Tuberculosis

Introduction
Tuberculosis (TB) is an airborne bacterial
infection caused by the organism
Mycobacterium tuberculosisthat primarily
affects the lungs, although other organs and
tissues may be involved.

It presents either as latent TB infection

(LTBI) or as progressive active disease.

Epidemiology

In 2010, there were an estimated 8.8

million new cases of TB globally with 1.1
million deaths among HIV-negative cases of
TB and an additional 0.35 million deaths
among people who were HIV-positive

The number of new TB cases in Malaysia

increased from 15,000 in 2005 to 19,251 in
2011

Risk factors
Low socioeconomic status
Crowded living conditions
Diseases that weakens immune system like HIV
Person on immunosuppresants like steroid
Health care workers
Migration from a country with a high number of cases

The following factors help to determine

whether a TB infection is likely to be
transmitted:
- Concentration of organisms
- Length of exposure time to contaminated air
- Immune status of the exposed individual

SITES INVOLVED
Pulmonary TB (85% of all TB cases)
Brain

Extra-pulmonary sites
Lymph node

Bone

Genito-urinary tract

Lymph
node

Bones & Joints

Meninges
Intestine
Skin

Larynx

Lung

Spine
Kidney

Symptoms
A persistent cough
Constant fatigue
Weight loss
Loss of appetite
Fever
Coughing up blood
Night sweats

Disseminated TB

Contagious bacterial infection in which TB

bacteria has spread from the lungs to other
parts of the body through the blood or
lymph system.

Investigations PTB

Sputum Smear
AFB direct smear
For 3 consecutive days
Important baseline modality
Low sensitivity

Fluorescent microscopy
Nucleic Acid Amplification Tests ( NAAT)
Rapid result
Greater sensitivity

Imaging

CXR

CT scan
more sensitive in demonstrating
endobronchial spread, lymphadenopathy
and pleural complication
useful in cases with high clinical suspicion
of TB with normal CXR.

Investigations EPTB

Lumbar puncture
Pleural tapping
FNA and/or biopsy from lymph node, pleura,
intestines, skin and other infected sites

Imaging in EPTB
MSK TB CT and MRI
CNS TB CT and MRI
Abdominal TB US, CT and barium studies
Genitourinary TB IVU, US, CT and MRI

Screening

Tuberculin skin test

Interferon-gamma release assay

An in vitro blood test based on IGRA with
antigens specific forM tuberculosiscan also
be used to screen for latent TB infection
IGRA tests measure T-cell interferon-gamma
response to antigens that are highly specific
forM tuberculosisand absent from the BCG
vaccine andM avium

LPA
- uses a PCR/hybridization technique to
identify members of the MTBC while
simultaneously identifying drug-resistant
strains by detecting the most common single
nucleotide polymorphorisms (SNPs)
associated with resistance.

MDR TB
defined as Mycobacterium tuberculosis
infection resistant to both isoniazid and
rifampicin with or without resistance to other
drugs

XDR TB
- is a condition when the Mycobacterium
tuberculosis is resistance to isoniazid and
rifampicin plus resistance to quinolones and at
least one second-line aminoglycosides

Treatment

Newly diagnosed

Treatment of Previously Treated Case

- Previously treated TB patients include those

patients treated as new cases who have
taken treatment for more than one month
and are currently smear or culture positive
again

a.

b.

i. Interruption in the intensive phase:

If 14 days, to restart from the beginning
i.e. Day 1
b. If <14 days, to continue from the last
dose

ii. Interruption in the maintenance phase:

a. If interruption occurs after patient receives 80% of
the total planned doses, the treatment may be
stopped If the sputum AFB smear was negative at
the initial presentation. If the sputum AFB smear
was positive, the treatment should be continued to
achieve the total number of planned doses

b.

b. If patient receives <80% of total planned doses

and interruption lapse is 2 months, restart
treatment from the beginning

c.

c. If patient receives <80% of total planned doses

and interruption lapse is <2 months, continue
treatment from date it stops to complete full course

Treatment EPTB

All extrapulmonary tuberculosis should be

treated with antituberculosis treatment for a
minimum of six months except for bone
(including spine) and joint tuberculosis for 6
- 9 months and tuberculous meningitis for 9
- 12 months

Management of ADR

Drug induced rashes

antiTB drugs need to be discontinued until
the rashes subside.
Individual drug is reintroduced sequentially
to identify the offending drug.
A suitable regimen can be provided when
an offending drug is identified and if
possible the regimen should include
isoniazid and rifampicin (the two most
potent drugs).

Drug-Induced Hepatitis (DIH)

Risk factors : slow acetylators, old age,
extensive TB disease, malnutrition,
alcoholism, chronic viral hepatitis B and C
infections, pregnancy until 90 days
postpartum, HIV and organ transplant
recipients.
It has been recommended to stop antiTB
drugs when the serum transaminase level
reaches three times the upper limit of normal
for patients with symptoms suggestive of
hepatitis or five times upper limit for those
without symptoms

Management of MDR TB

MDR regimens should include at least

pyrazinamide, a fluoroquinolone, an
injectable anti-TB drug, ethionamide (or
prothionamide) and either cycloserine or
PAS (para-aminosalycylic acid)

Duration
Intensive phase of 8 months
Maintenance phase of 12 months

Management of XDR TB
There is very limited data on the different
clinical approaches to XDR-TB
At least six drugs were used in the
intensive phase (8 months) and four in the
continuation phase ( 18months)

TB in pregnancy

Maternal TB has been associated with

increased risk of maternal mortality and
perinatal morbidity, namely premature
delivery, small-for-gestation age and low
birth weight

Isoniazid, rifampicin, ethambutol and

pyrazinamide are safe to be used in
pregnancy

Streptomycin should be avoided in

pregnancy due to foetal ototoxicity.

First-line antiTB drugs are safe in breast

feeding

Once active TB in the baby is ruled out, the

baby should be given six months isoniazid
prophylaxis, followed by BCG vaccination