The Greeks called the disease

“Phthisis” (consumption) emphasizing

the dramatic aspect of general wasting
(I waste away)
Study of TB Morton first called “Phthisiology”
The term “Tuberculosis” was first used
by Laennec referring to the small scars seen in the tissues
micobacterium tuberculosis complex-
M. tuberculosis/hominis,
M. bovis , M. africanum
The most frequent cause of pulmonary
tuberculosis is
M. Tuberculosis/hominis
M. Bovis - extrapulmonary
responsible for tuberculosis in domestic or
wild cattle. It is resistant to Z
Infection often passes to humans through
milk
obligate aerobe.

O 2
1882

R.Koch
M. tuberculosis is slightly
curved or straight
bacillus in size:

1-10 μm length
0,2-0,6 μ
m
width
neither gram-positive, nor gram-negative
Gram stain is not used
These organisms are also known as:
as acid-fast bacilli (AFB)
because they keep dye even after
washing with acid and alcohol)
The high lipid content
(mycolic acid) of their
cell wall makes
mycobacteria acid-fast
(alkali, alcohol)
M. tuberculosis cell wall contains:

wax
severalD, one
proteins
of the: active components, which is used

•mycolic acids
• combined with waxes - elicit delayed hypersensitivity
several
to enhance
antigens incomplex
theskin
the immune lipids:
, which
test (alsoresponse
as thetotuberculin
contribute
known many
to the antigens
skin test, in
experimental
organism’s
long-chain (C78
Mantoux test)areanimals
acid-fastness
– C90)
the sourcefatty acids called
of PPD (purified protein derivative) used for Mantoux test
Phosphatides (play a role in caseous necrosis)
The
The trehalose
trehalose6,6′-dimycolate,
6,6′-dimycolate, oneone of
of the
the
mycolic
mycolic acids,
acids, promotes
promotes to to the
the organisms
organisms stick
stick
together
together and
and lead
lead to
to formation
formation plait-like
plait-like
colonies
colonies on
on liquid
liquid medium.
medium.
This
This phenomenon
phenomenon isis called
called CORD
CORD FACTOR
FACTOR

Cord
Cord factor
factor isis correlated with virulence
correlated with virulence
of
of the
the organism.
organism.
Virulent
Virulent strains
strains of
of M.Tuberculosis
M.Tuberculosis grow
grow in
in
characteristic “serpentine”
aa characteristic “serpentine” cord-like
cord-like
pattern
pattern,, whereas
whereas non non virulent
virulent strains
strains do
do
not
not
 Tubercle bacilli are rapidly destroyed in
the ambient environment by ultraviolet
rays.
Direct sunlight kills MT in 5 minutes, but
they can survive in the dark for long
periods
Boiling quickly kills MBT
M. tuberculosis growth slowly

it has doubling time of 18-24 hrs

in contrast to most bacteria, which can double in
number in 1 hr or less
Forms of MBT
They can appear as

1. Branching forms
2. Cocoid elements
3. Rods
4. Filtrative forms
5. L- forms
6. Mycelium like forms
7. Ultra-fine(viral forms)
8. Drug resistant forms
o Also except MBT complex
there are

o M. leprae (the cause of leprosy)

o Atypical mycobacteria
M. Kansaii, M. marinum
M. Scrofulaceum
M. avium-intracellulare complex
M. fortuitum-chelonei complex
M. smegmatis
(rapidly growing atypical
mycobacterium)

is a part of the
normal flora of
smegma
Doesn’t develop
human disease
What is pathogenicity?
It is an ability of micro
organism to live and
reproduce inside macro
organism and cause specific
changes in it
What is virulence?
It is a degree of expression
of pathogenecity
 Ways of
transmission
• Airborne
Alimentary
• From milk products
• From sick animals
Contact
• through damaged skin
And mucous membranes
Transplacental
TB Pathogenesis
Immunology
1. Airborne
2. Alimentary
3. Contact

4. Transplacental
 • Air-droplets
• Air-dust
which are less than 5 μm in size are very
dangerous

…so the host can aspirate MT-s that are locatec both in the air droleps or air dust
Mtb do Not have
exotoxin
Delayed immune response
reaction appears in
2-3 weeks after infection
Monocytes

 Migrate through the blood

stream to organ around the body

 Adapt to their new environment

 Become macrophages
 Micobacteria

invasion

Ciliar
system

Effective defense – ineffective defense –

major part of bacteria bacteria cause an
is successfully infection
eliminated
 Macroph
age

incomplete Complete
phagocytosis phagocytosis
incomplete
phagocytosis

Normally
 phagosome
incomplete
phagocytosis

lysosome
 phagosome
incomplete
phagocytosis

But in case of incomplete

phagocytosis
lysosome
ncomplete
phagocytosis
PH > 5
incomplete
phagocytosis

Also it affects T-cells and decreases production of

INFy
Containers, phagocytosis-
macrophages have
Dual role

L-form
Macrophages- IL1, IL6, TNF-α

CD4+ lymphocytes- IL, γ-INF

High amount of TNF-α will cause tissue
necrosis, cavity formation and massive
muscle loss
SO IT has DUAL role too
NK cells (Natural Killers)
 Develop in the bone marrow
 Have a cytotoxic (cell killing)
ability

 Produce signaling chemicals called

cytokines

 Can destroy tumor cells

1.Caseous
necrosis(cheese
like)
2.macrophages
3.Epithelioid cells
4.lymphocytes
5.Giant-Pirogov
Langhans
6.Fibroblasts
Specific – formation of tubercles
with caseous necrosis when they
run together to become confluent

Non specific – edema\swelling,

cell’s reaction and fibrous changes
• Delayed immune response reaction
appears in 2-3 weeks after
infection
• Expressed cellular immunity is
formed after 8 weeks
Developing of DTHR(formation of TB granulomas)
Or in 5-10% Granulomas
effectively hold MT
of cases
inside them and
TB disease inhibit their growth
develops (non sterile
immunity)
M. tuberculosis can’t
multiply inside the
granuloma because of the:

Acidic pH

Low oxygen and iron levels

Toxic chemicals produced

by necrosis
Factors that increase the risk of
infection
immunosuppresion
co-morbidity
poor nutrition
length of contact
number of bacilli
size of droplet nuclei
Non sterile immunity- it
means that immune system
successfully protects us from infection
but bacili are not completely
killed,they are just suppressed and
inhibited and stay in that way for long
time
What is a case of tuberculosis?

“TB case” is A PATIENT in whom

tuberculosis has been confirmed
bacteriologically or diagnosed by
clinician

55
Due to the development of active
tuberculosis the greatest importance
is attached to

. the massiveness of the infection

. the duration of contact with the source
of infection
. the input pathways of infection
. the resistance of the human body
EPIDEMIOLOGY of TB
During the past 10 years rates of
morbidity and mortality have
been increased. The main
reasons for which are:
• Deterioration of socio-
economic conditions in Eastern
Europe
• Increased migration of
population
• Drug resistance
• Growth of diseases that
inhibiting immunity (especially
HIV/AIDS)
Smear positive patients can
infect 10 people in a year
Directly
Observed
Treatment
Short course
H R ZE S
Isoniazid(hydrazide of isonicotinic- acid)
Rifampicin
Pyrazinamide
Ethambutol
Streptomycin
1.
1. Incidence
Incidence of
of TB
TB infection
infection (TB
(TB infecting)
infecting) isisthe
the
number
numberofofpersons
personswith
withfirst
firstpositive
positivetuberculin
tuberculinskin
skin
test
testwithin
withinaayear
year(%)
(%)

2.
2. Incidence
Incidence of
of aa disease
diseaseisisexpressed
expressedby
bythe
thenumber
number
of
ofnew
newTB
TBcases
casesoccurring
occurringwithin
withinaayear
yearper
per100.000
100.000
population.
population.

3.
3. Prevalence
Prevalence of
of aa disease
diseaseisisthe
thenumber
numberof
ofall
allTB
TB
cases
casespresent
presentin
inthe
thecommunity
communityper
per100.000
100.000
population.
population.

4.
4. Mortality
Mortalityisisexpressed
expressedas
asthe
thenumber
numberof
ofTB
TBdeaths
deaths
 TB case

pulmonary
pulmonary -- PTB
PTB

extra
extra pulmonary-
pulmonary-ExPTB
ExPTB
 Pulmonary cases are
classified as:

• sputum smear-positive
(open pulmonary)
• sputum smear-negative
64
 New case

New case is a patient who

65
What are the ESSENTIAL
STEPS in TB DIAGNOSIS ?
• Contact with smear positive
TB case
• Clinical screening by
assessment of symptoms
suspecting TB
• Sputum smear microscopy,
culture
• PCR, GeneXpert MTB/RIF
• Chest X-ray, CT
• TST
• IGRA
• biopsy
 Sputum
microscopy
As a sample we can use

1. Sputum

2. Bronchial washings
1. Fluid from serous effusion
2. Cerebrospinal fluid(CSF)
3. Pus
4. Stool
5. Biopsy fragments
 Saliva
is
not sputum
An early morning sputum sample is more
likely to contain TB bacilli than one taken later
in the day
Secretion builds up in the airways overnight

80%
● it is recommended to examine
3 specimens (at least during 2 days) 12%
Many studies have shown that doing one
specimen we detect about 80-83% of
8%
infectious cases, 10-14% more on the second
fluorescence microscopy with
auramine
• Classic hot Ziehl-Neelsen
stain method
 ZIEHL-NEELSEN STAIN
Classic Ziehl-Neelsen stain
Needed reagents:

 fuchsine
acid alcohol or sulphuric
acid(H2SO4)
methylene blue
Culture
 Lowenstein-Jensen agar
If growth in the culture occurs, the organism can be identified
by biochemical tests.

M.tuberculosis(hominis) produces
niacin whereas almost no other
mycobacteria do
It also produces catalase and nitrate-reductase and that’s why
can restore (reduce) nitrates

More rapid identification tests using DNA probes are also

available
78
We can have results
after 2-8 weeks
Atypical micobacteria

This colonies produce yellow pigment and are too

smooth, wet and shining to be M. tuberculosis
 liquid
BACTEC
medium
BACTEC
MGIT 960
Rapid diagnosis of
BACTEC MGIT 960
Drug resistant TB
82
7-10 days
GeneXpert
MBT/RIF
90 minutes
Tuberculin
is an ultrafiltrated product
of vital activity of MBT
It contains
• Proteins
• Lipids
• Carbohydrates
• Nucleic acids
• TWEEN-80
(it prevents adsorption to the glass)
Alt tuberculin it’s a tuberculin
with proteins from growing media

(so it can give false results )

PPD solution (purified protein
derivative)

• PPD-RT23
• PPD-S (Seibert )
• PPD-L (Lennikova)
there are different variants of TST

• Mantoux test
• Heaf test
• Koch test
• Koch TST
(provocation test –that we use to
check activeness of TB )
TB activeness is determined by
following changes after Koch test

• general clinical
• local (x-ray changes,sputum
changes,thoracic signs)
• skin reaction/changes
Mantoux test
We use TST for several Aims

• For early diagnosis

• To find TB converters and people with
hyperergic reaction
• For surveillance of incidence of infection
• For differential diagnostics
• To check the need of revaccination
Mantoux TST technic

• Volume 0,1 ml (2 or 5 TU/IU)

• On anterior surface of
forearm
• Intradermal injection

TU = amount of tuberculin which

cause “+” reaction among 80-90 % of
infected people
• TB infected person develops allergy to tuberculin
• Among infected people Injected tuberculin produces
delayed local reaction
• This reaction indicates the degree of allergy
We interpret the results of TST after 48-72
hours

12h h
24
36
48
48-72
 Negative TST

• Induration less than

5mm

But remember “ - ” TST doesn’t

exclude TB
Because some forms of TB can
also show “ – “ TST result
 We have results in 2 cases

Positive anergy Negative anergy

People who have

• TB meningitis
Non infected • Miliary TB
people • Caseous pneumonia

• Co-infection
(HIV + TB)
 CONDITIONS THAT MAY SUPPRESS
THE TUBERCULIN SKIN TEST

• HIV infection
• Malnutrition
• Severe bacterial infections, including TB itself
• Viral infections (measles, chickenpox)
• Cancer
• Immunosuppressive drugs, steroids
• Incorrect injection of PPD
Positive TST

• Induration 10 and
more than 10mm
cause of weak tuberculin response is
sensitization due to atypical Mycobacteria

 A positive result is usual after BCG

vaccination but usually, is weaker with
diameter less than 10 mm and has a
tendency to decrease over the years (4-5-7
years) becoming negative
FALSE-POSITIVE REACTIONS AND FALSE-NEGATIVE RESULTS CAN
HAVE VARIOUS CAUSES

◙ False-positive reactions often are attributed to

 asymptomatic infection by environmental non

tuberculous mycobacteria (due to cross-reactivity)
 vaccination with live-attenuated virus
 Other diseases(pneumonia,reumatism)

◙ False-negative results may be due to

 anergy
 immunosuppression
 immune deficiency
 malnutrition
 improper administration
 Positive Allergy

• “+” allergy - Firm stable TST

(12mm) upon months and years
• Intensification of the previous
doubtful positive reaction by 6
mm and more
PPD converter –
is a person who
after -TST has got
+ TST
5-10 mm is not definitely “ + “
(doubtful)

We consider it as
among
-HIV-infected persons
-A recent contact of a person with TB
disease
-Persons with fibrotic changes on chest
radiograph consistent with prior TB
-Patients with organ transplants
-Persons who are immunosuppressed
for other reasons (e.g., taking the
equivalent of >15 mg/day of
prednisone for 1 month or longer,
taking TNF-a antagonists)
Hyperergic or strong Positive
TST

• Induration 17mm > among

children and teenagers
• 21mm > among adults
• If as a reaction we have
lymphangitis
• Lymphadenitis
• Vesiculo necrotic changes
• ulcerative changes
 HEAF TEST
• In this test a simple instrument – HEAF GUN
– is used
• Its common in Britain
changes of the general
blood test- leucocytosis
with lymphopenia and
increased ESR