently infected include Close contacts to persons with infectious TB Skin test converters (within past 2 years) Recent immigrants from TB-endemic areas (within 5 years of arrival to the U.S.) Children 5 years with a positive TST Residents and employees of high-risk congregate settings (e.g. correctional facilities, homeless shelters, healthcare facilities)
7

Increased Risk for Progression to TB Disease

Persons more likely to progress from LTBI to TB disease include HIV infected persons Those with history of prior, untreated TB Underweight or malnourished persons Injection drug use Those receiving TNF- antagonists for treatment of rheumatoid arthritis or Crohns disease Certain medical conditions

Latent TB Infection (LTBI)

Occurs when person breathes in bacteria

and it reaches the air sacs (alveoli) of lung Immune system keeps bacilli contained and under control Person is not infectious and has no symptoms
9

TB Disease
Occurs when immune system cannot keep bacilli contained
Bacilli begin to multiply rapidly Person develops TB symptoms

10

LTBI vs. TB Disease

LTBI TB Disease
Tubercle bacilli in the body TST or QFT-Gold result usually positive Chest x-ray usually normal Sputum smears and cultures negative No symptoms Chest x-ray usually abnormal Symptoms smears and cultures positive Symptoms such as cough, fever, weight, loss

Not infectious
Not a case of TB

Often infectious before treatment

A case of TB
11

Transmission and Pathogenesis of TB

Caused by Mycobacterium tuberculosis (M. tuberculosis) Spread person to person through airborne particles that contain M. tuberculosis, called droplet nuclei Transmission occurs when an infectious person coughs, sneezes, laughs, or sings Prolonged contact needed for transmission 10% of infected persons will develop TB disease at some point in their lives
12

Once organisms have made their way into the lung

host response can be completely effective and kill all bacilli no developing tuberculosis the organisms begin to multiply and grow immediately after infection primary tuberculosis bacilli may become dormant and never cause disease at all latent infection the latent organisms can eventually begin to grow reactivation tuberculosis

Binding of M. tb to Monocytes and Macrophages

Through complement receptors CR1, CR3, and
CR4 mannose receptors (MMRc) mediated through the mycobacterial surface glycoprotein lipoarabinomannan (LAM) CD 14 SP-A scavenger receptors ligand for

Fate of M. tuberculosis after Phagocytosis

They are subject to killing via a variety of mechanisms: Phagosome-lysosome fusion Generation of reactive oxygen intermediates Generation of reactive nitrogen intermediates, particularly nitric oxide Mycobacteria have ability to evade killing by macraphage

Phox : phagocyte NADPH oxydase

phox

O2
NADPH

O2NADPH+ + H2 O H2O2 + OH* ClHOCl- + OH* MPO antibacterial

O2 H 2 O2

LPS IL-1 TNF IFN-

INOS

Deaminasi oxydative L-arginin

NO + H2O2

NO + Thiol groups

peroxynitrit

nitrosothiol

Other immune cells help macrophage in controlling growth of mycobacteria

Cytotoxic T-lymphocytes - can ingest macrophages that have engulfed mycobacteria - secrete small proteins such as TIA-1 apoptosis

Microbiology of TB:
Mycobacteria fungus like.. Bacilli, Aerobic, non motile, no toxins, no spore. Mycolic acid wax in cell wall Carbol dye - Acid & alcohol fast (AFB) M. tuberculosis & M. bovis M. avium, M.intracellulare in AIDS Atypical TB

Properties of Mycobacterium spp. Acid-fast rods Cells are hydrophobic (they grow in clumps or at the surface of media) Cells are more resistant than other vegetative cells to: Acid Base Chemicals (5% phenol) Drying

AFB - Ziehl-Nielson stain

Colony Morphology LJ Slant

PPD Tuberculin Testing

Sub cutaneous Weal formation Itching no scratch. Read after 72 hours. Induration size. 5-10-15mm (nonende) < 72 hour is not diag* +ve after 2-4 weeks. BCG gives + result.

PPD result after 72 hours.

Groups to Target with the Tuberculin Skin Test

Persons with or at risk for HIV infection
Close contacts of persons with infectious TB Persons with certain medical conditions

Injection drug users

Foreign-born persons from areas where TB is common Medically underserved, low-income populations

Residents of high-risk congregate settings

Locally identified high-prevalence groups
29

Administering the TST

Use Mantoux tuberculin skin test
0.1 mL of 5-TU of purified protein derivative (PPD) solution injected intradermally Use a 27 gauge needle Produce a wheal that is 6-10mm in diameter
30

Reading the TST

Read within 48-72 hours Measure induration, not erythema Positive reactions can be measured accurately for up to 7 days Negative reactions can be read accurately for only 72 hours

31

TST Interpretation - 1
5 mm of induration is positive in:
HIV-infected persons Close contacts to an infectious TB case Persons who have chest x-ray findings consistent with prior untreated TB Organ transplant recipients Persons who are immunosuppressed (e.g., those taking the equivalent of >15 mg/d of prednisone for 1 month or those taking TNF- antagonists)
32

TST Interpretation - 2
10 mm induration is positive in:
Recent immigrants (within last 5 years) from a high-prevalence country Injection drug users Persons with other high-risk medical conditions Residents or employees of high-risk congregate settings Mycobacteriology laboratory personnel Children < 4 years of age; infants, children, and adolescents exposed to adults at high risk
33

TST Interpretation - 3
15 mm induration is positive in:

Persons with no known risk factors for TB

34

Evaluation for TB
Medical history
Physical examination

Mantoux tuberculin skin test

Chest x-ray Bacteriologic exam (smear and culture)
35

Symptoms of TB
Productive prolonged cough* Chest pain* Hemoptysis* Fever and chills Night sweats Fatigue Loss of appetite Weight loss
36

*Commonly seen in cases of pulmonary TB

Chest x-Ray
Obtain chest x-ray for patients with positive TST results or with symptoms suggestive of TB

37

Sputum Collection
Sputum specimens are essential to confirm TB
Specimens should be from lung secretions, not saliva

Collect 3 specimens on 3 different days Spontaneous morning sputum more desirable than induced specimens Collect sputum before treatment is initiated
38

Smear Examination
Strongly consider TB in patients with smears containing acid-fast bacilli (AFB) Use subsequent smear examinations to assess patients infectiousness and response to treatment

39

Culture
Used to confirm diagnosis of TB
Culture all specimens, even if smear is negative Initial drug isolate should be used to determine drug susceptibility
40

Drugs Sensitivity Testing

(DST)

Mengetahui tingkat kepekaan isolat kuman terhadap antibiotik Banyak metode, sesuaikan dengan kuman isolat

 Sumber referensi klinisi Acuan pemilihat obat Studi epidemiologi - MDR TB - XDR TB

Uji Resistensi kuman TB Ada 2 pendekatan 1. Uji fenotipik - pengujian fakta biologis kuman TB 2. Uji genotipik - keberadaan gen gen penyandi sifat resisten kuman : rpoB , inhA, katG gyrA

Di Indonesia : 1. Cara proporsi 2. Cara konsentrasi absolut 3. Cara rasio resisten 4. Cara media cair 5. Cara deteksi netabolit 6. Cara mycobacteriophaga 7. Deteksi gen penyandi sifat resisten

Uji resistensi cara proporsi -Angka proporsi resisten (pR) jml koloni pada medium + obat Jml koloni pada medium tanpa obat

x100 %

Jika pR < 1% dinyatakan sensitif Jika pR 1% dinyatakan resisten

Untuk menilai pR
- dipakai angka tertinggi jml koloni kuman pada media bebas obat.

- untuk medium yang mengandung obat pilih pengenceran yang menghasilkan jml koloni 20 200, jika tidak ada pilih pengenceran yang menghasilkan jml koloni 5 - 19

Yang perlu dipersiapkan 1. Suspensi kuman a. Suspensi kuman konsentrasi 1mg / ml b. Suspensi kuman konsentrasi 0,5 1,0 standart Mc Farland. Buat seri pengenceran 10-3 dan 10-5 (estimasi jml koloni 104 dan 102 kuman per ml )

2. Medium LJ dengan OAT

Isoniazid (INH) Streptomycin (S) : 0,2 g/ml
: 4 g/ml

Rifampicin : 40 g/ml Ehambutol : 2 g/ml 3. Medium LJ tanpa OAT

Perlakuan 1. Untuk setiap OAT diapkan 6 botol LJ (4 botol tanpa obat dan 2 botol dengan obat) 2. Dari 4 botol tanpa obat, 2 diinokulasi suspensi kuman pengenceran 10-3 dan 2 ditanami pengenceran 10-5 3. Pembacaan hasil dikaukan pada hari ke 28 dan 42 (kontrol)

4. Skala pembacaan hasil

Pembacaan >500 koloni 200-500 koloni 100-200 koloni 20-100 koloni 1-19 koloni Tidak pertumbuhan

Pencatatan 4+ 3+ 2+ 1+ Tulis jml koloni 0

5. Pembacaan hasil

Suspensi (1mg/ml 107/ml Media tanpa obat pengen(Estimasi ceran kuman)

Media dgn obat (mg/lt)

S(4) H(0) R(4) E(2)

10-1 10-2 10-3 10-4 10-5

( 106) ( 105) ( 104) ( 103) ( 102) pR

3+ , 4+ 4+(>500
)

3+

2+

35 ,45 45

12

20

<0,1 27% %

0,2% 44,4 %

interpretasi

S(1) pada 10-3, H(12) pada 10-5, R(8) pada 10-3 , E(20) pada 10-5

Perhitungan Streptomycin Isoniazid Rifampicin Ethambutol

+(500) 12/45 8/4+(500) 20/45

<0,1% (S) 27,0% R) 0,2% (S) 44,4%(R)

Uji Rasio Resiten

Menggunakan medium padat (LJ) Penentuan resisten dilakukan dengan membandingkan dengan kuman standart H37Rv Medium LJ dengan obat dengan berbagai konsentrasi Resistensi dinyatakan dengan : A . H37Rv. B% Jika nilai A > 4 dinyatakan resisten Jika nilai B > 1% dinyatakan resisten

Medium LJ dengan obat yang dipakai Streptomycin : 1 , 10 dan 100 g/ml Isoniazid : 0,1 , 1 dan 10 g/ml Rifampicin : 2,5 ; 5 ; 10 dan 20 g/ml Ethambutol : 1 ; 10 dan 100 g/ml

Uji kepekaan M.tb terhadap streptomycin

LJ dgn obat

0 g/ml kontrl 300

1 g/ml

10 g/ml 100g/ml

Sampel penderita H37 Rv

200

150

80

200

100

Resisten A x H37Rv (B%) Resisten 100 x H37Rv (26%)