a lesson for junior students

8/2/2019 A Lesson for Junior Students

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Tuberculosis

TB

2011-04-12


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Tuberculosis:

A wise adventure and opportunity capitalist

He can live anywhere but teeth


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History Pathogen

Symptoms and signs

Diagnosis (Auxiliary examination and Diagnostic

criteria)

Type

Management: based on the guideline of China

Prognosis


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History


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How old is tuberculosis?

More than 7000 years (Old Egypt----found from amummy)

When the emergence of human being, the TB too


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Pathogen


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Mycobacterium tuberculosis (MTB)

Two kinds discussed today:Mycobacterium tuberculosis(the most common reason)

Mycobacterium bovis (0.5~7.2%)

Africa (HIV/AIDS/malnutrition+TB)>

India (malnutrition) >China (malnutrition and DR/drug resistance)

Why the MTB is called anti-fast bacillus?

Ziehl-Neelsen staining

Background: blueMTB: red


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MTB


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Symptoms and Signs


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Symptoms including: Cough

Sputum

Hemoptysis / Blood stained sputum

Chest pain

Dyspnea

Systemic poisoning symptoms

Pharyngalgia (with hoarseness)

laryngophthisis


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Cough

Chief and/or first symptoms More serious in the night than daytime

Incidence: 71%

Cough and blood-stained sputum continuing more than 2weeks indicating TB strongly

Typical cough of TB:

Dry cough or irritating dry cough

Rough cough and a little frothy sputum

Cough and blood-stained sputum

Other type of cough with:White sticky phlegm

purulent sputum


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Sputum

Incidence: 40%

White mucous phlegm (white frothy sputum)

If the quantity of (purulent) sputum increased obviously, it

meansAccompanyed with infection: 50~60% is general bacteria

yellow purulent sputum (>100ml/d)

With bronchiectasis

Pyothorax and bronchopleural fistula (Acute or Chronic)


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Hemoptysis

What is Massive Hemoptysis:

>300ml per time or >500ml/24hr

More than 30% patients have died of Hemoptysis in China

Type: Blood; Blood-stained sputum


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Chest pain

Approximately 30%

No specificity; Not means exacerbation of TB

Mechanism:

TB invades parietal pleura

Adhesion or fraction of pleura

Patients with pleural effusion may suffer slight feeling of pain

A tips:Pulmonary tissue doesnt know pain


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Dyspnea

Not usual

If patients has this symptom, it means:Trachea or/and main bronchi are oppressed by enlarging lymph

nodes of mediastinum

Something in trachea or/and main bronchi obstructing them

Massive pleural effusion (constricting lungs obviously)

Accompanying with penumothoraxHematogenous disseminated pulmonary tuberculosis and ARDS

(acute respiratory distress syndrome)

Accompanying with PE (pulmonary Embolism) (dyspnea,

hemoptysis and chest pain)

Accompanying with acute exacerbation of Asthma or/and severe

infection

Extensive lung involved in


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Systemic poisoning symptoms

Fever (tidal fever)

Night sweating

Obvious or serious fatigue

Obvious weight loss

Abnormality of hematologic system (decrease of RBC, Plt and

WBC) Endocrine disturbance (parameniaamenorrhea) Insomnia

Systemic anaphylactic reaction


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Fever

60%

TB is active

Usually with night sweating and cheeks flush (like drunk looks)

Slight to moderate is common

Hyperpyrexia:

TBM (tubercular meningitis)TBP (tuberculous pleuritis)

CP (caseous pneumonia)

Acute hematogenous disseminated pulmonary TB

What is Tidal fever?


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Systemic anaphylactic reaction Arthritis

Red spot

Conjunctivitis

Anal fistula

Others: Pleural effusion

Fever

Rash


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Auxiliary examination

5 standard unit PPD test (purified protein derivation)

ESR (Erythrocyte Sedimentation Rate)

CRP (C-reaction protein)

Try to find MTB in the sputum by smear or/and culture; Biopsy

TB antibody in blood

TB-DNA through PCR (Polymerase Chain Reaction) CXR

CT

Others items: CBC (complete blood count / Blood routine)

Measurement of liver and kidneys function

Lumbar puncture and CSF examination (TBM)

Thoracic/Abdomen puncture and effusion

examination (TBP)


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Diagnostic criteria MTB has been found by any way

No direct evidence of TB but we can take no account of otherdiseases


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Typebased on pathogenesis

Type I: Primary complex Type II: Acute/Subacute/Chronic hematogenous disseminated

pulmonary TB

Type III: Secondary pulmonary TB

Type IV: TBP (tubercular pleuritis)

Type V: Extrapulmonary TB:

Bone TB (vertebral body

Abdominal TB

Tuberculosis of Celiac Lymph Node

Tuberculous peritonitisIntestinal TB


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TB-II Acute


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TB-II subacute


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42 years male, Bilateral pulmonary TB-III


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TB-III


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TBM


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TBM


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tuberculosis of lumbar spine

The vertebral body is destroyed by tuberculosisfrom outside to inside. Carcinoma brings theopposite effect: from inside to outside.


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Continuous destroy by TB


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Management: based on the guideline of China

Drugs belong 1st line:

Isoniazide-INH-H; Rifampicin-RFP-R

Ethambutol-EMB-E; Pyrazinamide-PZA-ZStreptomycin-SM-S

Drugs belong 2nd line:

Protionamide-1321Th; Dipasic-D (INH+PAS)

Ofloxacin-OFLX-O (can representing Moxifloxacin and

Levofloxacin)

Amikacin-Am-K

Drugs belong 3rd line:

Capreomycin-Cap-C; Rifabutin-RFB-B

Clarithromycin-Cla;

Amoxicillin and clavulanate potassium tablets;

Imipenem and Cilastatin Sodium-IMP;

Linezolid/Zyvox-Lzd


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Stages of management:

Intensive periodMaintenance period

IE: 2HREZ/7HRE

2HL2EZ/7HRE

Means biw (twice per week)


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What is the indications of stopping to take drugs?

Symptoms disappear completely?

No fever?

MTB cant be found in the sputum?

ESR is normal?

Imageology is normal?


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Persons with no TBbut need to be carefully

monitored Glucocorticoids (GCs) Immunosuppressant

HIV/AIDS

DM

Carcinoma

Severe malnutrition

Organ transplantation recipient

CTD (Connective Tissue Disease)

Other conditions


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Thanks

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