Download MBBS Pulmonary Medicine Presentations 9 Tuberculosis Lecture Notes

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? What are complications of tuberculosis?

? What are various presentations of EPTB?

? Drug resistant tuberculosis

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? DOTS & RNTCP

COMPLICATIONS
COMPLICATIONS

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? Local-?ARDS/respiratory failure

? Bronchiectasis/PTOAD

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? aspergilloma

? haemoptysis (symp )

? Pleural -Empyema/pneumo

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? 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-pulmonale


EPTB

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? Common sites:LN,PE

? Any site

? Diagnosis:more difficult

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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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e


Pleural Effusion

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? Pain/dyspnea/cough

? Fever/dec appetite

? Radiology

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? Pleural fluid analysis

SKELETAL 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 tuberculomas, , cranial

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nerve palsies and communicating hydrocephalus , cranial vasculitis

may lead to focal neurologic deficits.

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? Malaise, headache, fever, or personality change,A/S,seizures/focal

defects

? CSF ?lymphocytic,increased protein,ADA,CB NAAT

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Koch's abdomen

?Site-gut/peritoneum/LN

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?pain,nausea/vomitting

?altered bowel habbits

?Distension

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?Diagnosis:ascetic fluid

analysis/LN

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sampling/radiology
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)

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? Genitourinary-infertility, urinary difficulties

? 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

? Joint inflammation (monoarticular) with negative bacterial cultures

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? Persistent sterile pyuria

? Unexplained pericardial effusion, constrictive pericarditis, or pericardial

calcification/Vertebral osteomyelitis involving the thoracic spine

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MANAGEMENT
Principles of chemotherapy

? Variable bacilli 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(spontaneous resistance)

TREATMENT REGIMENS

Type of TB case

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Intensive Phase

Continuation Phase

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New(CAT 1)

2RHEZ

4RHE

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Retreatment(CAT 2) 2SIH

nt REZ

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ermi /

tt1R

en H

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t EZ

regimens 5RHE

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are being changed to

daily regimens under

RNTCP in India

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R;rifampicin,H:isoniazid,E:ethambutal,Z:pyrazinamide,S:streptomyci

n
? New case:CAT 1

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? Smear positive

? Smear negative

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? EPTB

? Retreatment:CAT 2

? Relapse

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? Defaulter

? failure

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? CAT 4 :MDR

? CAT 5:XDR

? Definitions

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? MDR:R and H

? XDR:R and H,any FQ,any injectables(kanamycin,amikacin,capreomycin)

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? Primary & acquired resistance

? Mono/poly drug resistance:DRTB
Drug Resistance:Magnitude

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? 3% Primary

? 12% Acquired

? XDR 4-20% of MDR

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Dx in drug resistant Tb

? MDR-TB:

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? Rapid Molecular Test ( LPA/ CB-NAAT)


? Liquid Culture & DST

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? Solid Culture & DST

? XDR-TB:

? Liquid Culture & DST

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? Solid Culture & DST

? LPA(Genotypic methods)

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Changed to

daily
OLD

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Grouping of antiTb drugs(2017 ,RNTCP

guidelines)

FQ

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Levo/moxi/gati

Injectable agents

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K/A/C

Other second line drugs

Etio/prothio/cycloserine/linezolid

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Add on drugs

D1:Z/E/H high dose,D2:Bedaquiline/delaminid

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D3:PAS,Amoxy-clav,Meropenem,imipenem

cilastatin

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RNTCP 2017
DR TB:Principles of Treatment

? MDR:4 second line drugs /not used

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? XDR:7 drugs

? Duration:24(MDR),36(XDR)

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DOTS plus previously

Second line drugs

? Treatment longer

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? Toxic
? Expensive

more

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? Stress:emergence rather than treatment of DRTb
Newer ATT

? Bedaquiline

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? Delaminid

? protaminid

MCQ

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? A pt on ATT C/O burning soles

? A pt on ATT C/O loss of appetite & vomittings

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? A pt on ATT C/O dec vision


DOTS & RNTCP

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Advantages

? Directly observed

? Standardised treatment

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? Free of cost
TB & HIV

? Increased chances of reactivation/relapse

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? Atypical presentations

? Higher ADR/drug interactions

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? Priorty to treat Tb first and then ART

TB & DM

? Higher risk

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? Glycemic control must for cure

? Higher chances of ADR