Mycobacterium Tuberculosis

Mycobacterium tuberculosis. Acid-fast stain.

Tuberculosis (TB) is caused by a bacterium called Mycobacterium tuberculosis. The bacteria usually attack the lungs, but TB bacteria can attack any part of the body such as the kidney, spine, and brain. If not treated properly, TB disease can be fatal.

How TB Spreads
TB is spread through the air from one person to another. The TB bacteria are put into the air when a person with TB disease of the lungs or throat coughs, sneezes, speaks, or sings. People nearby may breathe in these bacteria and become infected. TB is NOT spread by

shaking someones hand sharing food or drink touching bed linens or toilet seats sharing toothbrushes

kissing

Latent TB Infection and TB Disease

Not everyone infected with TB bacteria becomes sick. As a result, two TBrelated conditions exist: latent TB infection and TB disease. Latent TB Infection TB bacteria can live in the body without making you sick. This is called latent TB infection. In most people who breathe in TB bacteria and become infected, the body is able to fight the bacteria to stop them from growing. People with latent TB infection do not feel sick and do not have any symptoms. People with latent TB infection are not infectious and cannot spread TB bacteria to others. However, if TB bacteria become active in the body and multiply, the person will go from having latent TB infection to being sick with TB disease. TB Disease TB bacteria become active if the immune system can't stop them from growing. When TB bacteria are active (multiplying in your body), this is called TB disease. People with TB disease are sick. They may also be able to spread the bacteria to people they spend time with every day. Many people who have latent TB infection never develop TB disease. Some people develop TB disease soon after becoming infected (within weeks) before their immune system can fight the TB bacteria. Other people may get sick years later when their immune system becomes weak for another reason. For people whose immune systems are weak, especially those with HIV infection, the risk of developing TB disease is much higher than for people with normal immune systems.

Signs and Symptoms of TB Disease

Symptoms of TB disease depend on where in the body the TB bacteria are growing. TB bacteria usually grow in the lungs (pulmonary TB). TB disease in the lungs may cause symptoms such as

a bad cough that lasts 3 weeks or longer pain in the chest coughing up blood or sputum (phlegm from deep inside the lungs)

Other symptoms of TB disease are

weakness or fatigue weight loss no appetite chills fever sweating at night

Symptoms of TB disease in other parts of the body depend on the area affected. People who have latent TB infection do not feel sick, do not have any symptoms, and cannot spread TB to others.

Risk Factors
Some people develop TB disease soon after becoming infected (within weeks) before their immune system can fight the TB bacteria. Other people may get sick years later, when their immune system becomes weak for another reason. Overall, about 5 to 10% of infected persons who do not receive treatment for latent TB infection will develop TB disease at some time in their lives. For persons whose immune systems are weak, especially those with HIV infection, the risk of developing TB disease is much higher than for persons with normal immune systems. Generally, persons at high risk for developing TB disease fall into two categories:

Persons who have been recently infected with TB bacteria

Persons with medical conditions that weaken the immune system

Persons who have been Recently Infected with TB Bacteria This includes:

Close contacts of a person with infectious TB disease Persons who have immigrated from areas of the world with high rates of TB Children less than 5 years of age who have a positive TB test Groups with high rates of TB transmission, such as homeless persons, injection drug users, and persons with HIV infection Persons who work or reside with people who are at high risk for TB in facilities or institutions such as hospitals, homeless shelters, correctional facilities, nursing homes, and residential homes for those with HIV

Persons with Medical Conditions that Weaken the Immune System Babies and young children often have weak immune systems. Other people can have weak immune systems, too, especially people with any of these conditions:

HIV infection (the virus that causes AIDS) Substance abuse Silicosis Diabetes mellitus Severe kidney disease Low body weight Organ transplants Head and neck cancer Medical treatments such as corticosteroids or organ transplant Specialized treatment for rheumatoid arthritis or Crohns disease

What to Do If You Have Been Exposed To TB

You may have been exposed to TB bacteria if you spent time near someone with TB disease. The TB bacteria are put into the air when a person with active TB disease of the lungs or throat coughs, sneezes, speaks, or sings. You cannot get TB from

Clothes Drinking glass Eating utensils Handshake Toilet Other surfaces

If you think you have been exposed to someone with TB disease, you should contact your doctor or local health department about getting a TB skin test or a special TB blood test. Be sure to tell the doctor or nurse when you spent time with the person who has TB disease. It is important to know that a person who is exposed to TB bacteria is not able to spread the bacteria to other people right away. Only persons with active TB disease can spread TB bacteria to others. Before you would be able to spread TB to others, you would have to breathe in TB bacteria and become infected. Then the active bacteria would have to multiply in your body and cause active TB disease. At this point, you could possibly spread TB bacteria to others. People with TB disease are most likely to spread the bacteria to people they spend time with every day, such as family members, friends, coworkers, or schoolmates. Some people develop TB disease soon (within weeks) after becoming infected, before their immune system can fight the TB bacteria. Other people may get sick years later, when their immune system becomes weak for another reason. Many people with TB infection never develop TB disease.

TB Terms
Active TB disease an illness in which TB bacteria are multiplying and attacking a part of the body, usually the lungs. The symptoms of active TB disease include weakness, weight loss, fever, no appetite, chills, and sweating at night. Other symptoms of active TB disease depend on where in the body the bacteria are growing. If active TB disease is in the lungs (pulmonary TB), the symptoms may include a bad cough, pain in the chest, and coughing up blood. A person with active TB disease may be infectious and spread TB bacteria to others. BCG a vaccine for TB named after the French scientists who developed it, Calmette and Gurin. BCG is rarely used in the United States, but it is often given to infants and small children in other countries where TB is common. Chest x-ray a picture of the inside of your chest. A chest x-ray is made by exposing a film to x-rays that pass through the chest. A doctor can look at this film to see whether TB bacteria have damaged the lungs. Contact a person who has spent time with a person with infectious TB. Culture a test to see whether there are TB bacteria in your phlegm or other body fluids. This test can take 2 to 4 weeks in most laboratories. Directly observed therapy (DOT) a way of helping patients take their medicine for TB. If you get DOT, you will meet with a health care worker every day or several times a week. You will meet at a place you both agree on. This can be the TB clinic, your home or work, or any other convenient location. You will take your medicine while the health care worker watches. Extensively drug-resistant TB (XDR TB) - XDR TB is a rare type of TB disease that is resistant to nearly all medicines used to treat TB. Extrapulmonary TB active TB disease in any part of the body other than the lungs (for example, the kidney, spine, brain, or lymph nodes). HIV infection infection with the human immunodeficiency virus, the virus that causes AIDS (acquired immunodeficiency syndrome). A person with both latent TB infection and HIV infection is at very high risk for active TB disease.

INH or isoniazid a medicine used to prevent active TB disease in people who have latent TB infection. INH is also one of the four medicines often used to treat active TB disease. Latent TB infection a condition in which TB bacteria are alive but inactive in the body. People with latent TB infection have no symptoms, don't feel sick, can't spread TB to others, and usually have a positive skin test reaction. But they may develop active TB disease if they do not receive treatment for latent TB infection. Multidrug-resistant TB (MDR TB) active TB disease caused by bacteria resistant to two or more of the most important medicines: INH and RIF.

Mycobacterium tuberculosis bacteria that cause latent TB infection and active TB disease.
Negative usually refers to a test result. If you have a negative TB skin test reaction, you probably do not have TB infection. Positive usually refers to a test result. If you have a positive TB skin test reaction, you probably have TB infection. Pulmonary TB active TB disease that occurs in the lungs, usually producing a cough that lasts 3 weeks or longer. Most active TB disease is pulmonary. Resistant bacteria bacteria that can no longer be killed by a certain medicine. Rifampin (RIF) one of the four medicines often used to treat active TB disease. It is considered a first-line drug. Smear a test to see whether there are TB bacteria in your phlegm. To do this test, lab workers smear the phlegm on a glass slide, stain the slide with a special stain, and look for any TB bacteria on the slide. This test usually takes 1 day to get the results. Sputum phlegm coughed up from deep inside the lungs. Sputum is examined for TB bacteria using a smear; part of the sputum can also be used to do a culture.

TB skin test a test that is often used to find out if you are infected with TB bacteria. A liquid called tuberculin is injected under the skin on the lower part of your arm. If you have a positive reaction to this test, you probably have TB infection. Other tests will be needed to find out if you have latent TB infection or TB disease. TB blood test a new test that uses a blood sample to find out if you are infected with TB bacteria. The test measures the response to TB proteins when they are mixed with a small amount of blood. Examples of these special TB blood tests include QuantiFERON-TB Gold (QFT-G) and T-Spot.TB test. Tuberculin or PPD a liquid that is injected under the skin on the lower part of your arm during a TB skin test. If you have latent TB infection, you will probably have a positive reaction to the tuberculin.

Treatment
Tuberculosis (TB) is caused by a bacterium called Mycobacterium tuberculosis. The bacteria usually attack the lungs, but TB bacteria can attack any part of the body such as the kidney, spine, and brain. If not treated properly, TB disease can be fatal. Not everyone infected with TB bacteria becomes sick. As a result, two TBrelated conditions exist: latent TB infection and TB disease. Both latent TB infection and TB disease can be treated.

Treatment for Latent TB Infection

People with latent TB infection have TB bacteria in their bodies, but they are not sick because the bacteria are not active. People with latent TB infection do not have symptoms, and they cannot spread TB bacteria to others. However, if TB bacteria become active in the body and multiply, the person will go from having latent TB infection to being sick with TB disease. For this reason, people with latent TB infection are often prescribed treatment to prevent them from developing TB disease. Treatment of latent TB infection is essential for controlling and eliminating TB in the United States.

Because there are less bacteria in a person with latent TB infection, treatment is much easier. Four regimens are approved for the treatment of latent TB infection. The medications used to treat latent TB infection include:

isoniazid (INH) rifampin (RIF) rifapentine (RPT)

Certain groups of people (such as people with weakened immune systems) are at very high risk of developing TB disease once infected with TB bacteria. Every effort should be made to begin appropriate treatment and to ensure completion of the entire course of treatment for latent TB infection.

Treatment for TB Disease

TB bacteria become active (multiplying in the body) if the immune system can't stop them from growing. When TB bacteria are active, this is called TB disease. TB disease will make a person sick. People with TB disease may spread the bacteria to people with whom they spend many hours. TB disease can be treated by taking several drugs for 6 to 9 months. There are 10 drugs currently approved by the U.S. Food and Drug Administration (FDA) for treating TB. Of the approved drugs, the first-line anti-TB agents that form the core of treatment regimens include:

isoniazid (INH) rifampin (RIF) ethambutol (EMB) pyrazinamide (PZA)

Regimens for treating TB disease have an initial phase of 2 months, followed by a choice of several options for the continuation phase of either 4 or 7 months (total of 6 to 9 months for treatment). It is very important that people who have TB disease finish the medicine, taking the drugs exactly as prescribed. If they stop taking the drugs too soon, they can become sick again; if they do not take the drugs correctly,

the TB bacteria that are still alive may become resistant to those drugs. TB that is resistant to drugs is harder and more expensive to treat.

Treatment Completion
Treatment completion is determined by the number of doses ingested over a given period of time. Although basic TB regimens are broadly applicable, there are modifications that should be made under special circumstances (such as people with HIV infection, drug resistance, pregnancy, or treatment of children).

Testing & Diagnosis

Testing for TB Infection
There are two kinds of tests that can be used to help detect TB infection the TB skin test (TST) and TB blood tests. A positive TB skin test or TB blood test only tells that a person has been infected with TB bacteria. It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease. Other tests, such as a chest x-ray and a sample of sputum, are needed to see whether the person has TB disease. Mantoux tuberculin skin test The TB skin test (Mantoux tuberculin skin test) is performed by injecting a small amount of fluid (called tuberculin) into the skin in the lower part of the arm. A person given the tuberculin skin test must return within 48 to 72 hours to have a trained health care worker look for a reaction on the arm.
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Tuberculin Skin Testing Tuberculosis and Pregnancy Mantoux Tuberculin Skin Testing Materials

TB blood tests TB blood tests (also called interferon-gamma release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB. If your health care provider or local health department

offers TB blood tests, only one visit is required to draw blood for the test. The QuantiFERON-TB Gold In-Tube test (GFT-GIT) and TSPOT.TB test are two Food and Drug Administration approved TB blood tests. Test results are generally available in 24-48 hours.
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General information about TB blood tests Interferon-Gamma Release Assays

Who Should Get Tested for TB

Persons should get tested for TB by their doctor or local health department if they

have spent time with a person known or suspected to have active TB disease; or have HIV infection or another condition that weakens the immune system and puts them at high risk for active TB disease; or have symptoms of active TB disease; or are from a country where active TB disease is very common (most countries in Latin America and the Caribbean, Africa, Asia, Eastern Europe, and Russia); or live somewhere in the United States where active TB disease is more common such as a homeless shelter, migrant farm camp, prison or jail, or some nursing homes); or inject illegal drugs.

Testing for TB in BCG-Vaccinated Persons

BCG, or bacille Calmette-Gurin, is a vaccine for TB disease. Many persons born outside of the United States have been BCG-vaccinated. BCG vaccination may cause a positive reaction to the TB skin test, which may complicate decisions about prescribing treatment. Despite this potential for BCG to interfere with test results, the TB skin test is not contraindicated for persons who have been vaccinated with BCG. The presence or size of a TB skin test reaction in these persons does not predict whether BCG will provide any protection against TB disease. Furthermore, the size of a TB skin test reaction in a BCG-vaccinated person is not a factor in determining

whether the reaction is caused by latent TB infection (LTBI) or the prior BCG vaccination. TB blood tests (interferon-gamma release assays or IGRAs), unlike the TB skin tests, are not affected by prior BCG vaccination and are not expected to give a false-positive result in persons who have received prior BCG vaccination.

Diagnosis of TB Disease
Persons suspected of having TB disease should be referred for a medical evaluation, which should include Medical history, Physical examination, Test for TB infection (TB skin test or special blood test), Chest radiograph (X-ray), and Appropriate laboratory tests

TB and HIV Coinfection

In spite of fewer people in this country suffering with TB, it remains a serious threat, especially for HIV-infected persons. In fact, worldwide TB is one of the leading causes of death among people infected with HIV. People infected with HIV (the virus that causes AIDS) are more likely than uninfected people to get sick with other infections and diseases. TB is one of these diseases.

Without treatment, as with other opportunistic infections, HIV and TB can work together to shorten the life of the person infected. Someone with untreated latent TB infection and HIV infection is much more likely to develop TB disease during his or her lifetime than someone without HIV infection. Among people with latent TB infection, HIV infection is the strongest known risk factor for progressing to TB disease. A person who has both HIV infection and TB disease has an AIDSdefining condition.

The good news is that HIV-infected persons with either latent TB infection or TB disease can be effectively treated. The first step is to ensure that HIV-infected persons get a test for TB infection and any other needed tests. The second step is to help the people found to have either latent TB infection or TB disease get proper treatment. Rapid progression from latent TB infection to TB disease can easily be prevented.

Treatment
There are a number of treatment options for HIV-infected persons with either latent TB infection or TB disease. Consult with your state or local health department for treatment options.

Infection Control and Prevention

Infection Control in Health Care Settings
All health care settings need an infection-control program designed to ensure prompt detection, airborne precautions, and treatment of persons who have suspected or confirmed TB disease. In order to be effective, the primary emphasis of the TB infection-control program should be on achieving these three goals. In all health-care settings, particularly those in which persons are at high risk for exposure, policies and procedures for TB control should be developed, reviewed periodically, and evaluated for effectiveness to determine the actions necessary to minimize the risk for transmission of TB.

Infection Control in Health-Care Settings Respiratory Protection in Health-Care Settings

What to Do If You Have Been Exposed to TB

If you think you have been exposed to someone with TB disease, you should contact your doctor or local health department about getting a TB skin test or a special TB blood test. Be sure to tell the doctor or nurse when you spent time with the person who has TB.

Preventing Latent TB Infection from Progressing to TB Disease

Many people who have latent TB infection never develop active TB disease. But some people who have latent TB infection are more likely to develop active TB disease than others. Those at high risk for developing active TB disease include

People with HIV infection People who became infected with TB bacteria in the last 2 years Babies and young children People who inject illegal drugs People who are sick with other diseases that weaken the immune system Elderly people People who were not treated correctly for TB in the past

If you have latent TB infection and you are in one of these high-risk groups, you need to take medicine to keep from developing active TB disease. This is called treatment for latent TB infection. There are several treatment options. You and your health care provider must decide which treatment is best for you. If you take your medicine as instructed by your doctor or nurse, it can keep you from developing active TB disease. Because there are less bacteria, treatment for latent TB infection is much easier than treatment for TB disease. A person with active TB disease has a large amount of TB bacteria in the body. Several drugs are needed to treat active TB disease.

Preventing Exposure to TB Disease While Traveling Abroad

Travelers should avoid close contact or prolonged time with known TB patients in crowded, enclosed environments (for example, clinics, hospitals, prisons, or homeless shelters). Travelers who will be working in clinics, hospitals, or other health care settings where TB patients are likely to be encountered should consult infection control or occupational health experts. They should ask about administrative and environmental procedures for preventing exposure to TB. Once those procedures are implemented, additional measures could include using personal respiratory protective devices.

Tuberculosis Information for International Travelers

Drug-Resistant TB
TB bacteria can become resistant to the medicines used to treat TB disease. This means that the medicine can no longer kill the bacteria. Resistance to TB drugs can occur when these drugs are misused or mismanaged. Examples include

when patients do not complete their full course of treatment; when health-care providers prescribe the wrong treatment, the wrong dose, or wrong length of time for taking the drugs; when the supply of drugs is not always available; or when the drugs are of poor quality.

Multidrug-Resistant TB (MDR TB)

Multidrug-resistant TB (MDR TB) is TB that is resistant to at least two of the best anti-TB drugs, isoniazid and rifampicin. These drugs are considered first-line drugs and are used to treat all persons with TB disease.

Multidrug-Resistant TB

Extensively Drug-resistant TB (XDR TB)

Extensively drug-resistant TB (XDR TB) is a relatively rare type of MDR TB. XDR TB is defined as TB that is resistant to isoniazid and rifampin, plus resistant to any fluoroquinolone and at least one of three injectable secondline drugs (i.e., amikacin, kanamycin, or capreomycin). Because XDR TB is resistant to first-line and second-line drugs, patients are left with treatment options that are much less effective.

Vaccine and Immunizations

TB Vaccine (BCG)
BCG, or bacille Calmette-Gurin, is a vaccine for TB disease. This vaccine is not widely used in the United States, but it is often given to infants and

small children in other countries where TB is common. BCG vaccine does not always protect people from getting TB. If you were vaccinated with BCG, you may have a positive reaction to a TB skin test. This reaction may be due to the BCG vaccine itself or due to infection with the TB bacteria. Your positive reaction probably means you have been infected with TB bacteria if

You recently spent time with a person who has active TB disease; or You are from an area of the world where active TB disease is very common (such as most countries in Latin America and the Caribbean, Africa, Asia, Eastern Europe, and Russia); or You spend time where TB disease is common (homeless shelters, migrant farm camps, drug-treatment centers, health care clinics, jails, prisons).

The BCG vaccine should be considered only for very select persons who meet specific criteria and in consultation with a TB expert.

BCG Vaccine Testing for TB in BCG-Vaccinated Persons