Tuberculosis with a case presentation
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The document provides information on tuberculosis including its definition, epidemiology, etiology, pathophysiology, classification, clinical presentation, diagnosis, management, and a sample case presentation. Tuberculosis is defined as an infectious disease caused primarily by Mycobacterium tuberculosis that usually affects the lung parenchyma. It discusses trends in global and India-specific TB incidence and mortality. Etiology and characteristics of M. tuberculosis are explained. The pathophysiology, types of TB, and typical clinical signs and symptoms are summarized. Diagnosis involves medical history, physical exam, tuberculin skin test, chest X-ray, microbiological tests, and blood tests. Management outlined first and second-line anti-TB drug reg
Tuberculosis with a case presentation
- 2. CONTENTS • Definition • Epidemiology • Etiology • Pathophysiology • Classification • Clinical Presentation • Diagnosis • Management • Model Case Presentation
- 3. DEFINITION Tuberculosis is the infectious disease primarily affecting lung parenchyma is most often caused by MYCOBACTERIUM TUBERCULOSIS. It may spread to any part of the body including meninges, kidney, bones and lymph nodes. - Round nodule/Swelling - Condition “Tubercle” “Osis”
- 4. EPIDEMIOLOGY • Global incidence is 10 million • Mortality rate is 1.6 million • Out of 7 million 0.3 million are with HIV • In Pediatrics the incidence is about 1 million • Mortality rate is 230000 (Including HIV) • Most of the deaths in HIV patients is due to Tuberculosis only i.e., 40% • 457560 cases are detected as MDR TB • 558000 new cases is identified as the Rifampicin Resistant TB
- 5. INDIA COUNTRY PROFILE • Population of INDIA is 1339 millions • Mortality rate is 410000 (Excludes HIV + TB) • Mortality rate is 11000 (Includes HIV + TB) • Total cases notified in India is about 1908371 • Out of total cases NEW + RELAPSE is about 1786681
- 7. ETIOLOGY CAUSATIVE ORGANISMS • Mycobacterium tuberculosis: Human • Mycobacterium bovis: Animals OTHERS • Mycobacterium africanum • Mycobacterium microti • Mycobacterium leprae • Mycobacterium avium • Mycobacterium asiaticum
- 8. • TB is an air borne droplet infection caused by the ingestion of the bacterium when the infected person coughing, sneezing etc.
- 9. KOCH’S DISEASE : TUBERCULOSIS Robert Koch (1882) – Isolated the mammalian tubercle bacillus on Heat Coagulated Bovine Serum and proved its causative role in Tuberculosis by satisfying Koch’s Postulates Hence the tuberculosis is also called as KOCH’S DISEASE
- 10. Characteristics of MYCOBACTERIUM TUBERCULOSIS • M tuberculosis (MTB) is a slim, strongly acid– alcohol–fast rod like bacilli. • 0.2-0.5 μ in D, 2-4 μ in L. • It grows at 37oC, but not at room temperature, and it requires enriched or complex media for primary growth. • The classic medium, Lowenstein–Jensen, contains homogenized egg in nutrient base with dyes to inhibit the growth of non mycobacterial contaminants. Growth is very slow, with a mean generation time of 12 to 24 hours.
- 13. TUBERCULOSIS PULMONARY TB - Primary Disease - Secondary Disease EXTRA PULMONARY i. Lymph node TB ii. Pleural TB iii. TB of upper airways iv. Skeletal TB v. Genitourinary TB vi. Miliary TB vii. Pericardial TB viii. Gastrointestinal TB ix. Tuberculous Meningitis x. Less common forms
- 14. CLINICAL PRESENTATION • Cough • Haemoptysis • Nausea, vomiting • Weight loss • Abdominal pain • Headache • Chest pain • Fever • Night sweats • Lethargy/drowsiness
- 15. • TB disease is diagnosed by medical history, physical examination, chest x- ray, and other laboratory tests. • People suspected of having TB disease should be referred for a complete medical evaluation, which will include the following: 1. Medical History 2. Physical Examination 3. Test for TB Infection 4. Chest Radiograph 5. Diagnostic Microbiology 6. Blood Tests DIAGNOSIS
- 16. PHYSICAL EXAMINATION • Dullness to chest percussion • Auscultation revealed vocal fremitus sound
- 17. Tuberculin skin test (PPD) • 10 units of Purified Protein Derivative injected through intradermal ROA and waited for 48-72 hrs. • After 72 hrs. the induration is measured. Induration measurement Test for TB Infection
- 19. Chest Radiography • Chest X-Ray(CXR) • Chest CT Chest CT
- 20. 1.Bacteriological test: Zeihl-Neelsen stain Auramine stain(fluorescence microscopy) 2. Sputum culture test: Lowenstein –Jensen(LJ) Solid medium : 4-18 weeks Liquid medium : 8-14 days Agar medium : 7 to 14 days Diagnostic Microbiology
- 21. Blood Tests • CBP • ESR • PS Reading • Differential Leucocyte Count
- 22. TB disease can be treated by taking several drugs for 6 to 9 months. The first-line anti-TB agents that form the core of treatment regimens include: WHO group 1 1. ISONIAZID (INH) 2. RIFAMPIN (RIF) 3. ETHAMBUTOL (EMB) 4. PYRAZINAMIDE (PZA) 5. STREPTOMYCIN MANAGEMENT
- 23. Preferred Regimen Initial Phase Daily INH, RIF, PZA, and EMB* for 56 doses (8 weeks) Continuation Phase Daily INH and RIF for 126 doses (18 weeks) or Two-times-weekly INH and RIF for 36 doses (18 weeks) Alternative Regimen Initial Phase Daily INH, RIF, PZA, and EMB* for 14 doses (2 weeks), then two-times-weekly for 12 doses (6 weeks) Continuation Phase Two-times-weekly INH and RIF for 36 doses (18 weeks) Alternative Regimen Initial Phase Three-times-weekly INH, RIF, PZA, and EMB* for 24 doses (8 weeks) Continuation Phase Three-times-weekly INH and RIF for 54 doses (18 weeks)
- 25. THE SECOND-LINE ANTI-TB AGENTS • Aminoglycosides (WHO group 2): e.g., Amikacin (AMK), kanamycin (KM); • Polypeptides (WHO group 2): e.g., Capreomycin, viomycin, enviomycin; • Fluoroquinolones (WHO group 3): e.g., Ciprofloxacin (CIP), levofloxacin, moxifloxacin (MXF); • Thioamides (WHO group 4): e.g. Ethionamide, prothionamide • Cycloserine (WHO group 4)
- 26. PREVENTION • Isolation • Ventilate the room • Cover the mouth • Wear mask • Finish entire course of medication • Vaccinations
- 27. NAME : XXX AGE : 58 yrs. GENDER : Female WARD : General Medicine DATE OF ADMISSION : 24/1/16 DATE OF DISCHARGE : 29/1/16 IP NO : 5574/15 CONSULTANT : Dr. D. Kantha Reddy M.B.B.S Dr. P.N. Ravi Kumar Reddy M.D Pulmonologist
- 28. REASON FOR ADMISSION: • Cough X 1 month • SOB X 15 days • Fever, Headache, Body pains X 1 month • Anorexia X 1 month PAST MEDICAL HISTORY : K/C/O Hypertension, DM PAST MEDICATION HISTORY : Not under RX PERSONAL HISTORY : Nil FAMILY HISTORY : Not Known
- 29. DATE 24/1/16 25/1/16 26/1/16 27/1/16 28/1/16 29/1/16 TEMP 1000 F 98.60 F 98.60 F 1000 F 990 F 98.60 F BP 160/80 mm Hg 140/80 mm Hg 120/70 mm Hg 130/80 mm Hg 120/80 mm Hg 130/80 mm Hg PR 125 bpm 86 bpm 86 bpm 86 bpm 84 bpm 86 bpm RR 24 bpm 24 bpm 24 bpm 26 bpm 26 bpm 24 bpm
- 32. DATE TEST RESULT REF VALUE 24/1/16 Hb 10.2 gm./dl 12- 16 g/dl TLC 17000 cells/mm3 4000-11000 cells/mm3 DLC Neutrophils 82% 40-75% Lymphocytes 14% 20-45% Eosinophil’s 2% 1-6% Monocytes 2% 1-10% ESR 38 mm/hr. 0-20 mm/hr. Platelet count 2.4 L/mm3 1.4-4.4 L/mm3 RBS 295 mg/dl 80-150mg/dl Blood urea 24 mg/dl 10-50 mg/dl Sr. Creatinine 1.0 mg/dl 0.6-1.6 mg/dl 25/1/16 RBS 275 mg/dl 80-150mg/dl 26/1/16 RBS 230 mg/dl 80-150mg/dl 27/1/16 FBS 164 mg/dl 60-110mg/dl 28/1/16 RBS 200 mg/dl 80-150mg/dl 29/1/16 RBS 182 mg/dl 80-150mg/dl
- 33. CT CHEST PLAIN Impression: • Patchy area of consolidation and cavitatory area in Rt Upper Lobe. • Sputum for AFB: +ve
- 36. BRAND NAME GENERIC NAME DOSE FREQUENCY ROA DATE BEGUN DATE ENDED Inj. Oflomac Ofloxacin 200mg BD IV 24/1/16 29/1/16 Neb. Duolin and Budecort Ipratropium Bromide + Levosalbutamol 20mcg 50mcg TID Neb 24/1/16 29/1/16 Budesonide 100mcg T. Forecox Rifampicin Isoniazid Pyrazinamide Ethambutol 225mg 150mg 750mg 400mg OD PO 24/1/16 29/1/16 T. Pantop Pantoprazole 40mg OD PO 24/1/16 29/1/16 T. Dolo Paracetamol 650mg BD PO 24/1/16 29/1/16 T. Glycomet Metformin 500mg BD PO 24/1/16 29/1/16 T. Stamlo Amlodipine 5mg OD PO 24/1/16 29/1/16
- 37. BRAND NAME GENERIC NAME DOSE FREQUENCY ROA T. Forecox Rifampicin Isoniazid Pyrazinamide Ethambutol 225mg 150mg 750mg 400mg OD PO T. Pantop Pantoprazole 40mg OD PO T. Dolo Paracetamol 650mg BD PO T. Glycomet Metformin 500mg BD PO T. Stamlo Amlodipine 5mg OD PO Cap. Becosules Vit. B + Zinc 1C OD PO
- 38. DRUGINTERACTIONS Ofloxacin + Metformin: Concurrent use of FLUOROQUINOLONES and ANTIDIABETIC AGENTS may result in changes in blood glucose and increased risk of hypoglycaemia or hyperglycaemia. Clinical Management: If concurrent therapy with a fluoroquinolone and an antidiabetic agent is necessary, closely monitor the blood glucose level and adjust the dose of the antidiabetic agent as indicated; dose adjustment may be required after discontinuation of a fluoroquinolone. If a hypoglycaemic reaction occurs, the patient should initiate appropriate therapy immediately, discontinue the fluoroquinolone. Severity: Major Paracetamol + Isoniazid: Concurrent use of ACETAMINOPHEN and ISONIAZID may result in an increased risk of hepatotoxicity. Clinical Management: Use caution with concomitant administration due to the potential for isoniazid to induce CYP2E1, which may increase exposure to toxic acetaminophen metabolites. Acetaminophen use should be avoided or limited in patients taking isoniazid. Severity: Major
- 39. • Tuberculosis is the communicable disease which spreads through the droplets of the infected person, characterized by the persistent cough, cough with sputum, sudden weight loss, loss of apatite, chest tightness and pain. • Diabetes Mellitus is the endocrine disorder, which is characterized by the hyperglycemia, frequent urination, excessive thrust, excessive hunger. • Hypertension is the persistent elevation of arterial blood pressure.
- 40. • Isolate the patient in a separate room. • Advised to wear the face mask. • Maintain hygienic environment. • Cover your mouth while talking, coughing, sneezing, etc. • Restrict salt usage. • Take fiber rich food like wheat, oats, etc. • Take Brown rice instead of normal rice. • Avoid Sweets. • Avoid Non-Vegetarian food. • Avoid oil foods. • Avoid spicy foods. • Should not eat the banana, Mango, Custard apple, etc. • Take medication without skipping dose. • If any dose skipped next time don’t double the dose. • Take medication with more water.
- 41. • Eat leafy vegetables like spinach, etc. • Do regular exercise. • Do mild to moderate walk daily. • Keep your foot clean and dry. • If any injury occurred consult physician immediately. • If you feel any of dizziness consult physician, dizziness is due to the hypoglycemia that is low blood glucose levels than the normal. • Advised to monitor the blood glucose levels and blood pressure once in a month. • Urine may passed in orange color it is due to the Rifampicin.