Dr.

Susaniwati, SpP
Penyakit ok M Tuberculosis ( kadang-kadang
ok M.Bovis dan M.Africanum)
Penularan :
- Airborne  spreading dari inf droplets
- 1 x batuk  3.000 droplets
- Indoors
Resiko Infeksi :
- Sputum (+)  tinggi
- Sputum (-)  rendah
Penjalanan Penyakit
* Bertahun-tahun  selama hidup
* 90% (tanpa HIV)  tidak sakit hanya
tuberkulin test (+)
* Tanpa pengobatan setelah 5 tahun :
- 50%  mati
- 25%  sehat
- 25%  sakit (chronic infection)
Epidemiology
* 1995  1/3 penduduk dunia
 9 juta kasus baru dg 3 juta
kematian
* 95%  negara berkembang
* 75% †  Productive age (15-50 th)
* Indonesia :
SKRT 1995 : penyebab ke  ke-3
WHO 1999 : 583.000 ks baru/th
 140.000
± 130 px baru BTA pos / 130.000 peduduk
* M.TB  paru  multiplikasi  Ghon fokus
 aliran lympa  lympnode hilus 
complex primer  Hematogen 
seluruh tubuh.
* Respon imun (DHS & cellular immunity)
terjadi 4-6 minggu setelah infeksi primer 
multiplikasi stop (sbgn besar).
* Sbgn kecil  Dormant bacilli.
* Pd beberapa kasus  imun respon tdk cukup
u/ mencegah multiplikasi  sakit dlm
beberapa bulan.
 90%  tidak sakit [Tub.test (+)].
Hipersensitive Reaction :
* Erythema nodosum
* Phlyctenular Cony’is
* Dactilitis
Pulmonary & Pleural Dis :
* Pneumonitis TB
* Lobar collaps
Compl Primer * Pleural Effusion
Disseminated Disease :
* Lymphadenopathy
(cervical)
* Meningitis
* Pericarditis
* Miliary disease
 Primary or Ghon’s Complex

• Primary tuberculosis is
the pattern seen with
initial infection with
tuberculosis in
children.
• Reactivation, or
secondary
tuberculosis, is more
typically seen in
adults.
 Miliary TB
• Millet like – grain.
• Extensive micro spread.
• Through blood or
bronchial spread
• Low immunity
• Pulmonary or Systemic
types.
Miliary TB Lung
Miliary TB Lung
Adrenal TB - Addison Disease
Spinal TB - Potts Disease
Post Primer TB
* Setelah laten period ( bulan – tahun ).
* Reaktivasi atau reinfeksi.
* Response thdp triger sangat  imun sistem
(HIV).
* Sifat : * Extensive Destruction + Cavitas
* Sputum (+)
* Upper Lobe
* Intrathoracic Lymph Adenopathy
* Pada orang dewasa
 Post Primer TB

Pulmonary Extra Pulmonary

* Upper Lobe * Pleural Effusion
* Lymph Adenopathy
* Fibrosis
(cervical)
* Progressive Pneumonia
* CNS (meningitis,
* Endobronchial
tuberculoma)
* Pericarditis (Eff /
Constrictiva)
* Spine, Bone, Joint
 Cavitary Tuberculosis

• When necrotic tissue

is coughed up 
cavity.
• Cavitation is typical
for large granulomas.
• Cavitation is more
common in the
secondary reactivation
tuberculosis - upper
lobes.
Jarang :
* Empyema
* Genital tract : Epididimis, Orchitis,
Tuba ovarium, Endometrioum
* Ren, adrenal gland
* Skin
* Keluhan : - batuk > 3 mgg
- produksi sputum
- berat badan 
* Respiratory : hemoptisis, chest pain,
sesak nafas
* Sistemik : panas, keringat malam, lelah,
nafsu makan 
* Diagnose : - Sputum smear (3 sampel: SPS)
- Ziehl-Neelsen Stain
- IUAT-LD
1-9 AFB/100 Oil Emersi Field Scanty
10-99 ‘’ ‘’ + (1+)
1-10 AFB/ Oil Emersi Field + + (2+)
> 10 AFB/ Oil Emersi Field + + + (3+)
AFB - Ziehl-Nielson stain
Tuberculous Granuloma
Epitheloid cells in Granuloma
 PPD Tuberculin Testing
• Sub cutaneous
• Weal formation
• Itching – no scratch.
• Read after 72 hours.
• Induration size.
• 5-10-15mm (non-ende)
• BCG gives + result.
PPD Testing
Case Definition by Previous Treatments
* New case :
tidak pernah mendapat OAT, atau pernah tp
tidak > 1 bl

* Relapse (kambuh) :
Sudah mendapat OAT & dinyatakan sembuh,
kembali berobat dg dahak BTA (+) .

* Treatment Failure : BTA msh (+) setelah tx

5 bl atau lebih, atau BTA awal negatif, menjadi
positif pada akhir bulan ke-2.
Case Definition ………….

* Return after interruption (default) :

px telah mendapat OAT  1 bl & kembali
berobat setelah berhenti  2 bl

* Transfer in :
pindah berobat ke tempat lain stlh terdaftar

* Chronic TB :
BTA tetap (+) setelah selesai tx ulang (kat- 2)
Kategori - 1 : Px baru TB paru BTA positif
Px BTA neg. dg Ro. lesi luas
Px ekstra paru berat

Kategori - 2 : Relapse (kambuh)

Treatment failure (gagal)
Return after default BTA +

Kategori - 3 : smear (-) PTB with limited

parenchymal involvement;
Ekstra paru TB (less severe)

Kategori - 4 : Chronic Case

 I
Standardized Treatment Regimens by WHO
Treatment Patients TB treatment regimens
category Treatment category
NewIcases : 2HRZE (S) / 4H3R3
I - sputum smear (+) / 4HR
- sputum smear (-) w/ rÖ : / 6HE
far-advanced
- severe extra-pulm TB
II
Old cases : 2HRZES-1HRZE/ 5H3R3E3
II sputum smear (+) : / 5HRE
relaps, failure,
III TAI
New cases : 2HRZ / 4H3R3
III - sputum smear (-) w/ rÖ : / 4HR
IV
minimal lesion / 6HE
- less severe extra-pulm TB
IV Old cases : chronic case Refer. to specialized center
Extra Pulmonary TB
Severe : * Meningitis
* Miliary
* Pericarditis
* Peritonitis
* Bilateral / Extensive pl. Effusion
* Spinal
* Intestinal
* Genito urinary
Less severe :
* Lymph node * Peripheral Joint
* Unilat. Pl. Efusion * Adrenal Gland
* Bone excluding spine
* Menyembuhkan penderita TB
* Mencegah † dan aktif TB
* Mencegah relaps
*  Transmisi TB

Effective Anti TB drug

Short Course Chemotherapy

 Populasi TB Bacilli

* Metabolically active (Aktif membelah)

* Inside cells (Macrophage)
* Persisters (Semi Dormant)
* Dormant Bacilli
 OAT Action Potency Dose mg/Kg/BB
Daily Intermittent
3X 2X
INH (H) Bacterisidal Hight 5 10 15
RIF (R) Bacterisidal Hight 10 10 10
PZA (Z) Bacterisidal Low 25 35 30
Strep (S) Bacterisidal Low 15 15 50
Etham (E) Bacteriostatic Low 15 (30) 15

INH  Membunuh 90%

Active thdp metabolic active
RMP  Membunuh semi Dormant
PZA  Membunuh bakteri dlm suasana asam
Treatment Regimen
* Initial (intensive) phase  2 bulan
* Continuing phase  4 bulan

Initial Phase
* Rapid killing of TB bacilli
* 2 minggu  non infectious, sympton 
* BTA (-)
* DOT perlu dg PMO
* Protect Drug Resistance
Continuing Phase (4-6 bulan)
* Membunuh persisters  prevention relaps
setelah selesai terapi
* DOT tetap perlu
Indikasi Pemakaian Steroid
* TB meningitis
* TB pericarditis
* TB pleural effusion (massive)
* TB adrenal glans
* TB laringitis
* Renal tract TB
* Reaksi hipersensitive OAT
* Massive enlargement lymph node
OAT pada keadaan khusus
* Pregnancy
Streptomycin (-)
Ethambutol (-)
* Renal Failure
RMP, H, PZA  safe
SM & EMB  reduced dose
* Liver Disease
2 SHE / 6 HE
PZA (-)
* Pengguna Oral contraceptive
Oestrogen  (50 meg)
Kontrasepsi lain
Kombinasi 4 OAT
* Initial resisten M.TB tinggi

* Resiko selecting out drug resistent mutans

(cavitary pulm. TB)

*  Drug res, treatment failure & relaps

* Kematian ok TB 
* TB membunuh usia dewasa muda
* 2-3 juta † ok TB
* 1 penderita baru setiap 1 detik
* Tiap 10 detik bbrp orang † ok TB
* 1 orang active Tb (sputum (+) dapat
menulari 10-15 orang/th
* HIV   TB 
Multi Drug Resistant TB

* > 50 juta

* Pengobatan yang tidak rasional

(obat, dokter, supply)

* Public Health Prespective

- Incomplete Treatment
- Supervisi jelek
Pend TB paru ~ strategi DOTS
* Komitmen Politik
* Case Finding (BTA-Direct Smear)
* Short Course treatment
* OAT berkesinambungan
* Recording & Reporting

GERDUNAS