? Lungs
? Pleura
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? Lymph node
PULM
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PU O
L N
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MOANR
A Y
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RY-
CLINICAL SCENARIO
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SYMPTOMS(Pulmonary)? Cough+ exp (>2 weeks)
? Fever
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? Appetite/weight loss
? Chest pain
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? Haemoptysis? Dyspnea
SIGNS
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? General? Emaciated
? Anaemic
? Clubbing
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? Cyanosis? LN
? Edema
PRESENTATION(signs)
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? Respiratory
? consolidation
? fibro-cavitatory disease
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? Collapse? Effusions
? Pneumothorax
? hydro-pneumothorax
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? Wide variety of clinical findingsPRESENTATION(Pulmonary)
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EPTB-PRESENTATION
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LN TB
?LN-site
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?painless enlargement,systemic symptoms<50%
?Matting
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?Sinus/fistula
?FNAC/Bx/NAAT/smear/cultur
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eSKELETAL TB
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?Site?Pain/joint swelling/dec
range of motion.
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?Draining sinuses and
abscesses
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?Systemic symptoms?Radiographic changes
m/b nonspecific
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CNS TB
? Tuberculous meningitis(MC), intracranial
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tuberculomas, , cranial nerve palsies andcommunicating hydrocephalus , cranial
vasculitis may lead to focal neurologic deficits.
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? Malaise, headache, fever, or personality
change,A/S,seizures/focal defects
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? CSF ?lymphocytic,increased protein,ADA,CBNAAT
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Koch's abdomen?Site-gut/peritoneum/LN
?pain,nausea/vomitting
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?altered bowel habbits
?Distension
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?Diagnosis:ascetic fluidanalysis/LN
sampling/radiology
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Miliary
? Fever/dec appetite/wt loss/vague-elderly
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? Haematogenous? Fulminant disease -septic shock, ARDS,MOF
? CXR/Liver/spleen BX/BM
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? Haematological-anaemia(NCNC),hyponatremia
PRESENTATION(Extra-Pulmonary)
? Genitourinary-infertility, urinary difficulties
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? CVS-pericarditis(pain/dyspnea)
CLINICAL CLUES-EPTB
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? Ascites -lymphocyte predominance and negative bacterial cultures? Chronic lymphadenopathy (especially cervical)
? CSF -lymphocytic pleocytosis / elevated protein /low glucose
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? Pleural effusion -Exudative / lymphocyte predominance/negative
bacterial cultures
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? Joint inflammation (monoarticular) with negative bacterial cultures? Persistent sterile pyuria
? Unexplained pericardial effusion, constrictive pericarditis, or
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pericardial calcification/Vertebral osteomyelitis involving the thoracic
spine
COMPLICATIONS
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? Local-
? ARDS/respiratory failure
? Bronchiectasis/PTOAD
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? aspergilloma? haemoptysis (symp )
? Pleural -Empyema/pneumo
? Extensive lung destruction
? Rt middle lobe syndrome
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? Scar ca? Systemic-
? shock
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? amyloidosis
? disseminated tb-(laryngeal tb)
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? Cor-pulmonaleINVESTIGATIONS
? Active infection
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? Latent Infection? Drug resistance
TESTS FOR ACTIVE TUBERCULOSIS
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ACTIVE TUBERCULOSIS
? Radiology-X-ray
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? Microbiological-smear /culture
? NAAT-gene expert
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CXR? Abnormalities often seen in
apical or posterior segments
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of upper lobe or superior
segments of lower lobe
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? May have unusualappearance in HIV-positive
persons
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? Cannot confirm diagnosis of
TB!!
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? Sensitive,specificity is low? No chest X-ray pattern is absolutely typical of
TB
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? 10-15% of culture-positive TB patients notdiagnosed by X-ray
? 40% of patients diagnosed as having TB on the
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basis of x-ray alone do not have active TB
Proportion of patients with pulmonary
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TB who have positive AFB smearsSPUTUM SMEAR
? Rapid , results within hours
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? Inexpensive? simple, relatively easy to perform
? Reliable(40-64%sensitive,90%specificity)
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AFB - Ziehl-Nielson stain
CULTURE
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? Gold standard for TB diagnosis(100 bacil i)
? Culture al specimens, even if smear negative
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? Conventional(LJ-6-8wks)? Rapid ?liquid culture-Bactec/MGIT
? Al ows DST Vs smear
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Colony Morphology ? LJ SlantIMMUNOLOGICAL TESTS
? BANNED
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? Antigen/antibody detection method(ELISA )? Not specific, rapid, expensive
? Cannot differentiate active/past infection.
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TESTS FOR LTBI
WHAT is LTBI?
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1.PPD-infection with M tuberculosis produces a Delayed Type
Hypersensitivity (DTH) to certain antigenic components
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2.Interferon gamma release assays ?Quantiferon gold/Elispot
test
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? single patient visit? assesses responses to multiple antigens
? does not boost anamnestic immune responses
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? Less reader bias/reading
? moderate concordance between TST and QFT
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Mantoux test
Limitations
? Active Vs inactive disease
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? Old Vs new
? BCG /MOTT(though IGRA are less affected)
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TESTS FOR DRUG RESISTANCEDRUG RESISTANCE
? Conventional/rapid culture & DST
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? GOLD standard? NAAT-gene xpert LPA
MANAGEMENT
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Principles of chemotherapy? Variable bacil i population:rapid growers,slow
growers,dormant
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? Longer duration
? 2 phases of treatment
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? Need for multiple drugs to treat(spontaneousresistance)