TUBERCULOSIS IMMUNE RESPONSE,

TUBERCULIN TEST, & VACCINATION

BCG
DR. YANTI SUSIANTI SPA (K)
MONDAY, JANUARY 13 T H 2020
MODUL RESPIROLOGY
Introduction
In Indonesia suspect 1 million new patients tuberculosis (TB) per
100.000 population
2015 330.812 new TB cases
Variation every province 0,12% until 50%  different endemicity or
quality for diagnosis TB
Treatment TB in children : clinical symptoms, government program, and
public health efforts
About 500.000 children suffer from TB every year
200 children died in the world caused TB, 70.000 children died caused
TB every year
 ...introduction
TB in children : 0-14 years old
TB in children mostly range aged 5-14 years old
In developing countries the number of children less than 15 years old
was 40-50%.
Proportion TB children in Indonesia 2010 9,4%, 2011 8,5%, and 2012
8,2%, tahun 2013 7,9%, tahun 2014 16%, dan 2015 9%
Proporsi bervariasi antar Provinsi dari 0,12% sampai 50% mungkin
menunjukkan endemisitas yang berbeda antara provinsi atau karena
perbedaan kualitas diagnosis TB pada anak pada level Provinsi.
BTA + in 2010 5,4%, 2011 6,3%, and 2012 6%
Tuberculosis (TB)
Ancient Egyptian reliefs : people with gibbus
The disease is caused by bacteria
Mycobacterium tuberculosis and bovis
In 1882 this bacteria found by Robert Koch
TB is still mayor public health problem
worldwide.
Etiology
Mycobacterium tuberculosis and
Mycobacterium bovis

Characteristic :
1. Resistant for weeks in a dry
atmosphere
2. Not resistant to sunlight, ultraviolet
light, temperature ≥ 60°C.
3. Endotoxin (-), exotoxin (-)
4. Hematogen spread
5. Slow growing(24-32 hours)
6. Clinical manifestation not specific
7. Aerob, lung is organ
predilection
1. Replicates narrow spectrum becomes
dorman
 …tuberculosis
 Special issue on TB children: diagnosis, theraphy, preventif ,
and TB in HIV infection
 Most clinical manifestation TB in children not typical
 Diagnosis TB children difficults, often overdiagnosis 
overtreatment
 In the other hand underdiagnosis  undertreatment
Transmission
Adult patient, active pulmonary TB
cough, sneezing, talking, singing
droplet nuclei: 1-5
In the air can last for a long time
Inhalation, until alveoli, middle and lower lobe
Incubation period 2-12 weeks (4-8 weeks)
 Pathology
reg lymph node primary focus remote foci

resolution milliary spread

tubercle formation

calcification caseation granuloma

compresses airway fibrosis tuberculoma

liquefaction
cavity
aerodes airway

bronchiectasis 2nd lung lesions rupt to pleura rupt to airway

br pl fistula
Pathogenesis ...
lymphadenitis

lymphangitis

primary focus
 droplet nuclei
alveoli ingestion by PAM’S
inhalation

intracellular replication
of bacilli
destruction
destruction of PAM’S of bacilli

Tubercle formation Lymphogenic spread Hilar lymph nodes

primary focus lymphangitis lymphadenitis

hematogenic spread
primary
acute hematogenic occult hematogenic
complex
spread spread

multiple organs
CMI
disseminated primary TB remote foci
Figure. Pathogenesis of primary tuberculosis
TB immune Response
The body’s response to Mycobacterium tuberculosis: humoral and
celular responses
Humoral response mediated by B lymphocytes
Serological tests are sensitive & specific is not easy to find

TB germs consists of a variety of protein, carbohydrate, fat,

lipopolisaccharide, glicolipids, peptidoglikolipid & glycoproteins  Σ
Ag & epitop >> and complicated Ab production>> Ag
 …tb immune response
• Response to an Antigen TB varies to everyone  key humoral
immunity
• Influenced by several factors:
- Imunogenetic infected host
- Each stages production Ag varies
- Gene expression
- Σ bacteria in sputum
- TB treatment
 …tb immune response
Only ¼ from hundred protein in culture filtrate can react strongly
with Ab in serum of TB patiens
Positive Ab especially in the case of TB with cavities  Ag especially
when the process of replication of the bacteria extracellular inside
softening granuloma

Ab: IgM, IgG, and IgA

IgG most sensitive for determining active TB
IgA more specific for the diagnosis
IgM weakest but can assess TB rectifation
Combination IgA & IgG  sensitivity & specificity 90 % can found
active TB
Cellular immune response
 Mostly human body can prevent infection TB wit coordination
immune response through a network of cytokines
 Proinflammatory cytokines  leukocyte cells migration to germ TB
 Infected macrophages & dendritic cells produces IL-12 and IL-8
 IL-12 is most important cytokines to eradication germ TB
 ...cellular immune response
 IL-12 regulated immune response to Th1 response Interferon (IFN-
γ) production will supress productin IL-10 & IL-4
 Genetic deffect in IL-12, IL-12 receptor, or IFN-γ more susceptible to
tuberculosis infection
 Macrophage & T cell productin tumor necrosis factor –α (TNF- α)
 ...cellular immune response
 TNF- α and IFN-γ the mayor cytokines to activated 
 production macrophage inducible Nitric Oxide Synthase (iNOS)
 Keep tract Reactive Nitrogen intermediates (RNi)
 Formation effector molecule oxidatif

 Granuloma influenced by TNF- α and IFN-γ, and also TGF-β

(Transforming Growth Factor β) and limfotoksin α3
 ...cellular immune response
Oxidative molecule & nitrostative can supressed growing bacteria but
they can’t elimination the bacteria from cell
TB bacterian resistant from host effector mechanism because
peroxide and phosphonitrite reductase produced by the metabolism
of bacteria TB
TNF- α & TGF-β : developed a wall of fibrinous and granulation
encapsulation
 ...cellular immune response
 TNF- α prevent endogen spread bacteria by the modulating cytokines levels 
limiting the histophatologic process
 TB stimulating cytokines:
a. Proinflammation cytokines: TNF- α, IL-1β, IL-6, IL-12, IL-8, IL-15,& IFN-γ
b. Anti-inflammatory cytokines : IL-4, IL-10, & TGF- β
Inflammatory response to the
activation of phagocytic cells
bacteria TB
Mechanisms of cell activation of T lymphocytes,
machrophages detruction after stimulation
antigen bacteria TB
 Complications of nodes
1. Extension to bronchus
Complications of focus
1. Effusion 2. Consolidation
2. Cavitation 3. Hyperinflation
3. Coin shadow MENINGITIS OR MILIARY
in 4% of children infected
under 5 years of age
LATE COMPLICATIONS
Renal & Skin
Most children Most after 5 years
become tuberculin BRONCHIAL EROSION
sensitive
3-9 months
Uncommon under 5 years of age Incidence decreases
PRIMARY COMPLEX 25% of cases within 3 months As age increased
A minority of children 75% of cases within 6 months
Progressive Healing
experience :
Most cases
1. Febrile illness
BONE LESION
2. Erythema Nodosum Most within
3. Phlyctenular Conjunctivitis
1 2 3 4 3 years
5 6

infection Resistance reduced :

1. Early infection
(esp. in first year)
2. Malnutrition
3. Repeated infections :
measles, whooping cough 24 months
4-8 weeks 3-4 weeks fever of onset 12 months streptococcal infections
4. Steroid therapy
Development
Of Complex DIMINISHING RISK

But still possible

GREATEST RISK OF LOCAL & DISEMINATED LESIONS 90% in first 2 years Miller FJW. Tuberculosis in children, 1982
Factors affecting prognosis
A. BacteriaTB :
 Virulence bacillus TB
 infected dosages
B. Host factors:
 General state
 Age
 Nutitional status
 Infection again, example measles
 Physical and psychological pressure
 Presence of other disease
 Genetic
Classification TB (ATS/CDC modified)

Class Contact Infection Disease Treatment

0 - - - -
prophylaxis
1 + - - I
prophylaxis
2 + + - II
3 + + + treatment
 Diagnostic
Clinical manifestation
Tuberkulin test
X-rays
Microbiological examination
Anatomic pathological examination
Peripheral blood examination
Source infection
The others : - bronchoscopy
- serological
- interferon test
Clinical
manifestation
Clinical manifestation
Without symptoms
General symptoms/non-specific
Specific symptoms/specific
General symptoms/non-
specific
Chronic fever
Anorexia and body weight ↓ / not increased
Malnutrition
Malaise
Chronic cough
Continued or recurrent diarrhea
The others
 Specific symptoms
Respiratoric : cough, dyspneu, wheezing
Neurologic : seizures, stiff neck
Orthopaedic : gibbus, lame
Lymphe : hyperthrophy, scrofuloderma
Gastrointestinal tract : continuing diarrhea
The others
What is this?
Tuberculin Tests
 TUBERCULIN Tests
Tuberculin PPD-S Tuberculin OT
Strength
mg/dosage TU PPD RT 23 2 TUmg/dosage Dilution
Mild 1
0,00002 1 - 0,01
(First) 10,000
1
0,00001 5 2 -
Moderate 2,000
(Intermediate) 1
- 10 5 0,1
1,000
Strong 1
0,005 250 100 1,0
(Second) 100
PPD (Purified Protein Derivative) RT 23 2TU
From culture 7 strain special Mycobacterium
tuberculosis
 How to perform tuberculin
test
1. Mantoux test : intracutaneus injection
2. “Multiple puncture” : Heaf method 6 needle
Tine method 4 needle
3. “Patch test”
How to perform Mantoux test
With needle size 25-26 gauge
Take > 0.1 ml of fluid and remove air
Intracutaneus injection 0.1 ml in volar
forearm
Read the results after injected 48-
72 hour
Measuring the diameter of
induration not hyperemia
stated in mm
 Standard dose of Tuberculin test
Mantoux method 0.1 ml PPD - RT23 2 - 5 TU
PPD-S 5 - 10 TU
1 1
OT --------- - ---------
2.000 1.000
Intracutaneus injection, regio volar forearm

Diameter induration :
0 - 5 mm : negative
5 - 9 mm : positive/doubting
> 10 mm : positive
The meaning of positive
tuberculin test
1. TB infection :
 dorman (not active TB)
 active (active TB)

2. Immunization / BCG infection

3. Mycobacterium atipic infection
 Anergi
Tuberculin test negative for a while can be caused:
Severe TB such as milliary TB
Severe malnutrition
Long corticosteroid therapy
Virus infection : measles, varicella
Bacterial infection: typhoid, diphteria, pertussis
Virus vaccination: measles, polio
Malignancy : Hodgkin’s disease
Radiologic feature
 Radiologic examination
Routine : lung x-rays
The indication : bone, joints, abdomen
Lung x-rays not always typical
Lung x-rays anteroposterior and lateral view  lateral view more clear to
see enlarged lymph nodes
If we found diskongruensi (no match) between severe lung x-rays and mild
clinical manifestation  suspicious TB
Lung x-rays
Enlarge lymphe nodes in hilar or paratracheal with or without
infiltrates
consolidation segmental/lobar
Atelectasis
Calsification with infiltrates
Tuberculoma
Pneumonia
Cavitas
Pleural effusion
Milliary TB
Microbiological
examination
 Microbiological examination
Confirm the diagnosis TB
Direct smear microscopic examination to find acid-resistant bacteria and
culture M.tuberculosis examination
Adults: sputum examination, children with gastic lavage 3 days in a row
The results of culture takes 6-8 weeks, with Bactec cultures 1-3 weeks
 …microbiological
examination
PCR (polymerase chain reaction) : specific deoxyribonucleotic acid (DNA)
sequence amplification techniques
Hope will have high sensitivity
Weakness: variations in the level of sensitivity of PCR in the laboratory,
it’s easy contamination of other germ or bacteria  false +, and high
prices
Anatomic pathology
examination
Anatomic phatology
High value, specific picture
Granuloma: perkijuan (caseosa), characteristic or a necrosis caseosa
area in the middle of granulomas
Histopathologic: caseosa, epiteloid cells, lymphocytes, and datia
Langhans cells sometimes found in acid-fast bacilli
The easier speciment and always be check are lymphadenopathy colli
Peripheral blood
examination
Peripheral blood examination
Not specific
We can found high erythrocyte sedimentation rate (ESR)
Leukocyte count : high lymphocytes
WHO not recommended examination TB serology  examples IgG TB,
PAP TB, ICT TB, MycoDOT for diagnostic tools for TB
Source of
infection
Sources infection
Children cases : you must found the TB adults
The symptoms varies in adults : fatigue, ↓BW, night sweats, hemoptoe,
TB meningitis, milliaryTB and the others
Tuberculosis adults patients if we found +3 acid resistant bacteria (BTA)
from sputum
 Sources infection
Contact with active TB patients  diagnostic criteria
Shaw said (1954) TB patients with :

BTA (+) : 62.5 % contact Mt (+)

BTA (-), culture M.tb (+) : 26.8 % contact Mt (+)
BTA (-), culture M.tb (-) : 17.6 % contact Mt (+)
Bronchoscopy
Bronchoscopy
We can do this procedure if we found the cases no match between
clinical manifestation and the other supporting examination
Respirologist do that procedure
High price, manuver is difficult in young children
Serological
 Serological
Various research and development of immunological examination of specific
Ag-Ab for M. tuberculosis  PPD, A60, 38kDa, lipoarabinomanan (LAM)
Sample: blood, sputum, pleural fluid, bronchus fluid (bronchus &
bronchoalveolar lavage/BAL), and CSF
Examination: PAP TB, Mycodot, immunochromatographic test (ICT)
Interferon test
(interferon gamma
release assay, IGRA)
 Interferon test (INF-γ)
Tuberculin tes and INF-γ test  inflammatory cytokines
released from T lymphocytes cells, previously sensitized
by M. Tuberculosis Ag
INF-γ test  lymphocytes in peripheral blood smear
darah stimulated in vitro and level INF-γ produced by T
lymphocytes sensitized cells was measured by ELISA
Higher specificity of the tuberculin test, no cross rection
with vaccination BCG and M.atipik infection
Quantiferon TB gold & T-spot-TB
Guideline WHO for Diagnosis
TB in children
•Sick children, contact history with pasien definitive diagnosis TB
Suspicious •Children with:
•Clinical manifestation do not improve after measles or whooping cough
•Weigh loss, cough & wheezing do not improve with antibiotic theraphy for
TB respiratory disease
•Superficial enlearged lymph nodes doesnt hurt

•Chidren suspicious TB plus:

•Tuberkulin test + (≥ 10 mm)
May be TB •Lung x-rays: suggestive tubeculosis
• Histological biopsy suggestifvet uberculosis
•A good response to therapy TB

Confirmed • We found bacille tuberculosis in smear or culture

• Identification Mycobacterium tuberculosis on the
TB characteristic of culture
Scoring system to diagnosis TB in children
Parameter 0 1 2 3

Kontak TB Tidak jelas - Laporan kel (BTA – atau BTA (+)

tdk jelas)
Uji Tuberkulin negatif - - + (≥ 10 mm atau ≥
5mm pada keadaan
imunosupresi
BB/Keadaan gizi - BB/TB < 90% atau BB/U Klinis gizi buruk atau -
< 80% BB/TB <70% atau BB/U
< 60%
Demam tdk diketahui - ≥ 2minggu - -
penyebabnya
Batuk kronik - ≥ 3 minggu - -

Pembesaran kelenjar - ≥ 1cm, jumlah >1, tidak - -

limfe kolli, aksila, nyeri
inguinal
Pembengkakan - Ada pembengkakan - -
tulang/sendi panggul,
lutut, falang
Foto toraks N/kelainan tdk jelas Gambaran sugestif TB* - -
 ...scoring system to diagnosis
TB in children
Catatan:
◦ *Gambaran sugestif TB: pembesaran kelenjar hilus atau
paratrakeal dgn/tanpa infiltrat, konsolidasi segmental/lobar,
kalsifikasi dgn infiltrat, atelektasis, tuberkuloma. Milier tidak
dihitung dlm skor karena diperlakukan secara khusus
◦ Sebaiknya disediakan tuberkulin di tempat pelayanan
kesehatan
◦ Pasca imunisasi BCG, terjadi reaksi cepat ≤ 7 hari, evaluasi dgn
sistem skoring TB anak, BCG bukan alat diagnostik
◦ Diagnosis kerja TB bila jumlah skor ≥ 6 ( maksimal 13)
 Treatment of TB
In the beginning intensive phase 2 months and continuing phase 4-10 months,
depend on the severity of the disease and bacterial examination
Combination 3 or more drug TB
Regular and long treatment
Adequate nutrition
Treatment and preventing from the others disease
 Anti- Tuberculosis Drugs (ATD)
1. Isoniazid (INH) : 10 (7-15) mg/Kg BB/day, max. 300 mg/day
oral 1 - 2 x / day
2. Rifampicin : 15 (10 – 20) mg/Kg BB/day, max. 600 mg/day
oral 1 - 2 x / hari, empty stomach
3. Pyrazinamide : 35 (30 – 40) mg/Kg BB/day, max. 2 gram/day
oral 1 - 2 x / hari
4. Streptomycin : 15 - 40 mg /Kg BB/day, max. 1gram/day
IM
5. Ethambutol : 20(15 – 25) mg/Kg BB/day, max. 1,5 gram/day
oral 1 x /day, empty stomach
6. The others : Ethionamide, Kanamycin, Cycloserin,
Ciprofloxacin
 TB bacilli in patient
Cavitas, inside machrofage
Caseosa
extracellular (intracellular)

total population 107 - 109 104 - 105 104 - 105

Metabolism and Slowly and

Active Slowly
proliferation intermittent

pH Neutral/bases Neutral Acid

The effectiv e drug INH, RIF,

RIF, INH PZA, RIF, INH
(in a row) STREP
Toman K. Tuberculosis, WHO, 1979
Guideline
 Treatment of Tuberculosis
INH
RIF
PZA
EMB
STREP
PRED

1 bl 2 bl 6 bl 9 bl 12 bl
Guideline from patients
treated irregular
Retreatment TB in children
Supelementation
You can give vitamin B6 to minimize peripheral neuritis or less intake
vitamin B6
Dosage 5-10 mg per 100 mg INH per day in patients with HIV or severe
malnutrition
Treatment outcome
Preventive
Socio-economic changes
Chemoprophylaxis
Immunization: BCG
Vaccination BCG
 Vaccination BCG
• BCG (Bacille Calmette-Guerin): vaccine from
live attenuated Mycobacterium bovis
• Vaccination BCG does not prevent TB infection
but the risk of severe TB like TB meningitis dan
milliary TB
• Vaccine BCG given the age of 0-3 months, the
best time between 2-3 months
• Vaccine BCG intradermal 0.1 ml with needle
gauge 26-27 long syringe 10 mm
• Storage: should not be expose to sunlight,
stored at temperature 2-8°C ,not to be frozen
• Protection effect after 8-12 weeks around 0-80%
• Diluted vaccine should be used within 3-6 hours
The incidence of post-vaccination
follow-up BCG (KIPI)
Lymphadenitis  suppurative in axilla or neck, sometimes encountered
after vaccination BCG, doesn’t need treatment unless arishing fistula ,
you must treated with tuberculosis drugs
Disseminated BCG-itis is rare, are often associated with severe
immunodeficiency
The other complication: erythema nodosum, iritis, lupus vulgaris &
osteomyelitis
 BCG Contraindication
Results of tuberculin tes > 5 mm
Positive HIV or at hingg risk of HIV infection, immunocompromised due to
steroids, immunosuppresive drugs, radiation therapy, a malignancy of the
bone marrow or lymphatic system
Severe malnutrition
High fever
Suffered extensive skin infections
Hsitory of tuberculosis before
Pregnancy
Recommendation
BCG given at age 1-2 months
The baby close contact with TB patients +3 acid resistant bacteria (BTA
+3), the baby received INH prophylaxis therapy although asymptomatic
clinical manifestation
If the patient contact should performed sputum examination and if we
found BTA -, the patient should continue treatment, and the baby can
given vaccination BCG 2 weeks after treatment 6 months