Transmission When people with active pulmonary TB cough, sneeze, speak, sing, or spit, they expel infectious aerosol

droplets 0.5 to 5 m in diameter. A single sneeze can release up to 40,000 droplets. Each one of these droplets may transmit the disease, since the infectious dose of tuberculosis is very low and inhaling fewer than ten bacteria may cause an infection.

Pathogenesis About 90% of those infected with Mycobacterium tuberculosis have asymptomatic, latent TB infection (sometimes called LTBI), with only a 10% lifetime chance that a latent infection will progress to TB disease.However, if untreated, the death rate for these active TB cases is more than 50%. TB infection begins when the mycobacteria reach the pulmonary alveoli, where they invade and replicate within the endosomes of alveolar macrophages.M. tuberculosis usually enters the alveolar passages of exposed humans in an aerosol droplet, where its first contact is with resident macrophages.

Formation Of Granuloma--

Within 2-10 weeks, the immune system produces special immune cells called macrophages that surround the tubercle bacilli. The cells form a hard shell that keeps the bacilli contained and under control (TB infection)

-infected macrophages in the lung, through their production of chemokines, attract inactivated monocytes, lymphocytes, and neutrophils (297), none of which kill the bacteria very efficiently. -Products of activated T cells enhance the transformation of monocytes to Epithelioid cells and giant cells(Langhan's cells) -Then, granulomatous focal lesions composed of macrophage-derived giant cells and lymphocytes begin to form. This process is generally an effective means of containing the spread of the bacteria. -As cellular immunity develops, macrophages loaded with bacilli are killed, and this results in the formation of the caseous center of the granuloma, surrounded by a cellular zone of fibroblasts, lymphocytes, and blood-derived monocytes. -Thus a Tubecullar granuloma has centrally casseous necrosis,surrounded by collection of Epithelioid cells,containing ocassional Langhan's cells,surrounded by rim of Lymphocytes.

-The strength of the host cellular immune response determines whether an infection is arrested here or progresses to the next stages. This enclosed infection is referred to as latent or persistent TB and can persist throughout a person's life in an asymptomatic and nontransmissible state. -There is either elimination of the bacterium completely, containment of the

infection in a granuloma for a prolonged period (forever, or until an alteration in immune status results in breakdown of the granuloma and reactivation of latent infection), or immediate progression to active disease with clinical illness. This latter event usually occurs only in the setting of impaired immunity.

Gohn Complex-The primary site of infection in the lungs is called the Ghon focus, and is generally located in either the upper part of the lower lobe, or the lower part of the upper lobe. If the Ghon focus also involves infection of adjacent lymphatics and hilar lymph nodes, it is known as the Ghon's complex or primary complex.