tuberculosis and leprosy
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Tuberculosis – an overview
Presented by: Dave Jay S. Manriquez RN.
February 1, 2009
TB - Prevalence
• 1/3rd of humanity (2 billion people) infected
• One new infection every second
• 8.8 million new cases per year
• 1.6 million deaths/year
• Kills more humans per year than any other infectious disease
TB – worldwide distribution
Estimated Tuberculosis Case Rates, 1997
• India 1,799,000• China: 1,402,000• Indonesia: 583,000• Bangladesh: 300,000• Pakistan: 261,000• Nigeria 253,000• Philippines 222,000• South Africa 170,000• Russian Federation 156,000• Ethiopia 156,000• Vietnam 145,000• Democratic Republic of Congo 129,000
• Adapted from Dye C, Scheele S, Dolin P, et al. Consensus statement. Global burden of tuberculosis: Estimated incidence, prevalence, and mortality by country. WHO Global Surveillance and Monitoring Project. JAMA. 1999;282:677–686.
TB global stats
• 1/3rd of all new incident cases in Asia
• ½ of all deaths from tb occur in Asia
• In Africa, grew rapidly over last two decades due to HIV
• Period of decline, altered by worldwide epidemic of HIV
Bach Christian Hospital TB stats (2002)
• 141 new cases of tuberculosis (over 11 new cases per month)
• 840 total TB patients under treatment
• 100 patients discharged having completed treatment
TB and HIV
Tuberculosis and HIV
- over 8 million coinfected
- reactivation rates 20 times higher than in non HIV-infected persons
- 50% with dual infection develop active tb
Tuberculosis - resistance
- ½ of all new cases have some resistance
- Worst in 6 Asian countries of Bangladesh, China, India, Indonesia, Pakistan and Philippines
- Every country has resistance to at least one single drug
MDR Tuberculosis
• Defined as resistance to at least INH and rifampicin
• 450,000 cases per year
• XDR – extensive drug resistance – Generally where there is also HIV
Tuberculosis MDR distribution
• Highest in former USSR and China
Mycobacterium others, generally opportunistic and assoc. with HIV
M. Avium Intracellulare
M. Asiaticum
M. Flavenscens
M. fortuitum complex
M. Heamophilum
M. Kanasasii
M. Malmoense
M. Marinum
M. Scrofulaceum
M. Simiae
M. Genavense
M. xenopi
Mycobacterium tuberculosis- the pathogen – AFB staining
Mycobacterium tuberculosis – immune response
• Principle response is formation of a granuloma – monocyte and t cells are with multi-nucleated giant cells on the edge of an area of caseation
• Caseous necrosis and calcium deposition
Tuberculosis - pathology
• Caseous necrosis in kidney
Tuberculosis – clinical presentation
• Primary tb in childhood– Inhalation of organisms– Formation of hilar LAD– Only 5% develop symptomatic disease– 30% develop established infection– 3-5% chance of reactivation– 1/3rd of adult presentations due to new
infection
Primary Tuberculosis-hilar adenopathy and infiltrate
Pulmonary Tuberculosis
• Most cases reactivation of disease acquired years earlier
• Predominant symptoms of cough (78%), weight loss (74%), fatigue (68%), fever (60%), night sweats (55%), hemoptysis (33%)
Pulmonary Tuberculosis – CXR findings
• Apical lesions – mod. and severe w/cavity
Chest X-Ray findings, atypical
• Pneumonic consolidation
Pulmonary Tuberculosis – pleural effusion
• Usually appear 3-6 months after primary disease
• With or without lung infection
• Usually unilateral
• Predominance of lymphs
• Exudative w/protein >3 gms/dl
• Often AFB neg, cx positive
Miliary tuberculosis
• In immune-suppressed
• Follows blood-borne dissemination
• May present as FUO• High mortality rate
Miliary Tuberculosis - choroidal
Extra-pulmonary TBScrofula (lymphadenitis)
• most frequent extrapulmonary manifestation
• 80% cervical• Nearly always PPD
positive• Granulomas on
biopsy• Persistent nodes after
tx common
Extrapulmonary tb - GI
• Anywhere from mouth to anus
• 70% w/advanced pulmonary get GI
• Small bowell- ileocecal valve
• Perforations common• Responds well to tx
tapeworms roundworms
Extrapulmonary TB - peritonitis
• Ascites, pain, +/- fever, wt. loss
• Ascitic fluid seldom AFB positive
• Culture positive in only 25%
• Need tissue biopsy
• Diagnosis often delayed
Extrapulmonary TB - meningitis
• In early childhood, post-primary
• May present with subtle symptoms
• 3/4ths with miliary pattern on CXR
• AFB positive in 37% initially, 90% after 4th spinal tap
Extrapulmonary TB – osteomyelitis
• Pott’s most common – 50% of all osteo
• Low thoracic most common
• Anterior destruction
Extrapulmonary TB - arthritis
• Chronic, progressive, monoarticular
• Usually hip or knee
• AFB positive in only 1/4th
• Ideally, synovial biopsy
Extrapulmonary TB – cold abscesses
Extrapulmonary TB - urogenital
• Often asymptomatic, but kidney most commonly affected
• May present with cystitis symptoms, sterile pyuria
• Cultures 90% sensitive
• Males – scrotal mass, oligospermia
• Female – infertility with hematogenous focus in endosalpinx
Tuberculosis – laboratory investigations
• AFB – inexpensive
• Cultures – expensive, sensitivities helpful in MDR
• PCR – out of reach in poorer countries
• ESR – inexpensive and helpful, decreases with treatment
• Anemia of chronic disease
Tuberculosis - PPD
• 10mm – 90% infected
• >15mm – virtually all
• 5-10mm – may be result of BCG
• Unless recent BCG administration, if >10mm, then not from BCG
BCG vaccine
• Routinely administered in much of the world
• Efficacy 60-80%, though not uniformly
Tuberculosis - treatment
• INH (isoniazid) – bactericidal– Most common side effect hepatotoxicity – Check LFTs (20% of patients)– If occurs, may reintroduce one med at a time– Other side effect – peripheral neuritis,
prevented by coadministration of piridoxine
Tuberculosis - treatment
• Rifampin– Bactericidal– Many interactions with other drugs– Hepatotoxicity
Tuberculosis - treatment
• Pyrizinimide– GI intolerance– Hepatotoxicity – from elevated transaminases
to liver failure
Tuberculosis - treatment
• Ethambutol
-bactericidal
-side effect – retrobulbar neuritis, presenting initially with blurred vision
Tuberculosis – treatment
• Streptomycin– First antituberculous med– Side effects of ototoxicity, nephrotoxicity– Given IM
Tuberculosis – treatmentSecond line drugs
• Ethionamide
• Ciprofloxacin
• Capreomycin
• Kanamycin
• Amikacin
• Cycloserine
• Thiacetazone
Tuberculosis – treatment
• Bacteria killed over 6-mo period, but patient clinically improves in a few weeks
• Can do a 1-3 month interval AFB or culture evaluation
• Can follow ESR/weights
Tuberculosis - treatment
• Variety of regimens• BCH regimen
- for first 2 months, four drugs (INH/rifampin, pyrizinamide, ethambutal- next four months, only INH/rifampin
- CNS – 12 months - depending on clinical scenario DOTS Use of steroids
Leprosy
• Organism – mycobacterium leprae
• Infection of skin and nerves
Leprosy
Prevalence - 10-15 million in 1950s - 600,000 in 2000 Countries affected (>1/10,000) 122 in 1985 15 in 200083% in India, Brazil, Myanmar, Madagascar,
Nepal, Mozambique
Leprosy - transmission
• Generally nasal secretions, particularly in lepromatous
• Importance of proximity, but most cases sporadic
Leprosy - presentation
• Subclinical more common than clinical, as incubation 4-10 years
• Clinical – tuberculoid vs. lepromatous
Leprosy – clinical presentation
• Tuberculoid – limited by vigorous cell-mediated response
• Lepromatous – proliferation of bacteria with extensive skin and nerve involvement
Leprosy - tuberculoid
Leprosy - lepromatous
Leprosy - lepromatous
Leprosy – borderline tuberculoid
Leprosy – mid borderline
Leprosy – clinical presentation
• Reversal reactions– Occur in all forms except polar tuberculoid– Sometimes after initiation of treatment– Inflammation of existing lesions or new skin
lesions, may present with acutely swollen nerves
– Respond to steroids
Leprosy – reversal reactions
Leprosy - treatment
• Combination therapy with dapsone, rifampin, clofazimine, quinolones, minocycline, azithromycin
• Multibacillary vs. paucibacillary
• High dose steroids for reversal reactions
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