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Brig Gen Md. Nazim Uddin MBBS, FCPS, MD Adviser Spl in Medicine & Chest Diseases
History
Its a disease of great antiquity. Found in the vertebra of Neolithic man in
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Tubercle Bacillus
It is a acid-fast, alcohol-fast, aerobic or
microaerophilic, non-spore-forming, non-motile bacilli. Only M. Tuberculosis, M. Bovis and M. Africanum are recognized as Tubercle Bacilli. Optimal temperature for growth is 33-39 degree Celsius at pH 6.5-6.8 in an atmosphere of 510% CO2.
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Transmission
Transmitted by the airborne route. The unit of infection is a small particle
called a droplet nucleus.
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Epidemiology
Most common infectious disease in the
world. One third of the world population is infected. 2.5 million death annually. The incidence of the disease has been increasing both in developed and developing countries.
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Pathology
Deposition of Tubercle Bacilli in the alveoli
of the lungs is followed by vasodilatation and influx of polymorphonuclear leucocytes and macrophage. Macrophages crowed together as epitheloid cells to form the tubercle.
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Pathology (contd..)
Some mononuclear cells fuse to form the
multinucleated or Langerhans giant cells. Lymphocytes surround the outer margin of the tubercle. In the centre of the lesion a zone of caseous necrosis may appear that may subsequently calcify.
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Tuberculin test:
Mantoux test: 1. Intradermal inj of .1 ml of 5 TU PPD on
the volar surface of forearm. 2. Test is read after 48-72 hours. 3. Positive: > 10 mm.
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Tuberculin test:
Heaf test:
1. Done with a gun which has 6 needle. 2. The needle puncture the skin through a thin film of PPD 3. Test is read after 3-7 days. 4. Grade: 1-4 5. Gr. 3 and 4: past or present infection.
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BCG vaccination
Bovine strain of M. tuberculosis. 230 passage through media. Freeze-dried vaccine can be stored for
longer period. In developing countries the vaccine should be given to neonates or as early as possible to children.
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Chemoprophylaxis
Administration of chemotherapy to prevent
tuberculosis. A. Primary: usually not given. B. secondary: 1. Close contact of newly diagnosed patient. 2. Positive tuberculin test reactors with an abnormal but inactive X-ray. 3. Positive tuberculin test reactor with special clinical situations. Drug: INH-300 mg/day for 01 year.
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Congenital tuberculosis
Very rare. Three possible modes of transmission:
Haematogenous, aspiration, inhalation. C/F: wide spread disease i.e. respiratory distress, fever, hepatosplenomegaly, jaundice etc. Treatment: 3 drugs. Steroid may be added.
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involvement of draining lymph node. Primary complex. C/F: may be asymptomatic. Few may be symptomatic i. e. fever, cough, failure to gain wt, wheeze or features of collapse.
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Diagnosis:
X-ray chest Tuberculin test Gastric washing and sputum for AFB and AFB
C/S. Complications: Collapse/ consolidation, bronchiectasis, obstructive emphysema, broncholith, erythema nodosum, phlyctenular conjuntivits, pleural effusion etc.
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Miliary tuberculosis
Produced by acute dissemination of
tubercle bacilli by blood stream. Seeding of bacilli in the vessel wall cause caseous vasculitis with subsequent discharge of bacilli in the blood stream.
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pathology
The millet seed sized lesions consists of
epithelioid cells, Langhans giant cells with or with out central caseation. AFB may be present.
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Clinical features:
Acute or classical miliary tuberculosis:
common in children. May have anorexia, nausea, vomiting, fever, cough, dyspnoea, haemotysis etc. Clinically: creps, HSM, neck rigidity, choroidal tubercle etc.
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diagnosis
Radiology Gastric lavage, sputum, transtracheal
aspirate, FOB with washing for AFB and AFB C/S. BM, spleen and liver biopsy. Blood: TC, DC, ESR. Tuberculin test.
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Complications
ARDS Immune complex nephritis.
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Risk factors
Nutrition Homelessness Occupation Alcoholism HIV infection Immunosuppressive drugs Immunosuppressive diseases
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Clinical features
Disease of middle aged and elderly Symptom free - discovered on routine CXR. Persistent cough with or without sputum. General malaise. Recurrent colds Pneumonia. Haemoptysis.
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Signs
No physical signs. Fever, wt loss. Post tussive creps. Signs of consolidation. Evidence of fibrosis. Evidence cavity
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Investigations
CXR Sputum Gastric aspirate Laryngeal swab FOB Transtracheal aspirate FNAC Mediastinoscopy.
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D/D
Pneumonia Ca lung Lung abscess Pulmonary infarction
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Complications
Empyema TB laryngitis Tuberculosis of other organs COPD Cor pulmonale Amyloidosis Aspergiloma ARDS
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Complications (contd..)
Pulmonary tuberculoma Poncets disease
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Treatment
Before 1950s mainstay of Rx was: bed
rest, open air and sunshine. Surgical resection and collapse therapy were also practiced. Presently short course chemotherapy is the mainstay of Rx. Short course combination chemotherapy is usually given for 6 months.
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Newer drugs
Quinolons:
1. Ciproflxacin 2. Ofloxacin
Rifabutin Macrolides.
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Rx of MDR TB
At least 03 drugs to which the organisms
aresensitive. The drugs should be continued for 6-12 months after sputum become culture negative.
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