This Presentation is made by Dr. Ashok Jaisingani for study purpose, if any one like this than give comments.

1. TUBERCULOSIS
BY DR. ASHOK JAISINGANI

2. Tuberculosis
Tuberculosis is the specific communicable disease caused by
the mycobacterium tuberculosis
Primarily affecting the lungs But also affecting secondarily
Intestine
Meninges
Bones
Joints
Lymph Nodes
Skin and other tissues of the body

3. Causative Agents
Mycobacterium Tuberculosis of three types
a) Humane types
b) Bovine type
c) Atypical type

4. Host Factors
Man is the host of the infection
Age: Extreme of the age I.e. very old and too young are
more prone
Sex: More in male because of the more exposure to the work
places (Occupational disease)
Nutritional Status: In poor nutrition state the chances of the
infection is increase
Endocrine Disorder: In Case of the DM the chances of the
TB are increased
Environment: Overcrowding, poor hygiene and housing
Poor living condition all increase the risk of the tuberculosis
infections

5. Reservoir
Infected persons (Cases)
Infected animals
Source of the infection:
Humane sources such as sputum or excreta of the TB pts
Bovine source such as infected milk from the cow suffering
from the TB

6. Period Of The Communicability &
Incubation Period
Period Of the Infectivity:
Patients are infected as long as they are untreated
Incubation Period:
3 – 6 weeks (it may be week, month or year)

7. Mode Of The Transmission
Droplet infection (within the range of the 30 cm)
Dust loaded with the sputum (M – Tuberculosis survive for
the year in dry sputum)
Food handled by the infected persons ( Food borne)
Flies sitting on the infected material (Fomite – borne)
Directly by contact with the patients (By kissing the TB pt)
Use of the common smoking huqqa
Contaminated milk

8. Portal Of The entry
1) By inhalation through the nose and throat from there
reach the alveoli causing the tuberculosis of the
respiratory tract
2) By ingestion through the mouth causing the tuberculosis
of the alimentary tract

9. Pathology Of The Primary
Tuberculosis
Bacteria on reaching the alveoli are taken up by the the
phagocytes and multiply
Exudation of the cells takes place and pneumonic focus is
formed this is called primary focus or Ghon focus
Tubercle bacilli are carried by the lymphatic to related hilar
lymph nodes which enlarge and the cessation takes place
The Ghon focus, tuberculous lymphaginitis and the hilar
glandular lesion together constitute “primary complex”

10. Factors Responsible In The
Occurrence Of The TB
1) Dose and virulence of the bacteria
2) Resistance of the host
3) Environmental factors

11. Dose & Virulence Of Bacteria
The larger the number of the bacilli in the infecting dose
More likely to be it cause the infection

12. Resistance Of The Host
Natural Resistance:
Species resistance, Racial Resistance and individual
resistance are depend upon the
Heredity:
Age: TB in the children under 2 – years tend to be acute and
generalized miliary tuberculosis and tuberculosis meningitis
Sex:
No difference before the puberty
At puberty girls are more prone than boys
At 60 years of the age males are more than female
Diet:
Economic Status:
Mental State:

13. Acquired Resistance Of The
Host
a) Produced by the natural infection
b) Also produced by the BCG vaccination

14. Environmental factors
a) Unhygienic living condition
b) Overcrowding
c) Malnutrition
d) Poverty
e) Mental stress
f) Intercurent infection and concomitant disease
g) Diabetes
h) Repeated Pregnancies
I) Occupational Lung Diseases

15. Metastasis Of The Tuberculosis
1) Laryngeal Tuberculosis
2) Cervical Lymph node tuberculosis
3) Intestinal Tuberculosis & perianal fistula
4) Urogenital tuberculosis
5) Bone & Joints Tuberculosis

16. Tuberculin Test
A positive reaction to the test is generally accepted as
evidences of the past or present infection by M –
Tuberculosis

17. Tuberculin & Types Of The
Tuberculin Tests
Tuberculin: It is a antigen or test material used for the
tuberculin test it is of the two types
a) Old tuberculin
b) Purified Protein Derivatives
Types Of The Tuberculin Test:
1) Heat Test:
It is usually preferred for the testing the large groups of the
peoples because it is quick and easy to performs thus reliable
and cheep
2) Montoux Test:
It is favorable when a more precise measurement of the
tuberculin sensitivity is required

18. Old Tuberculin
A six week old culture of the tubercle bacilli, in beef broth is
heated to kill the bacilli and is then filtered
The filtrate is evaporated by the heat to 1/10th of its volume
until appear golden yellow syrups liquid thus obtained is
called old tuberculin
As the old tuberculin consist of the beef broth in addition to
the products of the bacillary bodies
Occasionally non – specific reaction to the proteins of the beef
broth may be elicited

19. Purified Protein Derivatives
This is obtained by the precipitating the proteins by adding
the excess of the tubercle bacilli in the synthetic medium
PPD is pure it gives few non – specific reactions
PPD is standardized, in terms of the biological reactivity as
tuberculin unit (TU)
The standard PPD contain 50,000 tuberculin units per mg
One TU is equal to 0.01 ml of OT or 0.0002 mg of PPD
The WHO advocate a PPD tuberculin known as PPD – RT –
23

20. Montoux Test
It is carried out by the injecting intradermally on the flexor
surface of the forearm 1 TU of PPD in 0.1 ml
The result of the test is read after 48 – 72 hours

21. Positive Montoux Test
The person is infected with the M – Tuberculosis not
necessarily suffering from the tuberculosis thus having the
infection not the disease
Children below the 2 – years has an active tuberculous lesion
in the body even if it is not manifested
BCG vaccination has been done

22. Negative Montoux Test
The person is not suffering from the tuberculosis
The person is suffering from the TB but he is
immunocompromised
The dermal hypersensitivity to the tuberculin can also be lost
in malignancy, Hodgkin’s Disease
The Person is taking the INH if the previously positive

23. Interpretation Of The Result
Tuberculin reaction consist of the erythema & induration
Erythema is disregarded and only induration is measured
Reaction exceeding 10 mm are consider as positive
Reaction less than 6 mm are considered as negative
Reaction between the 6 & 9 mm are considered doubtful thus
these reaction may be due to the M – Tuberculosis or
atypical mycobacterium

24. Control Of The Tuberculosis
Aim Of The National T.B Control Program:
1) Reducing the reservoir of the infection
2) Improvement of the resistance
3) Minimizing the chance of the spread

25. Reducing The Reservoir Of The
Infection
It is carried out by the
Case finding
Treatment

26. Case Finding
Case: The first step in TB control program is early detection
of the sputum positive cases
Target Group:
Person having the persistent cough and fever is the most
fertile group for case finding

27. Case Finding Technique
There are three case finding techniques
1) Sputum Examination
2) Mass Miniature Radiotherapy (MMR)
3) Tuberculin Test

28. Sputum Examination
Direct microscopy of the sputum smear of the tubercle bacilli
is the method of the choice
Examination Of The two consecutive specimen is sufficient
to detect a large number of the infectious cases in community
Culture examination of the sputum is only second in
importance

29. Mass Miniature Radiotherapy
It is now stopped due to
Lack of the definitives thus more presence of the X- ray
shadow is not indicative of the case unless the presence of the
tubercle bacilli are demonstrated
High Cost
Very low yield of the cases

30. Treatment
1) Two – phase chemotherapy
2) Different Regimen
a) 6 – Month Durations
b) 9 – Months Duration
c) 12 – Month Duration

31. Two – Phase Chemotherapy
1) The first is short aggressive or intense phase, early in the
course of the treatment, lasting 1 – 3 months
During this phase three or more drugs are combined to
kill of as many bacilli as possible
2) The second or continuation phase is aimed at sterilizing
the smaller number of the dormant or persisting bacilli

32. Treatment Of The 6 – Months
Duration
Initial Phase: (2 – Months)
Ethambutol or streptomycin + Isoniazed + Rifampicine +
Pyrazinamide
Continuation Phase: (4 – Months)
Isoniazed + Rifampicine

33. Treatment Of The 9 – Months
Duration
Initiative Phase: (2 – Months)
Ethambutol or Streptomycin + Isoniazed + Rifampicine +
Pyrazinamide
Continuation Phase: (7 – Months)
Isoniazed + Rifampicine

34. Treatment Of The 12 – Months
Duration
Daily Dose:
Isoniazed + Thiocetazone
Twice Weekly Dose:
Streptomycin 1 gm intramuscularly
Isoniazed + pyridoxine orally

35. Improving The Resistance
BCG Vaccination: Stimulate a acquired resistance to
possible subsequent infection with the virulent tubercle
bacilli and thus reduce the morbidity & mortality from the
primary tuberculosis among those at most risk.

36. The Vaccine & Its Dosage
BCG is only widely used bacterial vaccine derived from an
attenuated bovine strain of the tubercle bacilli
Types Of The Vaccine:
1) Liquid Vaccine (Fresh)
2) Freeze – Dried Vaccine
Dosage:
1) The usual strength is 0.1 mg in 0.1 ml volume
2) The dose to new borne aged below 4 weeks in 0.05 ml

37. Administration Of The vaccine
The vaccine is injected intradermally, using a tuberculin
syringe just above the insertion of the deltoid muscle without
using an antiseptic or detergent
Age:
Early in infancy either at birth or at 6 – weeks of the age
simultaneously with the DPT & Polio

38. Phenomenon After The Vaccine
1) A papule is develop at the site of the vaccination after the
2 – 3 weeks
2) It increase in size, reach to about 4 – 8 mm in about 5 –
weeks
3) It then subside or heals in to shallow ulcer, usually seen
covered with the crust
4) Healing occurs spontaneously within 6 – 12 weeks leaving
a permanent, tiny round, scar typically 4 – 8 mm in diameter

39. Complication
1) Prolong severe ulceration at the site of the vaccination
2) Supurative Lymphadenitis
3) Osteomyelitis
4) Disseminated BCG infection
5) It may cause the death

40. Contraindication
1) Generalized Eczema
2) Infected Dermatosis
3) Hypogammaglobulinemia
4) H/O deficient immunity

41. Minimizing The Chance OF The
Spread
Isolation
Care of the patient in the home
Destruction of the sputum
Visit by the health Visitors
Promoting the health education
Improving the living standard
Chemoprophylaxis with INH for one year or INH plus
ethambutol for 9 – months