1. Tuberculosis The greatest killer in the history of mankind
Brig Jawad Ansari FCPS,FCCP,FRCPE
Professor of Medicine & Pulmonologist

2. EPIDEMIOLOGY 1/3rd of world population is infected
TB contribute 25% of avoidable deaths
95% cases in developing world
98% of TB deaths in developing world
75% of TB cases in productive age group
Pakistan is 7th in ranking with reported cases 0f per annum and prevalence of 1810/100,000

3. What are these ?

4. Acid Fast Bacilli

5. What is this ?

6. Tubeculous Granuloma

7. Mycobacterium TB Complex (Tubercle bacilli) (Acid Fast bacilli:AFB)
M.tuberculosis (majority)
M. bovis
M.africanum
Can remain dormant / persist for many years
Atypical Mycobacterium/ Opportunistic

8. Transmission of Infection
Coughing patient of pulmonary TB
Single cough: 3000 droplets nuclei
Also spread by talking, sneezing, spitting , singing
Direct sunlight kill AFB in 5 minutes
Transmission is mostly indoor
Risks of exposure; concentration of droplet nuclei and the time spent in contaminated air
Bovine TB: cervical lymph node/ intestinal TB

9. Is TB transmitted by following?
Food
Water
Sexual intercourse
Blood transfusion
mosquitoes

10. Is TB transmitted by following?
Food
Water
Sexual intercourse
Blood transfusion
mosquitoes NO

11. Infection to disease
90% of infected individuals do not develop disease
Only evidence of infection is positive tuberculin test
Chances of disease are higher soon after infection
Higher in infants and children
Emotional and physical stress
HIV infection

12. Natural History of TB If Untreated: then by 5 years 50%: will be dead
25%: cured by their immune system
25%: become chronic

13. WHO/CDS/TB/2003.313TREATMENT OF TUBERCULOSIS:GUIDELINESFOR NATIONAL PROGRAMMESTHIRD EDITION 2003

14. is much more common than
Pulmonary TB
is much more common than
Extra-pulmonary TB
( 80% v 20%)
Ladies and gentleman,
Solitary nodules in lung field are not uncommon, but sometimes it is very hectic and tiring to find out the exact cause, which is infact very important to treat these cases effectively.

15. EXTRA-PULMONARY TB (WHO Categorization)
Meningitis
Miliary
Pericarditis
Peritonitis
Bilateral/ Extensive pleural effusion
Spinal
Intestinal
Genitourinary
SEVERE FORMS: Cat 1

16. EXTRA-PULMONARY TB (WHO Categorization)
Meningitis
Miliary
Pericarditis
Peritonitis
Bilateral/ Extensive pleural effusion
Spinal
Intestinal
Genitourinary
Lymph nodes
Unilateral pleural effusion
Bones ( excluding spine
Peripheral joints
Adrenal glands
SEVERE FORMS: Cat 1
LESS SEVERE FORMS: Cat 3

17. First year MBBS Teacher to student “Be good You will be fine”

18. In 3rd year
Must Work Hard Man

19. Must Work Very Hard You Know
In fourth year
Must Work Very Hard You Know

20. Can You hear me ? You must work hard
In final year
Can You hear me ? You must work hard

21. Diagnosing Tuberculosis

22. Diagnosis: Clinical Suspicion
Cough for more than 2-3 weeks
Sputum production
Weight loss
Night sweats
Fatigue & tiredness
No sign is specific

23. Diagnosis: Lab Tests Culturing of AFB & sensitivity Chest X-ray
Detection of AFBs in sputum smears
Culturing of AFB & sensitivity
Chest X-ray
Tuberculin Skin Test ?
ESR ???
PCR

24. SPUTUM SAMPLING At least three isolated samples Sputum and not saliva
Early morning samples preferable
If no cough:
Assisted cough
Induced Sputum
Alternate to sputum
Gastric washings
Bronchial washings

25. Slide reporting Using 1000x magnification
Number of bacilli
Result reported
No AFB
1-9 AFB per 100 oil immersion fields
Scanty
10-99 AFB per 100 oil immersion fields +
1-10 AFB per oil immersion field ++
AFB / oil immersion field
+++

26. Interpretation Smear positive Smear Negative Indeterminate
At least 2 smears examined and both positive for AFB
Smear Negative
At least 02 smears reported as negative
Indeterminate
Only one smear examined
03 smears examined and only one reported as positive

27. MYCOBACTERIAL CULTURES
Growing AFB on culture confirms diagnosis
AFB grown can be tested for their sensitivity against various drugs
Methods
Lowenstein Jensen
Liquid media
Bactec
Limitations: 6-8 weeks, skilled lab,

28. Tuberculin Skin Test
In population with high prevalence of TB, skin test is of little diagnostic value
Does not distinguish disease from infection

29. Positive Tuberculin Test
Active TB
Previous TB
Previous BCG vaccination
Atypical mycobacteria
Sarcoidosis ( in less than 30%)

30. False Negative Tuberculin Test
HIV infection
Malnuitrition
Immunosupressive drugs like steroids
Severe bacterial infection
Milliary TB/ Fulminant TB
Viral infections like measles, chicken pox, glandular fever
Cancer
Incorrect injection of PPD

31. ESR AND TB
It can not be relied upon for the diagnosis of Tuberculosis and should not be advised in routine.
Not recommended by WHO and by local guidelines

32. Role of Raidiology
There is no radiological findings which can be diagnostic of Pulmonary Tuberculosis
But
There are certain typical patterns, where TB can be strongly suspected

33. GHON’S COMPLEX
PRIMARY TB

51. Tuberculous Pericarditis

58. TUBERCULOMAS

65. TREATMENT OF TUBERCULOSIS

66. Tuberculosis Pulmonary Extra-pulmonary Smear positive Smear negative
Histopathology
Cultures
WHO/CDS/TB/ TREATMENT OF TUBERCULOSIS:GUIDELINESFOR NATIONAL PROGRAMMESTHIRD EDITION 2003

67. (plus) c/s + M. tuberculosis
Smear positive ( PTB+ )
>02 sputum smear pos
01 sputum smear pos
(plus) c/s + M. tuberculosis
01 sputum smear pos
(plus) radiological evidence of active TB
WHO/CDS/TB/ TREATMENT OF TUBERCULOSIS:GUIDELINESFOR NATIONAL PROGRAMMESTHIRD EDITION 2003

68. WHO/CDS/TB/2003.313TREATMENT OF TUBERCULOSIS:GUIDELINESFOR NATIONAL PROGRAMMESTHIRD EDITION 2003

69. DRUG SENSITIVE TB
Tuberculosis where AFBs are sensitive to first line anti-tuberculosis drugs

70. FIRST LINE DRUGS RIFAMPICIN (R) ISONIAZID (H) ETHAMBUTOL (E)
PYRIZINAMIDE (Z)
VERY POTENT
LESS SIDE EFFECTS
ECONOMICAL
SHORT DURATION
(6-8 months)

71. DIRECTLY D O T S
OBSERVED
TREATMENT
SHORT- COURSE

72. Treatment after default
TB case
Previous ATT NO
YES
New case
Re-treatment case
Rarely sputum smear negative
never taken ATT or ATT < 1 month
relapse
Completed ATT
Treatment after default
Incomplete ATT
Treatment failure
Not responded to standard regimen
chronic
after re-treatment regimen
WHO/CDS/TB/ Treatment Of Tuberculosis:guidelinesfor National Programmesthird Edition 2003

73. New Cases (PTB +/- and Extra PTB)
04 Drugs-02months
2 HRZE
Initial phase
Check sputum smear
Smear -
Smear +
Repeat initial phase-01month
1 HRZE
Smear -
02 Drugs-06months
6 HE
02Drugs-05months
5 HE
Continuation phase
4HR
4HRE
Guidelines for Diagnosis & Management of Tuberculosis. Pakistan Chest Society. March 2002.

74. Re-treatment cases (Relapse, Failures, Default: Smear positive)
2 HRZES / 1 HRZE
Initial phase
Check sputum smear
Smear -
Smear +
1HRZE
If smear+, send c/s
5 HRE
4 HRE
Continuation phase
Still smear positive
Chronic case
MDR-TB ?
Guidelines for Diagnosis & Management of Tuberculosis. Pakistan Chest Society. March 2002.