TUBERCULOSIS Diagnosis & treatment

2. TUBERCULOSISDiagnosis & treatment Dr. FazliWahab FCPS(Med), FCPS(Pulmonology) Assisstant Prof Peshawar Medical College

3. Diagnostic Tools • Microscopy • AFB smear • Histology • AFB Culture • Radiology • Tuberculin skin test • Serological Tests

4. AFB smear Rapid and inexpensive

5. Granuloma

6. Mycobacterial Culture • Definitive diagnosis • Growth detected after 4–8 weeks.

7. Radiographic Procedures The "classic" picture is that of upper-lobe disease with infiltrates and cavities,

8. X-ray chest appearance can be any of the following • Infiltration • Cavitations • Fibrosis with traction • Enlargement of hilar and mediastinal lymph node • Pleural effusion/empyema • Nodular/ Miliary shadows

13. Mantoux Tuberculin Test (MT)/ Tuberculin Skin Test (TST) Test TB infection in adults and children

14. Serological Tests • Not routinely used • Polymerase Chain Reaction (PCR) • Interferon Gamma release assays (IGRS) • Enzyme Assays & Chromatographic assays: • Unreliable & Ineffective methods • No role in diagnosis in any form of TB • Mycodot assay • ICT TB

15. Treatment

16. Two aims • Interrupt transmission • Prevent morbidity and death.

17. Anti-tuberculosis Drugs 1ST LINE DRUGS: • Isoniazid (H) • Rifampicin (R) • Pyrazinamide (Z) • Ethambutol (E) • Streptomycin (S)

19. Regimens Standard short course regimens 6-8 months. An initial, intensive or bactericidal, phase and A continuation, or sterilizing, phase.

20. DOTS DOTS(directly observed treatment, short-course), the WHO-recommended TB control strategy.

21. New Cases • Sputum smear positive pulmonary TB • Sputum smear negative pulmonary TB • Extra-pulmonary tuberculosis • WHO Category I: • New SS +VE Pulmonary TB • Severe Extra-Pulmonary • Severe SS –VE Pulmonary TB • WHO Category III: • New SS-VE Pulmonary TB • Extra-Pulmonary (less severe) Initial Intensive Phase HRZE : 2 Months Continuation Phase HR: 4months OR HE: 6 Months

22. RE-TREATMENT CASES/ WHOCategory II: • Relapse • Treatment Failures • Smear positive patients who have taken ATT for more than one month and defaulted INITIAL INTENSIVE PHASE (3months)HRZES: 2MONTHS Then HRZE:1 Month CONTINUATION PHASE HRE: 5 Months

23. No Treatment is better than Poor Treatment • Drug-resistant TB is caused by: • Inconsistent or partial treatment, when patients do not take all their medicines regularly for the required period. • Doctors and health workers prescribe the wrong treatment regimens, or because • The drug supply is unreliable.

24. The ultimate result is the multidrug-resistant TB (MDR-TB) or extensively-drug resistant TB (XDR-TB) In MDR-TB the Mycobacterium Tuberculosis is resistant to Rifampacin and INH with or without resistance to other 1st ATT. Treatment is difficult and expensive.

25. Prevention • The best way to prevent tuberculosis is to Treat. • Additional strategies include • BCG vaccination and • Treatment of persons with latent tuberculosis infection who are at high risk of developing active disease.

26. ATT in Special situations • Pregnancy • Infants of T.B. mothers & Breast Feeding • Women on O.C.P • Renal Impairment • ATT Induced Hepatitis • HIV - Infected or AIDS

27. Pregnancy • H, R, Z, E : Safe • Streptomycin: Ototoxic • May cause deafness in babies • Contraindicated

28. Infants of T.B. mothers & Breast Feeding • Mothers must continue A.T.T during feeding • Child should not be separated • Mother should cover her mouth during cough particularly if smear +ve • INH prophylaxis : 5 mg/Kg 2 months

29. Infants of T.B. mothers & Breast Feeding • Do T.T: • If –ve • Stop INH, give BCG • If +ve • Continue INH 4 months • Then BCG • Do not give BCG while on INH • INH resistant BCG • Rifampicin + INH – 3 months

30. Women on O.C.P • Rifampicin: • Hepatic enzyme inducer • O.C.P may become ineffective

31. Renal Impairment • General principle: • Standard chemotherapy • Standard duration • Dose interval modification • Rifampicin and INH • Safe and use normal dose • Pyrazinamide • Needs dose interval adjustment

32. Renal Impairment • Ethambutol • Nephrotoxic , Renal excretion - 80% unchanged • Ocular toxicity – dose dependent • Serum monitoring required • Amino glycosides – Streptomycin • Nephrotoxic, renal excretion- 80% unchanged • Needs dose interval adjustment in all stages • New recomandations • Avoid Aminoglycosides

33. ATT Induced Hepatitis • Usually present early but may present any time • Mild / transient derangement in LFTs is normal (15 – 20 %) • TYPES: • Hepatocellular: • Cholestatic • Mixed

34. ATT Induced HepatitisRISK FACTOR • Age >35 years • Female sex • Oriental race (EAST ASIAN) • Pre-existing liver disease • Extensive tuberculosis • High alcohol consumption • Malnutrition and hypo Albuminemia • Other hepatotoxic drugs • Slow Acetylator status • High dosage in relation to body weight

35. Management • ↑ ALT/AST (< Twice normal) • Continue ATT • Check after 2 weeks • ↑ ALT/AST (>Twice normal) • Continue ATT • Check LFTs weekly for 2 weeks • Then every 2 weeks until normal

36. Management • ↑ ALT/AST (>Thrice normal) + Symptoms • Anorexia, Nausea, Vomiting, Abdominal Pain , Jaundice • STOP ATT • ↑ ALT/AST (>5 time normal) OR ↑ Bilirubin • Even If Patient Asymptomatic • Stop ATT • If patient is smear –ve / Clinically stable • Wait until LFTs are normal • No need for alternate drugs • If patient is smear +ve / Clinically unstable • Start Ethambutol, Streptomycin and one of the reserve drugs until LFT‘s are normal • Continue safe drugs until LFTs are normal

37. Management • When LFT’s are normal • Reintroduce ATT to detect offending drugs • Start with least hepatotoxic one by one • INH > RIF > PZA • If no reaction • Continue ATT • Stop alternate drugs • If reaction has developed • Stop offending drug • Continue remaining drugs • Ensure adequate regimen and duration

38. HIV - Infected or AIDS • Standard regimen – usually good response • Drug reactions more common • Thiacetazone should be avoided • Prolonged treatment

39. Thanks