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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
slide16
Two aims
    • Interrupt transmission
    • Prevent morbidity and death.
anti tuberculosis drugs
Anti-tuberculosis Drugs

1ST LINE DRUGS:

  • Isoniazid (H)
  • Rifampicin (R)
  • Pyrazinamide (Z)
  • Ethambutol (E)
  • Streptomycin (S)
regimens
Regimens

Standard short course regimens 6-8 months.

An initial, intensive or bactericidal, phase and

A continuation, or sterilizing, phase.

slide20
DOTS

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

slide21
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

slide22
RE-TREATMENT CASES/ WHOCategory II:
  • Relapse
  • Treatment Failures
  • Smear positive patients who have taken ATT for more than one month and defaulted

INITIAL INTENSIVE PHASE (3months)HRZES: 2MONTHS Then HRZE:1 Month

CONTINUATION PHASE

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.
slide24
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
Prevention
  • 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
  • Pregnancy
  • Infants of T.B. mothers & Breast Feeding
  • Women on O.C.P
  • Renal Impairment
  • ATT Induced Hepatitis
  • HIV - Infected or AIDS
pregnancy
Pregnancy
  • 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
  • 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
  • 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
  • Rifampicin:
    • Hepatic enzyme inducer
    • O.C.P may become ineffective
renal impairment
Renal Impairment
  • 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
  • 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
  • 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 HepatitisRISK 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
Management
  • ↑ 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
management1
Management
  • ↑ 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
management2
Management
  • 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
  • Standard regimen – usually good response
    • Drug reactions more common
    • Thiacetazone should be avoided
    • Prolonged treatment
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