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TUBERCULOSIS Diagnosis & treatment. Dr. Fazli Wahab FCPS(Med), FCPS( Pulmonology ) Assisstant Prof Peshawar Medical College. Diagnostic Tools. Microscopy AFB smear Histology AFB Culture Radiology Tuberculin skin test Serological Tests. AFB smear. Rapid and inexpensive. Granuloma.

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Tuberculosis diagnosis treatment

TUBERCULOSISDiagnosis & treatment

Dr. FazliWahab

FCPS(Med), FCPS(Pulmonology)

Assisstant Prof Peshawar Medical College

Diagnostic tools
Diagnostic Tools

  • Microscopy

    • AFB smear

    • Histology

  • AFB Culture

  • Radiology

  • Tuberculin skin test

  • Serological Tests

Afb smear
AFB smear

Rapid and inexpensive

Mycobacterial culture
Mycobacterial Culture

  • Definitive diagnosis

  • Growth detected after 4–8 weeks.

Radiographic procedures
Radiographic Procedures

The "classic" picture is that of upper-lobe disease with infiltrates and cavities,

X ray chest appearance can be any of the following
X-ray chest appearance can be any of the following

  • Infiltration

  • Cavitations

  • Fibrosis with traction

  • Enlargement of hilar and mediastinal lymph node

  • Pleural effusion/empyema

  • Nodular/ Miliary shadows

Mantoux tuberculin test mt tuberculin skin test tst
Mantoux Tuberculin Test (MT)/ Tuberculin Skin Test (TST)

Test TB infection in adults and children

Serological tests
Serological Tests

  • Not routinely used

  • Polymerase Chain Reaction (PCR)

  • Interferon Gamma release assays (IGRS)

  • Enzyme Assays & Chromatographic assays:

    • Unreliable & Ineffective methods

    • No role in diagnosis in any form of TB

    • Mycodot assay

    • ICT TB

  • Two aims

    • Interrupt transmission

    • Prevent morbidity and death.

Anti tuberculosis drugs
Anti-tuberculosis Drugs


  • Isoniazid (H)

  • Rifampicin (R)

  • Pyrazinamide (Z)

  • Ethambutol (E)

  • Streptomycin (S)


Standard short course regimens 6-8 months.

An initial, intensive or bactericidal, phase and

A continuation, or sterilizing, phase.


DOTS(directly observed treatment, short-course), the WHO-recommended TB control strategy.

  • New Cases

  • Sputum smear positive pulmonary TB

  • Sputum smear negative pulmonary TB

  • Extra-pulmonary tuberculosis

  • WHO Category I:

    • New SS +VE Pulmonary TB

    • Severe Extra-Pulmonary

    • Severe SS –VE Pulmonary TB

  • WHO Category III:

    • New SS-VE Pulmonary TB

    • Extra-Pulmonary (less severe)

Initial Intensive Phase

HRZE : 2 Months

Continuation Phase

HR: 4months OR HE: 6 Months


  • Relapse

  • Treatment Failures

  • Smear positive patients who have taken ATT for more than one month and defaulted



HRE: 5 Months

No treatment is better than poor treatment
No Treatment is better than Poor Treatment

  • Drug-resistant TB is caused by:

    • Inconsistent or partial treatment, when patients do not take all their medicines regularly for the required period.

    • Doctors and health workers prescribe the wrong treatment regimens, or because

    • The drug supply is unreliable.

The ultimate result is the multidrug-resistant TB (MDR-TB) or extensively-drug resistant TB (XDR-TB)

In MDR-TB the Mycobacterium Tuberculosis is resistant to Rifampacin and INH with or without resistance to other 1st ATT.

Treatment is difficult and expensive.

Prevention or extensively-drug resistant TB (XDR-TB)

  • The best way to prevent tuberculosis is to Treat.

  • Additional strategies include

    • BCG vaccination and

    • Treatment of persons with latent tuberculosis infection who are at high risk of developing active disease.

Att in special situations
ATT in Special situations or extensively-drug resistant TB (XDR-TB)

  • Pregnancy

  • Infants of T.B. mothers & Breast Feeding

  • Women on O.C.P

  • Renal Impairment

  • ATT Induced Hepatitis

  • HIV - Infected or AIDS

Pregnancy or extensively-drug resistant TB (XDR-TB)

  • H, R, Z, E : Safe

  • Streptomycin: Ototoxic

  • May cause deafness in babies

  • Contraindicated

Infants of t b mothers breast feeding
Infants of T.B. mothers & Breast Feeding or extensively-drug resistant TB (XDR-TB)

  • Mothers must continue A.T.T during feeding

  • Child should not be separated

  • Mother should cover her mouth during cough particularly if smear +ve

  • INH prophylaxis : 5 mg/Kg 2 months

Infants of t b mothers breast feeding1
Infants of T.B. mothers & Breast Feeding or extensively-drug resistant TB (XDR-TB)

  • Do T.T:

  • If –ve

    • Stop INH, give BCG

  • If +ve

    • Continue INH 4 months

    • Then BCG

  • Do not give BCG while on INH

    • INH resistant BCG

  • Rifampicin + INH – 3 months

Women on o c p
Women on O.C.P or extensively-drug resistant TB (XDR-TB)

  • Rifampicin:

    • Hepatic enzyme inducer

    • O.C.P may become ineffective

Renal impairment
Renal Impairment or extensively-drug resistant TB (XDR-TB)

  • General principle:

    • Standard chemotherapy

    • Standard duration

    • Dose interval modification

  • Rifampicin and INH

    • Safe and use normal dose

  • Pyrazinamide

    • Needs dose interval adjustment

Renal impairment1
Renal Impairment or extensively-drug resistant TB (XDR-TB)

  • Ethambutol

    • Nephrotoxic , Renal excretion - 80% unchanged

    • Ocular toxicity – dose dependent

    • Serum monitoring required

  • Amino glycosides – Streptomycin

    • Nephrotoxic, renal excretion- 80% unchanged

    • Needs dose interval adjustment in all stages

  • New recomandations

    • Avoid Aminoglycosides

Att induced hepatitis
ATT Induced Hepatitis or extensively-drug resistant TB (XDR-TB)

  • Usually present early but may present any time

  • Mild / transient derangement in LFTs is normal (15 – 20 %)

  • TYPES:

    • Hepatocellular:

    • Cholestatic

    • Mixed

Att induced hepatitis risk factor
ATT Induced Hepatitis or extensively-drug resistant TB (XDR-TB) RISK FACTOR

  • Age >35 years

  • Female sex

  • Oriental race (EAST ASIAN)

  • Pre-existing liver disease

  • Extensive tuberculosis

  • High alcohol consumption

  • Malnutrition and hypo Albuminemia

  • Other hepatotoxic drugs

  • Slow Acetylator status

  • High dosage in relation to body weight

Management or extensively-drug resistant TB (XDR-TB)

  • ↑ ALT/AST (< Twice normal)

    • Continue ATT

    • Check after 2 weeks

  • ↑ ALT/AST (>Twice normal)

    • Continue ATT

    • Check LFTs weekly for 2 weeks

    • Then every 2 weeks until normal

Management or extensively-drug resistant TB (XDR-TB)

  • ↑ ALT/AST (>Thrice normal) + Symptoms

    • Anorexia, Nausea, Vomiting, Abdominal Pain , Jaundice

    • STOP ATT

  • ↑ ALT/AST (>5 time normal) OR ↑ Bilirubin

    • Even If Patient Asymptomatic

    • Stop ATT

  • If patient is smear –ve / Clinically stable

    • Wait until LFTs are normal

    • No need for alternate drugs

  • If patient is smear +ve / Clinically unstable

    • Start Ethambutol, Streptomycin and one of the reserve drugs until LFT‘s are normal

    • Continue safe drugs until LFTs are normal

Management or extensively-drug resistant TB (XDR-TB)

  • When LFT’s are normal

    • Reintroduce ATT to detect offending drugs

    • Start with least hepatotoxic one by one

  • INH > RIF > PZA

  • If no reaction

    • Continue ATT

    • Stop alternate drugs

  • If reaction has developed

    • Stop offending drug

    • Continue remaining drugs

  • Ensure adequate regimen and duration

Hiv infected or aids
HIV - Infected or AIDS or extensively-drug resistant TB (XDR-TB)

  • Standard regimen – usually good response

    • Drug reactions more common

    • Thiacetazone should be avoided

    • Prolonged treatment

Thanks or extensively-drug resistant TB (XDR-TB)