Tuberculosis TB

2011-04-12

Tuberculosis: A wise adventure and opportunity capitalist He can live anywhere but teeth

History Pathogen Symptoms and signs Diagnosis (Auxiliary examination and Diagnostic criteria) Type Management: based on the guideline of China Prognosis

History

 How old is tuberculosis? More than 7000 years (Old Egypt----found from a mummy) When the emergence of human being, the TB too

Pathogen

 Mycobacterium tuberculosis (MTB) Two kinds discussed today:

Mycobacterium tuberculosis(the most common reason) Mycobacterium bovis (0.5~7.2%)

Africa (HIV/AIDS/malnutrition+TB)> India (malnutrition) > China (malnutrition and DR/drug resistance) Why the MTB is called anti-fast bacillus?
Ziehl-Neelsen staining Background: blue MTB: red

MTB

Symptoms and Signs

Symptoms including: Cough Sputum Hemoptysis / Blood stained sputum Chest pain Dyspnea Systemic poisoning symptoms Pharyngalgia (with hoarseness)
laryngophthisis

 Cough
Chief and/or first symptoms More serious in the night than daytime Incidence: 71% Cough and blood-stained sputum continuing more than 2 weeks indicating TB strongly Typical cough of TB:
Dry cough or irritating dry cough Rough cough and a little frothy sputum Cough and blood-stained sputum

Other type of cough with:

White sticky phlegm purulent sputum

 Sputum
Incidence: 40% White mucous phlegm (white frothy sputum) If the quantity of (purulent) sputum increased obviously, it means
Accompanyed with infection: 50~60% is general bacteria yellow purulent sputum (>100ml/d) With bronchiectasis Pyothorax and bronchopleural fistula (Acute or Chronic)

 Hemoptysis
What is Massive Hemoptysis:
>300ml per time or >500ml/24hr

More than 30% patients have died of Hemoptysis in China Type: Blood; Blood-stained sputum

 Chest pain
Approximately 30% No specificity; Not means exacerbation of TB Mechanism:
TB invades parietal pleura Adhesion or fraction of pleura Patients with pleural effusion may suffer slight feeling of pain A tips: Pulmonary tissue doesnt know pain

 Dyspnea
Not usual If patients has this symptom, it means:
Trachea or/and main bronchi are oppressed by enlarging lymph nodes of mediastinum Something in trachea or/and main bronchi obstructing them Massive pleural effusion (constricting lungs obviously) Accompanying with penumothorax Hematogenous disseminated pulmonary tuberculosis and ARDS (acute respiratory distress syndrome) Accompanying with PE (pulmonary Embolism) (dyspnea, hemoptysis and chest pain) Accompanying with acute exacerbation of Asthma or/and severe infection Extensive lung involved in

 Systemic poisoning symptoms

Fever (tidal fever) Night sweating Obvious or serious fatigue Obvious weight loss Abnormality of hematologic system (decrease of RBC, Plt and WBC) Endocrine disturbance (parameniaamenorrhea) Insomnia Systemic anaphylactic reaction

 Fever
60% TB is active Usually with night sweating and cheeks flush (like drunk looks) Slight to moderate is common Hyperpyrexia: TBM (tubercular meningitis) TBP (tuberculous pleuritis) CP (caseous pneumonia) Acute hematogenous disseminated pulmonary TB What is Tidal fever?

 Systemic anaphylactic reaction

Arthritis Red spot Conjunctivitis Anal fistula Others: Pleural effusion Fever Rash

 Auxiliary examination
5 standard unit PPD test (purified protein derivation) ESR (Erythrocyte Sedimentation Rate) CRP (C-reaction protein) Try to find MTB in the sputum by smear or/and culture; Biopsy TB antibody in blood TB-DNA through PCR (Polymerase Chain Reaction) CXR CT Others items: CBC (complete blood count / Blood routine) Measurement of liver and kidneys function Lumbar puncture and CSF examination (TBM) Thoracic/Abdomen puncture and effusion examination (TBP)

 Diagnostic criteria
MTB has been found by any way No direct evidence of TB but we can take no account of other diseases

 Typebased on pathogenesis
Type I: Primary complex Type II: Acute/Subacute/Chronic hematogenous disseminated pulmonary TB Type III: Secondary pulmonary TB Type IV: TBP (tubercular pleuritis) Type V: Extrapulmonary TB: Bone TB (vertebral body Abdominal TB
Tuberculosis of Celiac Lymph Node Tuberculous peritonitis Intestinal TB

TB-II Acute

TB-II subacute

42 years male, Bilateral pulmonary TB-III

TB-III

TBM

TBM

tuberculosis of lumbar spine The vertebral body is destroyed by tuberculosis from outside to inside. Carcinoma brings the opposite effect: from inside to outside.

Continuous destroy by TB

 Management: based on the guideline of China

Drugs belong 1st line: Isoniazide-INH-H; Rifampicin-RFP-R Ethambutol-EMB-E; Pyrazinamide-PZA-Z Streptomycin-SM-S Drugs belong 2nd line: Protionamide-1321Th; Dipasic-D (INH+PAS) Ofloxacin-OFLX-O (can representing Moxifloxacin and Levofloxacin) Amikacin-Am-K Drugs belong 3rd line: Capreomycin-Cap-C; Rifabutin-RFB-B Clarithromycin-Cla; Amoxicillin and clavulanate potassium tablets; Imipenem and Cilastatin Sodium-IMP; Linezolid/Zyvox-Lzd

 Stages of management:
Intensive period Maintenance period IE: 2HREZ/7HRE 2HL2EZ/7HRE

Means biw (twice per week)

 What is the indications of stopping to take drugs?

Symptoms disappear completely? No fever? MTB cant be found in the sputum? ESR is normal? Imageology is normal?

 Persons with no TBbut need to be carefully monitored

Glucocorticoids (GCs) Immunosuppressant HIV/AIDS DM Carcinoma Severe malnutrition Organ transplantation recipient CTD (Connective Tissue Disease) Other conditions

Thanks