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Pulmonary Tuberculosis

Mohd Hanif Gandoh

Clinical Features

chronic cough >2 weeks

loss of appetite
unexplained weight loss
night sweats and fatigue
Investigations and Diagnosis
chest xray
-usually shows upper lobe
consolidation, sometimes with
Management of PTB
- to cure patient
-to reduce morbidity and mortality
-to protect the patient family and community from infection
-to prevent development of resistant bacteria
indication for hospitalization
-very ill, respiratory distress, dissaminated tb, MDRTB, patient with poor
compliance, patient who developed severe side effect to treatment

supervision and monitoring of treatment

-all patient should be on Directly Observed Treatment (DOTS)
-hospitalization if DOTS is not possible
-at time of diagnosis, baseline investigations should be done.
-patient should be reviewed by doctor at least in 2 months during treatment
-upon completion of treatment, patient should be followed up at 3,9,18 months
with sputum DS for AFB and CXR.
Anti Tubercular Therapy

First line drugs: Second line drug:

Isoniazid (H) amikacin,kanamycin
Rifampicin (R) cycloserine
Pyrazinamide (Z) ciprofloxacin
Streptomycin (S)
Ethambutol (E) dapsone
Treatment categories

Category 1 : New case

Category 2 : Relapse, treatment after interupption , treatment failure
Category 3 : Chronic case
Category 1 : New Case

Intensive phase Maintenance phase

( 2 months) (4 months)

2EHRZ or 2SHRZ isoniazid

or 2HRZ rifampicin
treatment less 6 months results in high relapse and is not
if rifampicin cannot be used, drug therapy should be extended to 12-
18 months
if isoniazid cannot be used, then patient can be treated with
rifampicin, etahmbutol, pyrazinamide for 9 months
if ethambutol cannot be used , streptomycin can be used to replace
if pyrazinamide cannot be used, treat for 9 months.
Category 2 : Relapse, treatment after interruption,
treatment failure
send TB culture and sensitivity test. Rapid culture method can be
used if available
rpoB gene analysis
refer to chest physician for further advice
Relapse and Treatment failure
check compliance, drug dosages, underlying diabetes or
Do sputum C/S and review previous C/S
consider WHO retreatment regimen (2SHRZE/1HRZE/5HRE) while
awaiting C/S result
consider second line drugs if multi drug resistance
Treatment after interruption
Re-evaluate patient to confirm diagnosis, assess sputum AFB status
Educate the patient
treatment need to be restarted from the beginning if interruption 2
weeks during intensive phase or >2 months during maintenance
if interruption less than mentioned above, treatment can be
continued and prolonged to replace missing dose
Category 3 : Chronic Case

sputum specimen sent for culture and drug sensitivity test (DST).
Rapid molecular DST should be done if available.
All patient should be referred to physician experience in treating drug
resistance TB for consideration of MDRTB regimen before DST
Side Effects of Anti-Tuberculous Drugs
Isoniazid Rifampicin Pyrazinamide Streptomycin Ethambutol
Major -Peripheral -Hepatitis -Hyperuricaemia - 8th nerve -Retrobulbar
neuropathy -Rash -Hepatitis damage neuritis
-Hepatitis -GI disturbance -GI disturbance -Rash -Arthralgia
Minor -Lupoid -Interstitial -Rash -Nephrotoxicity -Peripheral
reactions nephritis -Photo- -Agranulocytosis neuropathy
-Seizures -Thrombo- sensititasion -Rash
-Psychoses cytopenia -Gout
Management of TB in specific situation
a) Tuberculosis in pregnancy and lactation
-isoniazid ,rifampicin,ethambutol and pyrazinamide are safe to be used
-Streptomycin should be avoided (feotal ototoxicity)
-pyridoxine (25mg/daily) should be given to all prregant women( feotal neurotoxixity)
-first line antiTB are safe in breast feeding

b) Women taking OCP

-rifampicin reduce the contraceptive efficacy
-take higher dose of estrogen following consultation with physician or could take another
form of contraception
c) Renal impairment
-avoid streptomycin if possible (nephrotoxicity)
-adjust the dose of pyrazinamide and ethambutol to three time weekly
d) Liver disease
-patient can recieve the usual short course chemotherapy regiments
provided there is no clinical evidence of Chronic liver disease, hepatitis
, excessive alcohol consumption
-baseline liver enzyme (ALT) should be done at begining of treatment.
-drugs should be stopped if liver enzyme rise >3x or patient develops
-in established chronic liver disease:(depend on severity)
2 hepatotoxic drugs regimen :2SEHR/6HR ,2EHR/7HR,9REZ
1 hepatotoxic drug regimen : 2SHE/10HE
no hepatotoxicity drug regimen : 18-20 months of
streptomycin,etahmbutol and flouroquinolone
-pyrazinamide should be avoided if possible in established liver disease

e) positive AFB after 2 months of intensive treatment:

- check compliance , drug dosages, underlying DM or
-extend intensive treatment for 1-2 months and do sputum C/S if not
-If AFB remains postive after 3-4 months consider WHO retreatment
regiment or 2nd line drugs according to C&S
e) Extrapulmonary tuberculosis
- tuberculous meningitis, miliary tb, and bone and joint tb
- treatment may have to be extended to at least 1 year (2 months
intensive and 10 months triweekly)
-TB lymphadenitis (9-12 months)
-considered steroids therapy
Steroids therapy
a) indication b) dosage and duration
cerebral disease or meningitis TB meningitis : Dexamethasone
severely ill patients who 0.4 mg/kg/day
peritoneal and pericardial TB TB pericardium : Prednisolone
60 mg daily for 4w
renal infection , TB of the eye
and larynx
drug hypersensitivity reactions