basics
Dr.T.V.Rao MD
Dr.T.V.Rao MD
HISTORY of
Tuberculosis
Tuberculosis Is
an Ancient
Disease
Spinal
Tuberculosis in
Egyptian
Mummies
History
dates to 1550
1080 BC
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Robert
Koch
Discoverer
of
Mycobacter
ium
Tuberculosi
s
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What are
Mycobacteria?
Obligate aerobes growing
most successfully in tissues
with a high oxygen content,
such as the lungs.
Facultative intracellular
pathogens usually infecting
mononuclear phagocytes
(e.g. macrophages).
Dr.T.V.Rao MD
Classification of
4. Atypical
Mycobacteria Mycobacteria
1.
2.
3.
Tubercle bacilli
a)
b)
c)
d)
e)
Human MTB
Bovine M. bovis
Murine M. microti
Avian M. avium
Cold blooded M.
marinum
Lepra bacilli
a)
b)
Human M. leprae
Rat M. leprae
murium
Mycobacteria
causing skin ulcers
a)
b)
M. ulcerans
M. belnei
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(Runyon Groups)
a)
b)
c)
d)
Photochromogens
Scotochromogens
Nonphotochromogens
Rapid growers
5. Johnes bacillus
M. paratuberculosis
6. Saprophytic
mycobacteria
a)
b)
c)
d)
e)
M. butyricum
M. phlei
M. stercoralis
M. smegmatis
Others
Gram's stain
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Mycobacterium
tuberculosis complex
M.bovis
Primarily infection among
the cattle
M.bovis infects Tonsils,
Cervical nodes, can
produce Scrofula.
Enter through Intestines
infects the Ileocecal
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Atypical
Mycobacterium
1 Photochromogens
2 Scotochromogens
3 Non
Photochromogens
4 Rapid growers
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What are
Mycobacteria?
Obligate aerobes growing
most successfully in tissues
with a high oxygen content,
such as the lungs.
Facultative intracellular
pathogens usually infecting
mononuclear phagocytes
(e.g. macrophages).
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General characters of
the genus
Slender rods
Resist staining
but once stained,
resist
decolonization by
dilute mineral
acids; hence
called ACID FAST
BACILLI (AFB)
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Aerobic, Non-motile,
Non-sporing, Noncapsulated.
Growth generally
slow
Genus includes
Obligate parasites
Opportunist
pathogens
Saprophytes
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Morphology of
Mycobacterium
tuberculosis
Straight, slightly
curved Rod
shaped 3 x
0.3microns
May be single, in
pairs or in small
clumps
On conditions in
growth appears
as filamentous,
club shaped, or
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Important
Mycobacterium
Mycobacterium tuberculosis,
along with M. bovis, M.
africanum, and M. microti all
cause the disease known as
tuberculosis (TB) and are
members of the tuberculosis
species complex. Each member
of the TB complex is pathogenic,
but M. tuberculosis is pathogenic
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Avian Tuberculosis
Transmitted by ingestion and inhalation of
aerosolized infectious organisms from feces.
Oral ingestion of food and water contaminated
with feces is the most common method of infection.
Once ingested, the organism spreads throughout
the bird's body and is shed in large numbers in the
feces.
If the bacterium is inhaled, pulmonary lesions and
skin invasions may occur
transmission of avian TB is from bird to human not
from human to human.
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The
character
Why they are
Acid
Fast
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of Acid
fastness is due
to presence of
Unsapnofiable
wax ( My
colic acid and
semi
permeable
membrane
around the
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MTB : Cultural
characters MTB grows more
Grow slowly.
luxuriantly (eugonic)
Generation
than M. bovis
time 14-15 hrs
(dysgonic).
Colonies
Addition of 0.5%
appear after 2
Glycerol supports
weeks or at 6-8 growth of human
strains. No effect or
weeks
inhibitory effect on
MTB - Obligate
bovine strains.
aerobe
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Nature of Media
Used
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Lowenstein Jensens
Medium
Contain
coagulated
egg
Mineral salt
solution
Asparagine's
Malachite
green
Agar
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Other Medium
Middle brook
Sula's medium
But not
routinely used
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Nature of Growth
Characters
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On L J Medium
M.tuberculosis
appear dry, rough
raised irregular
colonies
Appear wrinkled
They appear
creamy white
Become yellowish
M.bovis appear as
flat smooth, moist,
white and break up
easily
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On Liquid Medium
Appear as long
serpentine cords in
liquid medium
Virulent strains
grow in a more
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Resistance of
Mycobacterium
Mycobacterium are killed at 600c in
15 20 mt
In sputum they survive for 10 30 mt
Relatively resistant to several
chemicals including Phenol 5 %
Sensitive to Glutaraldehyde and
Formaldehyde
Ethanol is suitable application to
superficial surfaces and skin gloves
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Resistance to
several agents
Bacilli survive in Droplets for 8
10 days
Survive in
5% phenol,
15% Sulphuric acid
3% Nitric acid,5% oxalic
acid,
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Biochemical Tests on
Mycobacterium spp
Niacin test
10%
cyanogen's
bromide and
4% Aniline in
96% ethanol
are added to
suspension of
C canary
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Other Tests
Aryl sulphatase test Positive in Atypical
Mycobacterium
Bacilli grown in 0.001 tripotassium
phenolpthalein disulphide / 2 N. Sodium
hydroxide added drop by drop a pink color
develops
Catalase peroxidase test
Differentiates Atypical from Typical
Most Atypical are strongly Catalase
positive
Tubercle bacilli are weakly positive
Tubercle bacilli are peroxidase positive
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Catalase Test
30 Vol of H2O2 and 0.2 % alcohol
in distilled water is added to 5 ml
of test culture
Effervescence indicates Catalase
positive
Other test
Amidase test
Nitrate reduction test
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Antigenic Characters
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Bacteriophages
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Molecular Typing
DNA finger printing
differentiates different
strains of
Mycobacterium
species
Treating the organism
with Restriction
endonuclease yields
Nucleic acid
fragments of varying
length and strain
specific
Use in epidemiological
studies
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Genome of Mycobacterium
tuberculosis
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How tuberculosis
spreads
Tuberculosis (TB) is a contagious
disease. Like the common cold, it
spreads through the air. Only people
who are sick with TB in their lungs
are infectious. When infectious
people cough, sneeze, talk or spit,
they propel TB germs, known as
bacilli, into the air. A person needs
only to inhale a small number of
these to be infected.
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Tuberculosis spread by
Respiratory route
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Tuberculosis highly
Communicable Disease.
Someone in the world is newly
infected with TB bacilli every second.
Overall, one-third of the world's
population is currently infected with
the TB bacillus.
5-10% of people who are infected
with TB bacilli (but who are not
infected with HIV) become sick or
infectious at some time during their
life. People with HIV and TB infection
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Pathology and
Pathogenesis of
Tuberculosis
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Spread of Tuberculosis
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Generation of Droplet
Nuclei
One cough
produces 500
droplets
The average TB
patient generates
75,000 droplets
per day before
therapy
This falls to 25
infectious droplets
per day within two
weeks of effective
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Predisposing
Factors
Genetic basis,
Age
Stress,
Nutrition,
Co existing infections Eg
HIV
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Mechanisms of
Infection
Mycobacterium do not produce
toxins.
Allergy and Immunity plays the
major role.
Only 1/10 of the infected will get
disease.
Cell Mediated Immunity plays a
crucial role.
Humoral Immunity not
Important.
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Mechanisms of
Infection
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Lymphocyte
Giant cells
Fully activated
Partially activated
macrophage
macrophage
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Basis of Tubercle
formation.
Tubercle is a Avascular
granuloma Contain central
zone of giant cells with or
without caseation and
peripheral zone of
Lymphocytes and Fibroblasts.
Produce lesions may be
Exudative or
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Diagram of a
Granuloma
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Tubercle
discharging
Bronchial tree
TNF-
TNF-
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Immunity in
Tuberculosis.
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Immunity in
Tuberculosis
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Lesions in
Tuberculosis
Exudative and
Productive
Exudative Acute
inflammatory reaction with
edema fluid contains
PolymorphsLymphocytes later
Mononuclear cells.
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Primary
Tuberculosis
Initial response
In Endemic countries Young children
Events of Primary complex
1 Bacilli are engulfed by Alveolar
Macrophages
2 Multiply and give raise to Sub pleural
focus of Tuberculosis,Pneumonia,involve
lower lobes and lower part of upper lobes.
Called as Ghons focus.
The Hilar Lymph nodes are also involved
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Primary complex
This is known as the primary
complex or primary infection. The
patient will heal and a scar will
appear in the infected loci. There will
also be a few viable bacilli/spores
may remain in these areas
(particularly in the lung). The
bacteria at this time goes into a
dormant state, as long as the
person's immune system remains
active and functions normally this
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Primary complex
Ghons focus with Enlarged lymph nodes
appear after 3- 8 weeks after infection.
Heals in 2 6 months calcified,
Some bacteria remain alive and produce
latent infections.
Infection activated in Immunosuppressed
conditions Eg. HIV infections and AIDS
Can produce Meningitis, Miliary
tuberculosis, other disseminated
Tuberculosis.
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Reactivation of
Tuberculosis
When a person's
immune system
is depressed., a
secondary
reactivation
occurs. 85-90%
of the cases
seen which are
of secondary
reactivation type
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Kochs
Phenomenon
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Post Primary
Tuberculosis
Mainly occurs due to Reactivation of
Latent infection.
May also due to Exogenous
reinfection
Differs from Primary Infection.
Leads to
Cavitation's of Lungs,
Enlargement of Lymph nodes,
Expectoration of Bacteria laden
sputum
Dissemination into Lungs and other
extra pulmonary areas.
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Multiorgan Involvement
in Tuberculosis.
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Complication of
Tuberculosis.
1. Meningitis.
2. Pleurisy,
3. Involvement of Kidney,
4. Spine ( Potts spine )
5. Bone Joints,
6. Miliary tuberculosis
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Tuberculosis Pneumothorax
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Extra pulmonary
Tuberculosis
Bacteria on circulation leads to
bacteremia leads to involvement
of
GUT, Genito urinary system,
Meningitis
Gastro Intestinal system, skin,
Lymph nodes Bone marrow.
Spinal infection Potts spine,
Arthritis
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Tuberculosis Lymphadenitis
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Epidemiology
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Diagnosis of
Tuberculosis
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Types of specimens:
-Sputum.
- BAL.
-Pleural effusions
- Urine
- Stool
-CSF
-Aspiration ( gastric cold abscess)
- Blood in case of haematogenous TB
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Laboratory Diagnosis
1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum
samples are needed to diagnose pulmonary TB.
Advantage: - cheap rapid
- Easy to perform
- High predictive value > 90%
- Specificity of 98%
Disadvantages:
- sputum ( need to contain 5000-10000 AFB/ ml.)
- Young children, elderly & HIV infected persons
may not produce cavities & sputum containing AFB.
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Advantages:
- More sensitive
- Rapid
Disadvantages:
- Hazards of dye toxicity
- more expensive
- must be confirmed by Z-N stain
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3- Cultures on L J media
Lowenstein Jensen medium is an egg based media
with addition of salts, 5 % glycerol, Malachite green &
penicillin.
Advantages: - Specificity about 99 %
- More sensitive (need lower no. of bacilli 10100 / ml)
- Can differentiate between TB complex &
NTM using biochemical reactions
- Sensitivity tests for antituberculous drugs
( St, INH, Rif., E)
Disadvantages: Slowly growing ( up to 8 weeks )
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Tuberculin Test
Interpretation:
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- Corticosteroid therapy
Malnutrition
- AIDS
* Children below 5 years of age with no
exposure history:
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HIV Considerations
HIV is the strongest risk
factor for progression to
active disease
HIV kills CD4+ T Helper cells
which normally inhibit M.
tuberculosis
HIV interferes with PPD skin
test
Protease inhibitors interfere
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MDR tuberculosis
Multidrug resistant tuberculosis has
become a global threat.
In 1993 WHO declared Tuberculosis a
Global emergency
Animals shed the bacilli in Milk,
humans get infected after drinking
the unsterilized Milk
Pasteurization has reduced the
incidence of Bovine tuberculosis.
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Why Tuberculosis
continues to be
Important
Someone in the world is newly infected
with TB bacilli every second.
Overall, one-third of the world's population
is currently infected with the TB bacillus.
5-10% of people who are infected with TB
bacilli (but who are not infected with HIV)
become sick or infectious at some time
during their life. People with HIV and TB
infection are much more likely to develop
TB.
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Treatment
Drugs used :
1- First line drugs :
- Isoniazid - Rifampicin Pyrazinamide
- Ethambutol
- Streptomycin
2- Second line drugs (more toxic and less
effective):
- Kanamycin
- capreomycin
Cycloserin
- ethionamide
- ciprofloxacin
Ofloxacin
* Noncompliance (failure to complete the course):
Directly observed therapy (DOT)
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Immuno-prophylaxis
Intradermal injection of live
attenuated vaccine Bacille CalmetteGuerin (BCG).
The strain causes self limited lesion
and induces hypersensitivity &
immunity.
Coverts tuberculin negative person
to positive reactor.
Immunity lasts for 10-15 years.
Immunity 60-80%
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BCG
Given at birth without tuberculin
testing
Protects against TB, the disease
runs milder course in protected,
prevents skeletal, meningeal &
miliary forms.
Also found useful in leprosy,
leukaemias and other
malignancies by non-specific
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Programme created by
Dr.T.V.Rao MD for
Medical and
Paramedical students in
the Developing World
Email
doctortvrao@gmail.com
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