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Definition
Multisystemic disease caused by various strains
of
mycobacteria,
usually
Mycobacterium
tuberculosis.
Intrapulmonary (85%)
Extrapulmonary - TB lymphadenitis, pleural effusion,
genitourinary, bones/joints, military TB, meningitis
TB

In 2014, 9.6 million people fell ill with TB and

1.5 million died from the disease.
TB is a leading killer of HIV-positive people: in
2015, 1 in 3HIV deaths was due to TB.

Mycobacterium Tuberculosis

Etiology

Obligate aerobe
nonspore-forming
nonmotile
Rods shaped slender or
slightly curve
size 2-4 m x 0.2-0.5 m
Intaracellular
parasite
(monocyte/macrophaes)
Weak gram postive
Grow slowly (15-20 hrs)
Optimum T : 37 C
The
bacilli
cannot
be
decolorized by acid alcohol;
this characteristic justifies
their classification as acidfast bacilli

Transmission
spread primarily as an airborne
aerosol from an individual who is
in the infectious stage of TB
The following factors help to
determine whether a TB infection
is likely to be transmitted:
1.
2.
3.
4.

Number of organisms expelled

Concentration of organisms
Length of exposure time to
contaminated air
Immune status of the exposed
individual

Risk Factor

HIV infection
Intravenous (IV) drug abuse
Alcoholism
Diabetes mellitus (3-fold risk increase)
Immunosuppressive therapy
Cancer of the head and neck
Hematologic malignancies
End-stage renal disease
Low body weight - In contrast, obesity in elderly patients has
been associated with a lower risk for active pulmonary TB
Smoking - Smokers who develop TB should be encouraged to
stop smoking to decrease the risk of relapse [24]
Age below 5 years

Pathogenesis

Diagnosis
Clinical
- Sign and symptoms
Radiological (CXR)
Bacteriological evidence (Lab)
Mantoux test

Symptoms

Chest x-ray

Cor tidak membesar

Sinuses dan diafragma normal
Paru: hili kabur, corakan bronkovaskular bertambah.
Tampak bercak lunak di lapang apeks dan atas kedua paru.
Tampak bayangan opak noduler batas tidak tegas, irreguler di lapang atas karu
kanan.
Kesan: TB paru aktif dengan kavitas (moderate)

Cor tidak tampak membesar

Sinuses dan diafragma noral
Paru: hili kabur. Corakan
bronkovaskular normal. Tampak
bercak lunak kecil2, multiple, di
seluruh lapang kedua paru.

Sputum

Specimen collection
Best specimen comes from the lung, cough deeply from the
chest
Saliva or nasal secretions are unsatisfactory
3 sample required : spot morning - spot
Quality of
sputum

% AFB

SALIVA

4.9

SALIVA + MUCUS

7.7

MUCOPURULENT

19.2

PURULENT

39.1

Mantoux test

Suspect PTB
3x AFB sputum
AFB result
+++
++-

AFB result
+ --

AFB result
---

Abx non TB regime

CXR

worsenin
g

Improvin
g

3x AFB sputum
AFB result
+++
+++--

AFB result
--CXR

PTB
NOT PTB

Treatment Regimen
New
- Never had treatment for TB or taken anti-TB drug < 1 month
Relapse
- Declared cured > AFB +ve
Failure
- On treatment 5th month AFB still +ve
- On treatmen After 2 month AFB ve > +ve
Default
- Stop taking anti-TB treatment for > 2 month
Chronic
Fail category 2 treatment

Anti tuberculosis drug

1.
.
.
.
.
.

First line drugs:

Isoniazid (H) - bactericides
Rifampicin (R) - bactericides
Pyrazinimide (Z) - bactericides
Streptomycin (S) - bactericides
Ethambutol (E) - bacteriostatic

2.
.
.
.
.
.

Second line drugs:

Ethionamide
Quinolone
Amikacin, kanamycin
PAS
Macrolides

RECOMMENDED ANTITB
DRUGS

DRUG

RECOMMENDED DOSES
Daily
3X a week
Dose
Maximum Dose
Maximum
(range) in in mg
(range) in in mg
mg/kg
mg/kg
body
body
weight
weight
5 (4 - 6)
300
10 (8 - 12)
900

Isoniazid
(H)
Rifampicin 10 (8 - 12)
(R)
Pyrazinami
25 (20 de (Z)
30)
Ethambuto
15 (15 l (E)
20)

600

10 (8 - 12)

600

2000

35 (30
40)*
30 (25
35)* 17

3000*

1600

2400*

Weight
(kg)

Intensive phase (2
month)
Akurit 4
(H 75mg + R 150mg + Z
400mg + E 275mg)

Maintenance phase (4
month)
Akurit Tablet
(H 75mg + R 150mg)

30 - 39

2 tablet daily

2 tablet daily

40 - 54

3 tablet daily

3 tablet daily

55 - 70

4 tablet daily

4 tablet daily

> 70

5 tablet daily

5 tablet daily

Phase
Intensive phase
- In 2 weeks no more transmission
- In 2 months; AFB +ve > -ve
Maintenance phase
- Kill dormant bacteria
- To prevent relapse

Category
Category 1
- 2RHZE/4(RH)3
- New case and extrapulmonary
Category 2
- 2 RHZES/RHZE/5(RHE) 3
- relapse, failure, default

CATEGORY 1 (new case and extrapulmonary)

2RHZE/4(RH)3
2nd MONTH (Intensive
phase)
AFB +ve

RHZE + 1 month

CURED

Repeat AFB

Previously
AFB ve > +ve

AFB -ve

FAILURE

Continue to
Maintanance
phase

CATEGORY 2

5 MONTH

FAILURE

Repeat AFB

AFB +ve

AFB -ve

CATEGORY 2 (relapse, failure, default)

2 RHZES/RHZE/5(RHE) 3
3rd MONTH (Intensive
phase)
AFB +ve

Repeat AFB
AFB -ve

RHZE + 1 month

Continue to
Maintanance
phase

Drug Sensitivity
Test

7 MONTH

CHRONIC/ MDR-TB

Repeat AFB

AFB +ve

CURED

AFB -ve

Side effect

Drugs responsible

MINOR

Management
CONT. TB DRUG

Anorexia, nausea,
abdominal pain

H,R,Z

Give drug with small

meal or before bed
time.

Joint pains

Pyrazinamide

Aspirin or PCM

Burning, numbness
sensation in the
hand/feet

Isoniazide

Pyrodixine 50-75mg
OD

Orange/red urine

Rifampicin

Reassurance.

MAJOR

STOP TB DRUG

Deafness/ vertigo and Streptomycin

nystagmus
Visual impairment

Ethambutol

Jaundice, hepatitis

H,R,Z

Shock, purpura, ARF

Rifampicin

Skin rash with or w/o

itching

H,R,Z,S

TO START OR NOT?
Interruption in intensive phase:
If 14 days, to restart from beginning
i.e. Day 1.
If <14 days, to continue form last dose.

24

TO START OR NOT?
Interruption in maintenance phase:
If interruption occurs after patient receives
80% of total planned doses, treatment may be
stopped if sputum AFB smear was negative at
initial presentation. If sputum AFB smear was
positive, treatment should be continued to
achieve total number of doses.
If total doses <80% & interruption lapse is 2
months, restart treatment from beginning.
If total doses is <80% & interruption lapse is
<2 months, continue treatment from date it
stops to complete full course.
25

EPTB Treatment

Latent TB
Latent TB is defined as infection with Mycobacterium tuberculosis complex,
where the bacteria may be alive but in the state of dormancy and not
currently causing any active disease/symptoms.

Diagnosis
Close contact with Mantoux test > 10mm
no active symptoms
normal CXR
SAFB negative

Referral criteria

TAKE HOME MESSAGES

Every physician must be able to

diagnose TB
Use correct doses & adequate
duration
Ensure compliance
Treatment needs to be individualised
Consult a doctor/physician with
experience in TB management when
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