Tuberculosis

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Tuberculosis Presented By Dr. Nuchovich
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Tuberculosis

• 8 Million New Infections a Year
• 3 Million TB related Deaths a Year

People at Risk Immigrants Prison
Inmates Homeless Nursing Homes HIV IVDA Ment
al Health Institution
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Tuberculosis

• TB Disease
• TB Infection
• Biopsy Caseating non-caseating Granulomas with
  Giant Cells.

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Primary TB

• Lower Lobes Bacteremia

Clinical Findings

• Asymptomatic
• Fever
• Dry Cough
• Erythema Nodosum
• Pneumonia (only 5)

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Primary TB

• Chest X-ray
• Lobar or Segmental Infiltrate and Hilar
  Adenopathy
• Ghon Nodule-Parenchymal Resolution
• Calcifies with time
• Rankes complex-Calcified Hilar Lymph Node

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Secondary TB

• Reactivation

Clinical Findings

• Fever, Leukocytosis
• Hyponatremia, Hypercalcemia
• Chest X-ray
• Upper Lobes
• Cavitary Foci

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PPD Test

• Negative Test does not Rule out TB
• Positive Test alone does not Establish Diagnosis
• Converter PPD positive, whose PPD was negative
  in the last 2 Years.
• Reactor PPD positive, whose PPD was negative
  more than 2 years ago.

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• Anergy TB infection can not be ruled out.
• BCG PPD If BCG gt 5 years ago, PPD positive
  No relation to BCG
• Booster Effect Repeated PPD testing may
  sensitize persons who were previously positive
  their immunity has weaned.

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Positive PPD

• 10 mm Induration in patients less than 35 years
  of age.
• 15 mm Induration in patients more than 35 years
  old.

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Tuberculosis

• Only 10 of the infected patients develop the
  disease.
• Of this 10 half will develop the disease in the
  first 2 years.

Progression Factors Genetics Nutritional
Status Cancer Low Immune Status Drugs Diabetes
IVDA Renal insufficiency
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TB HIV

• HIV Risk 10 increase per year
• 100 Times more frequent
• Early HIV disease less likely to be
  extrapulmonary disease

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Multi-Drug Resistant

• MDR the most threatening
• MDR when disease is resistant to at least 2
  drugs
• Cause Inadequate or Incomplete TX

Population at Risk

• HIV-IVDA
• Residents in MDR area
• Persistence of Fever in a Pt. Receiving 4 drug
  therapy suggests MDR

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Advanced HIV Disease

• Bone Marrow
• GI GU
• CNS
• Blood Cultures positive 30
• PPD not certain
• Gram Stain Less Sensitive than cultures

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Treatment

• Suspicion? ISOLATION
• Infectious Disease Consult
• AFB Smear positive Start Treatment

Standard of Care Direct Observation Therapy

• Sputum conversion from positive to negative
  equal in HIV non-HIV, but relapse rates are
  Different

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TB Prophylaxis

• In HIV patients 5 mm Induration
• Hx of close contact with Active TB regardless of
  PPD results.
• Anergy in HIV patient with Hx of prolonged
  exposure to TB.
• HIV PPD positive (According to CDC)
• INH 300 mg po Q day X 9 Months
• Rifabuting PZA for patients on protease
  inhibitors
• Rifampin 600 mg po X 6-12 Months (60 doses)

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Prophylaxis in MDR

• PZA Quinolone X 12 Months
• PZA Ethambutol

Management

• 4 Drugs X 6 Months

Induction

• 4 Drugs X 2 Months
• INH Rifampin ETH PZA

Continuation

• 2 Drugs X 4 Months
• INH Rifampin

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Management MDR

• Principles are the same BUT add Bactericidal
  Bacteriostatic Drugs.
• Duration depends on Response
• 3 Drugs until cultures become Negative then at
  least 2 Drugs for 12-24 Months.