TB by mwebaza victor 2021..pdf

M W E B A Z A®
VICTOR
BMS/9114/172/DU MBchB4.2
mwebazavictor1997@gmail.com
Africa Uganda
October/2021
TUBERCULOSIS Presentation .
Internal medicine department mubende
regional hospital
Supervisor:- Dr Wabwona William
(MRRH-H.O.D Medical department)
Kampala international university western
campus-mubende site(MUBENDE RRHosp)
mubende Uganda.
2022/3/24 MWEBAZA VICTOR MBchB TB presention

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Introduction
Epidemiology
Definition
Aetiology
Transmission
Pathogenesis
Clinical presentation
Case definition
Classification of Tb
Laboratory diagnosis
Fixed drug combition
Aim of treatment
AntiTb medicine, side effects, route of administration,contraindications, and drug interactions
Adjunctive treatment
Tb Rx regimens
Rx monitoring
Rx out come
IPT
Latent Tb
Treatment of Tb in special situations:- preg,BF, liver diseases, renal diseases, bone,jointandspinal Tb, Tb
meningitis, and Tb/HIV co-infection
IRIS
Additional Resources on Tb
Further reading on Tb
References
Outline

Introduction: Burden of Tuberculosis in
uganda
The National TB prevalence survey conducted in 2015
puts the incidence of TB at 234/100,000 population
for all TB cases and prevalence of TB is 253/100,000
population. The survey further showed that about 24%
of TB patients are HIV co-infected.
Based on the 2015 global TB report, the mortality rate
from TB (excluding HIV positive TB) in 2014 was
estimated at 12/100,000 population.
Multidrug resistant TB is an emerging problem with
more than 1,040 estimated cases every year and the
actual case ﬁnding is around 200 cases per year.

Epidemiology of Tuberculosis worldwide on 24/march/2021 Report™

Tuberculosis is a communicable chronic
granulomatous disease caused by
mycobacterium tuberculosis, it usually involve
the lungs but can affect other organs or tissues
in the body .
Typically the center of tubercular granulomas
undergo caseous Necrosis
Deﬁnition

Aetiology
Tuberculosis (TB) is usually caused by a bacterium,
Mycobacterium tuberculosis (M.tb)
complex (such as Mycobacterium tuberculosis,
Mycobacterium bovis, Mycobacterium africanum and
Mycobacterium microti).
In clinical and laboratory settings, these bacteria are
also referred to conventionally as tubercle bacilli
(because they cause lesions in tissues called tubercles)
or acid-fast bacilli (AFB), because they retain a red dye
after washing with alcohol following staining.
M.bovis infection arise from drinking non-sterilised
milk from infected cows.

In few cases mycobacterium bovis that causes TB in
animals can cause TB among humans. However, the
most common cause is myc. tuberculosis.

Transmission
Transmission of tubercle bacilli occurs when a patient
suffering from pulmonary TB who is not on effective
treatment expels into the environment air containing
droplets with the bacilli (coughing, singing or
sneezing). The liquid in the droplets evaporates
leaving the droplet nuclei containing the bacilli.

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The droplet nuclei are small enough to be inhaled
into the lungs and deposited into the alveoli.
Transmission is easier in the following situations:
Closed environment where ventilation is poor.
High number of TB bacilli in the sputum
Close contact over a prolonged period with a
pulmonary TB sputum smear-positive patient who
is not yet on treatment increases the chance of
becoming infected with M.tb.
Duration of exposure to the infectious source
High prevalence of TB in the community.

On the other hand, the chance of getting
infection is low if the contact is occasional or
the patient has extra-pulmonary TB.

Pathogenesis
of TB infection
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This occurs in ﬁve steps which are
Entry into macrophages
Replication in the macrophages
The Th1 response
Th1 mediated macrophages activation
Granulomatous inﬂammation and tissue
damage

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Entry into the macrophages (0-3weeks)
This is by phagocytosis mediated by protein
molecules on both MTB and phagocyte ie the
mannose and C3b on MTB bind with mannose
receptor and CR3 respectively on the phagocytes
Replication in macrophages (ﬁrst 3weeks)
After being phagocytized The MTB multiply in the
vesicle after inactivating the macrophages though
blocking formation of phagolydosomal contents
They block phagolysosomal formation by:-
Inhibiting Ca++ signal
Inhibiting of recruitment and assembly of the
proteins that mediate phagolysosomal formation

After the multiplication phase some microbes
get disseminated in blood circulation leading to
bacteremia and ﬂu like illnesses in some pts.
The Th1 response(3-4weeks)
Th1 response is mounted roughly three weeks
after infection and this involves activation of the
macrophages.
®Innate immune receptors TLR2 recognize the
multiple pathogen then the TLR2 become
stimulated by the mycobacterial ligands thus
this makes them activated
The activated TLR2 stimulate the dendritic cells

Stimulated dendritic cells migrate to near by lymph node
then produce IL12
The IL12 cause the Tcell to undergo differentiation
producing Th1 cell
Th1 mediated activation of macrophages and killing of
the bacteria
Th1 cell in the lymph node or lungs produce INF-gamma
this cause classical activation of the macrophages
Activated macrophages produces cytokines for example
IL1,IL2,IL3,IL6,IL8,IL23,more IL12 on addition to
maturation of phagolysosomes in the infected
macrophages, activation off Nitric oxide synthesis
All those proinﬂammatory mediates are produced to kill
the microbes

Granulomatous inﬂammation and Tissue
damage
The activated macrophages aggregate around
the microbes forming giant cells thus forming
Ghan complexs, milliary consolidation
due to the inﬂammatory mediates produced by
the Activated macrophages affects the normal
parenchymal cells of the lungs causing
caseation necrosis of the tissues also erosion of
lung blood vessels and tissues contributing to
hemoptysis and thick sputum and formation of
lung cavitations

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NOTE:-
in primary TB Ghan focus are formed at the
lower part of the upper lung lobe and upper
part of the lower lobe close to the the lateral
pleural border.
In secondary TB granulation occurs /involves
the apex of the upper lobe of one or both lung
And these are seen on CXRay

Clinical presentation
General signs and symptoms include fever, chills,
night sweats, loss of appetite, weight loss, and
fatigue.Signiﬁcant nail clubbing may also occur.
Pulmonary Symptoms may include chest pain and a
prolonged cough >2weeks producing purulent
sputum. About 25% of people may not have any
symptoms (i.e. they remain "asymptomatic").
Occasionally, people may cough up blood in small
amounts, and in very rare cases, the infection may
erode into the pulmonary artery or a Rasmussen's
aneurysm, resulting in massive bleeding.

Extrapulmonary
In 15–20% of active cases, contribute to EPTB
Extrapulmonary TB occurs more commonly in
immunosuppressed persons and young children. In
those with HIV, this occurs in more than 50% of
cases.
Notable extrapulmonary infection sites include the
pleura (in tuberculous pleurisy), the central nervous
system (in tuberculous meningitis), the lymphatic
system (in scrofula of the neck), the genitourinary
system (in urogenital tuberculosis), and the bones
and joints (in Pott disease of the spine), among
others.

When it spreads to the bones, it is also known as "
osseous tuberculosis",a form of osteomyelitis.
Sometimes, bursting of a tubercular abscess through
skin results in tuberculous ulcer.An ulcer originating
from nearby infected lymph nodes is painless, slowly
enlarging and has an appearance of "wash leather". A
potentially more serious, also TB of the intestines.

Case defination
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Presumptive TB refers to a patient who presents
with symptoms or signs suggestive of TB
(previously known as a TB suspect).
A bacteriologically confirmed TB case is one from
whom a biological specimen is positive by smear
microscopy, culture or WRD (such as Xpert MTB/
RIF). All such cases should be notified, regardless
of whether TB treatment has started.
A clinically diagnosed TB case is one who does not
fulfil the criteria for bacteriological confirmation
but has been diagnosed with active TB by a
clinician or other medical practitioner who has
decided to give the patient a full course of TB
treatment.

Classification of TB
Infection
Classification based on Site of the disease
Pulmonary tuberculosis (PTB); Refers to any
bacteriologically confirmed or clinically diagnosed case of
TB involving the lung parenchyma or the tracheobronchial
tree. Tuberculous intra-thoracic lymphadenopathy
(mediastinal and/or hilar) or tuberculous pleural effusion,
without radiographic abnormalities in the lungs, constitutes
a case of extra-pulmonary TB.
Extra-pulmonary tuberculosis (EPTB); Refers to any
bacteriologically confirmed or clinically diagnosed case of
TB involving organs other than the lungs, e.g. pleura, lymph
nodes, abdomen, genitourinary tract, skin, joints bones, and
meninges.
A patient with both pulmonary and extra-pulmonary TB
should be classified as a case of PTB.

Classiﬁcation based on History of treatment
1) New patients: These are patients who have never
been treated for TB or have taken anti-TB drugs for
less than one month.
2) Previously treated TB patients: These are patients
who have received one month or more of anti TB
drugs in the past. They are sub classiﬁed as follows:-
i) Relapse patients have previously been treated for
TB, completed treatment, were declared cured or
treatment completed at the end of their most recent
course of treatment, and are now diagnosed with a
recurrent episode of TB (either a true relapse or a new
episode of TB caused by reinfection).

ii) Treatment after failure patients: are those who
have previously been treated for TB and whose
treatment failed at the end of their most recent
course of treatment.
iii) Treatment after loss to follow-up patients: have
previously been treated for TB and were declared
lost to follow-up at the end of their most recent
course of treatment. (These were previously known
as treatment after default patients).
iv) Other previously treated patients are those who
have previously been treated for TB but whose
Outcome after their most recent course of treatment
is unknown or undocumented.

Classification based on HIV infection status
HIV-positive TB patient refers to any
bacteriologically confirmed or clinically
diagnosed case of TB who has a positive result
from HIV testing conducted at the time of TB
diagnosis or other documented evidence of
enrolment in HIV care, such as enrolment in the
pre-antiretroviral therapy (ART) register or in the
ART register once ART has been started.
HIV-negative TB patient refers to any
bacteriologically confirmed or clinically
diagnosed case of TB who has a negative result
from HIV testing conducted at the time of TB
diagnosis.

Any HIV-negative TB patient subsequently found to be
HIV-positive should be reclassified accordingly.
HIV status unknown TB patient refers to any
bacteriologically confirmed or clinically diagnosed
case of TB who has no result of HIV testing and no
other documented evidence of enrolment in HIV care.
If the patient’s HIV status is subsequently determined,
he or she should be reclassified accordingly.

Classification based on Drug resistance
Mono resistance: resistance to one first-line anti-
TB drug only.
Poly drug resistance: resistance to more than
one first-line anti-TB drug (other than both
Isoniazid and Rifampicin).
Multidrug resistance: resistance to at least both
Isoniazid and Rifampicin.
Extensive drug resistance: resistance to any
fluoroquinolone and to at least one of three
second line injectable drugs (Capreomycin,
Kanamycin and Amikacin), in addition to
multidrug resistance.

Rifampicin resistance:
Resistance to Rifampicin detected using
phenotypic (usual drug susceptibility testing,
DST) or genotypic methods (commonly Xpert
MTB/Rif), with or without resistance to other
anti-TB drugs.

Post TB patients
A post TB patient is a patient who was successfully
treated for TB who presents with respiratory symptoms.
Many people who have been treated and cured of TB
continue to present with respiratory symptoms long
after their TB is cured.
The common symptoms are chest pain, cough,
shortness of breath and hemoptysis.
The public health importance of these patients is just
being recognized. There are no standard guidelines on
how they can be evaluated and treated. Health workers
should immediately repeat

Diagnosis of TB
Microscopy
It is the most commonly available test currently for
diagnosis of TB. It can be either ZiehlNeelsen
microscopy or Fluorescence microscopy . It can be
used to examine sputum specimen or gastric
aspiration ﬂuid or any other body material suspected
to contain the TB bacilli.

Xpert MTB/Rif
is the most used NAAT(Nuclear Acid Amplification
Test) in Uganda. Xpert MTB/Rif is an automated DNA
test for mycobacteria and for the mutation that
causes resistance to Rifampicin.
The following body fluids or samples can be
examined for TB using XpertMTB/Rif: Sputum, Lymph
node tissue and aspirates, Pleural fluid, Cerebrospinal
fluid and Gastric aspirates
http://www.who.int/tb/areas-of-work/laboratory/
policy_statements/en/.

Culture
Culture is done using LJ media(Löwenstain-Jensen media)
or DST media. culture of MTB is very sensitive and speﬁc but
expensive as its a complex and sophisticated procedure.
It require aspecilized laboratory setup and culture results are
available only after 6 to 8 weeks for LJmedia, culture results
of DSTmedia can take a very long period.
If available, culture can be used for diagnosis or
conﬁrmation of the diagnosis of TB in patients with PTB and
EPTB. Since it is more sensitive than smear, culture may also
have a role in the diagnosis of smear-negative, HIV-positive
TB suspects who are likely to be paucibacillary.
http://www.tbfacts.org/culture-tb/#sthash.YFcLUfu1.dpuf

TB LAM test
is based on the detection of LAM in urine and has the
potential to be point-of-care tests for TB.
WHO recommends the test to assist the diagnosis of
TB in HIV positive adult inpatients with signs and
symptoms of TB (pulmonary and/or extra-pulmonary)
with a CD4 cell count less than or equal to 100 cells/
μL, and people living with HIV who are deemed
“seriously ill”.
http://www.who.int/tb/areas-of-work/laboratory/
policy_statement_lam_web.pdf
CSF Analysis.
Those pt who present with CNS signs and symptoms
on addition to chronic cough, B-syptoms. ℅ meningeal
Tb.® how to analyse CSF Analysis results in line with
Tb-meningititis.

Radiology
Radiology investigations such as chest X-ray:
Features of chest X-ray consistent with TB disease
include cavitation milliary picture, pleural effusion
and mediastinal lymph gland enlargement with lung
infiltration.
Although the findings of radiology are nonspecific,
abnormalities like any heterogeneous opacities and
cavitation, if located in the upper parts of the lung,
are more likely to be caused by TB

Ultrasound
Diagnostic ultrasound is a useful test in the diagnosis
of extra pulmonary TB. For example,ultrasound is
useful in abdominal TB in which case you can see
omental thickening, increase in mesenteric thickness
and an increase in the mesenteric echogenicity (due to
fat deposition), combined with retroperitoneal and
mesenteric lymphadenopathy.
Presence of dilated and matted small bowel loops and
ascites further substantiate the diagnosis.
Calciﬁcations within granulomas due to TB in the liver
and spleen can also be picked by abdominal
ultrasound scans

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Histology
Pathology can play a complementary role in confirming the
diagnosis of EPTB, such as tuberculosis lymphadenitis.
Multiplication of tubercle bacilli in any site of the human
body causes a specific type of inflammation, with
formation of characteristic granuloma that can be found on
histological examination.
Samples can be taken in the following ways:
Fine needle aspiration of the lymph nodes: affected
peripheral lymph nodes, particularly cervical nodes, can
be aspirated.
Tissue biopsy: serous membranes (pleura, pericardium
and peritoneum), skin, lymph node, endometrium,
bronchial mucosa or liver tissue can be taken.

Management of Tuberculosis and
FDC
Early diagnosis and effective treatment is the key
to stop the spread of TB and to improve treatment
outcomes of patients suffering from TB.
Individuals should start treatment as soon as
possible after a diagnosis of TB is made and
should be treated according to NTLP
recommended regimens (for uganda)under Directly
Observed Treatment (DOT)
And the drugs are usually given as ﬁxed-dose
combinations (FDC). The FDCs contain two or more
drugs in a single tablet with known strength (mg) of
the drugs in each table

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FDC tablets have the following advantages:
Prescription errors are minimized. Dosage
recommendations are more accurate and
adjustment of the dose according to patient
weight is easier.
The patient has fewer tablets to swallow, which
contributes to adherence.
If the treatment is not supervised, patients cannot
be selective about which the drugs to swallow

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The aims of treatment are to:
Cure the TB patient
Prevent complications and death from TB disease
Prevent TB relapse
Reduce TB transmission
Prevent development of drug-resistant TB

Anti-TB medicines and there side effects,
Route of administration, contraindications,
and important drug interactions.
Anti-TB medicines can be classified into first and second
line.
First-line anti-TB medicines are used for the treatment of
susceptible TB while second line medicines are used for
treatment of drug resistant TB.
The first-line anti-TB medicines, together with their
standard abbreviations, are shown below:
Rifampicin (R)
Isoniazid (H)
Pyrazinamide (Z)
Ethambutol (E)

Adjunctive treatment in TB
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Pyridoxine (vitamin B6). 25mg OD given
concomitantly with Isonizid for the duration
of treatment to prevent peripheral Neuropathy.
® isonizid interfere with vitamin B6
metabolism thus leading to vitB6 deficiency.
Prednisolone in TB pt in whom complication
of fibrosis are anticipated because of severe
inflammation such as Tb meningitis

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TB Treatment Regimens
Anti-TB drugs are given in combinations called
regimens. The regimens have the following
characteristics;
Contain at least one of the most effective
anti-TB drugs (Rifampicin or Isoniazid) in
both the initial and continuation phase of
treatment
Must be written in abbreviation that clearly
identiﬁes the drugs in the initial and
continuation phases of treatment

Initial phase: The initial phase is the ﬁrst two months
of treatment. The combination of 4 drugs used during
this phase is Isoniazid, Rifampicin, Pyrazinamide and
Ethambutol (RHZE).
Using these 4 drugs, results in rapid killing of the
tubercle bacilli. Patients become non-infectious in
about 2 weeks. Symptoms reduce, and most smear-
positive cases become smear-negative within the ﬁrst
2 months.
Continuation phase: The continuation phase is the
second part of treatment which lasts 4 months. Here,
two drugs are used in combination, usually Rifampicin
and Isoniazid (RH).

Treatment monitoring
Once a TB patient is started on treatment, it is
important to ﬁnd out if the patient is getting better as
a result of the treatment. This is called treatment
monitoring. The following methods are used for
treatment monitoring in order of importance:
Laboratory monitoring– Sputum microscopy (or
culture) must be used for monitoring all pulmonary
TB patients.
Sputum smears are performed at the end of the initial
phase (2 months), at beginning of 5 months and
beginning of 6th month of treatment. This should be
done for both smear-positive and smear-negative
pulmonary TB patients

Treatment out comes

Isoniazid preventive therapy (IPT)
IPT is currently strongly advocated by NTLP for all
HIV positive persons and under 5 child contacts of
patients with active TB. NTLP has published an IPT
health workers guide to assist health workers in
initiating IPT.
It is important that before IPT is initiated that active
TB is excluded. This is done to avoid monotherapy for
active TB because TB should always be treated with
combination therapy.

The following key points from the IPT guidelines need to
always be remembered:
1. Adults and adolescents living with HIV should be
screened for TB using the four symptom screening tool for
TB in PLHIV(people Living with HIV and AIDS). Those who
do not report any one of the symptoms of current cough,
fever, weight loss, or night sweats are unlikely to have
active TB. And those unlikely to have active TB upon
screening should be offered Isoniazid preventive therapy.
2. Adults and adolescents living with HIV who report any
one of the symptoms of current cough, fever, weight loss,
or night sweats may have active TB. These individuals
should be evaluated for TB and other diseases

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3. Adults and adolescents living with HIV who are
unlikely to have active TB should receive at least six
months of Isoniazid Preventive Therapy (IPT). This
should be irrespective of:
The degree of immune suppression,
Whether the patient is on antiretroviral therapy or
not,
Whether the patient is pregnant or not.
4. A Tuberculin Skin Test (TST) is not a requirement
for initiating IPT in PLHIV.
5. PLHIV who have a positive TST beneﬁt more from
IPT. TST should be used where feasible to identify
such individuals.

6. Providing IPT to PLHIV does not increase the risk
of developing Isoniazid resistant TB. Therefore,
concerns regarding the development of Isoniazid
resistance should not be a barrier to providing IPT.
7. Children living with HIV who do not have any one of
the following symptoms: poor weight gain, fever, or
current cough are unlikely to have active TB.
8. Children living with HIV who have any one of the
following symptoms: poor weight gain, fever, current
cough or contact history with a TB case may have TB.
These children should be evaluated for TB and other
conditions. If the evaluation shows no TB, such
children should be offered IPT except if they less than
1 year. Children less than 1 year can be offered IPT if
they are active TB contacts.

9. Children living with HIV who are more than 12
months of age: For those who are unlikely to have
active TB and have no contact with a TB case should
receive six months of IPT (10 mg/kg/day).
10. Children living with HIV who less than 12 months
are of age (infants) This group should only receive
IPT if there is a history of contact with a TB case and
they have no active TB.
11. All children under ﬁve years: Those who have a
history of contact with a TB case should be screened
for active TB using the Intensiﬁed TB Case Finding
Guide. Those who have no symptoms and signs
suggestive of active TB should receive six months of
IPT

Latent TB
Diagnosis of latent TB is conﬁrmed by positive
Tuberculin skin test(TST) the commonest method
for TST is the manotoux method.
A standard dose of tuberculin units (TU - 0.1 ml) is
injected intradermally and read 48 to 72 hours later.
This intradermal injection is termed the Mantoux
technique. A person who has been exposed to the
bacteria is expected to mount an immune response
in the skin containing the bacterial proteins.
The reaction is read by measuring the diameter of
induration across the forearm in millimeters. If there
is no induration, the result should be recorded as "0
mm". Erythema (redness) should not be measured.

>/=5mm high Risk group
>/=10mm moderate risk group
>/=15mm low risk group.
TST has +ve when the TST has a diameter of 5mm
and above in HIV +ve pt and 10mm and above for
HIV -ve pt .
Reactivation of latent TB to active TB occurs in:-
Pt who are immunosuppressed or those with
underlying pathological condition.

Heaf test, a diagnostic skin test used in latent Tb was long
performed to determine whether or not children had been
exposed to tuberculosis infection.
The gun injected tuberculin purified protein derivative (PPD)
equivalent to 100,000 units per ml to the skin over the
flexor surface of the left forearm in a circular pattern of six.
The test was read between 3-7 days later. The injection
could not be into sites containing superficial veins.
The reading of the Heaf test was defined by a scale:
Negative - No induration.
Grade 1 - four to six papules (also considered negative)
Grade 2 - Confluent papules form indurated ring (positive)
Grade 3 - Central filling to form disc (positive)
Grade 4 - Disc >10 mm with or without blistering (strongly
positive)

Grades 1 and 2 could result from previous BCG or avian
tuberculosis, rather than human TB infection.
Children who were found to have a grade 3 or 4 reaction
were referred for X-ray and follow-up


TREATMENT OF TUBERCULOSIS IN SPECIAL
SITUATIONS
Pregnancy
The number of pregnant women with TB has
increased because of the current HIV epidemic. The
clinical presentation of TB in pregnancy is like non-
pregnant women. Once a diagnosis of TB is made,
treatment should be promptly started because
untreated
The NTLP-recommended regimen of 2RHZE/4RH for
susceptible TB is safe for use in pregnancy.
All pregnant women diagnosed with TB should be
screened for HIV and if positive managed according
to national TB-HIV management guidelines.

Breastfeeding
A breastfeeding woman who has TB should be treated
with a full course of a standard regimen recommended
by the NTLP. The concern here is to ﬁnd out if the child
already has TB disease or is just a contact likely to be
infected by the mother. Concentrations of anti-TB drugs
in breast milk are too low to prevent or treat TB in infants.
The child should therefore be investigated for TB
disease and, if found to have TB disease, must be given
full course of anti-TB treatment.
If the child does not have TB disease, give Isoniazid
preventive therapy (10mg/kg body weight) for 6 months.

Mother and child should stay together
and breastfeeding should continue
normally but standard TB infection
prevention measures are recommended.
BCG vaccination of the child should then
be postponed until the end of Isoniazid
preventive therapy.

Treatment in Patients with Liver Disease
Patient can have pre-existing liver disease or develop it
as a toxicity of TB drugs.
In patients with liver failure, a regimen without
Rifampicin may be used. Streptomycin and Ethambutol
may be used if treatment is necessary for patients with
severe liver disease.
These patients should be referred to higher level of care
for specialised management

Treatment of patients with drug induced liver
injury
Suspect liver damage when a patient on anti-TB
drugs has developed jaundice plus or minus other
symptoms of liver injury such as abdominal pain,
nausea and vomiting
If the liver enzymes (ALT/AST) are elevated more
than three times the normal upper limit, all
medications including non-TB medications should
be discontinued and the patient monitored until the
enzymes normalise

Treatment of Patients with Renal Failure
Isoniazid, Rifampicin, and Pyrazinamide may be given
in normal dosage to patients with renal failure, since
these drugs are eliminated almost entirely by biliary
excretion or are metabolised into non-toxic
compounds.
Patients with severe renal failure who are receiving
Isoniazid should also receive pyridoxine to prevent
peripheral neuropathy.
These patients should be referred to a higher level of
care for further management.

Bone, Joint, and Spinal Tuberculosis
TB can virtually affect any tissue in the body. TB
infects bone, joint tissues and the spine. TB of these
tissues requires extended TB treatment durations
longer than the standard six months.(12month) 2
RHZR/10RH
There is additional beneﬁt of surgical debridement in
combination with chemotherapy

TB Meningitis
TB meningitis requires longer duration of
treatment than TB in pulmonary site. The range of
duration is 9-12 months.
The usual regimens of TB treatment are used.
However, a choice can be made between
ethambutol and an injectable aminoglycoside. In
adults, ethambutol is usually suﬃcient. In children,
there is preference for an aminoglycoside.
Adjunctive corticosteroid therapy recommended
in the treatment of TB meningitis with
dexamethasone or prednisolone tapered over 6–8
weeks for patients.

 TB/HIV CO-INFECTION
HIV is the strongest risk factor for developing
tuberculosis (TB) disease in those with latent or
new Mycobacterium tuberculosis infection.
The risk of developing TB disease is between 20
and 37 times greater in people living with HIV
(PLHIV) than among those who do not have HIV
infection

TB prevention in HIV
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Intensified TB case-finding:- All people living
with HIV (children, adolescents & adults),
wherever they receive care should be
regularly screened for TB using the
Intensified TB Case Finding too
Isoniazid preventive therapy (IPT)
Infection Control
Co-trimoxazole preventive therapy (CPT)
Provider Initiated HIV testing and counselling
HIV prevention methods in the TB clinics
Provision of antiretroviral treatment

After diagnosis of HIV/TB Co-infection before
you iniate ARVs start with antiTBs for 8weeks
then introduce the ARVs this helps to prevent
IRIS

IRIS
Immune reconstitution inﬂammatory syndrome
(IRIS) is a condition seen in some cases of AIDS
or immunosuppression, in which the immune
system begins to recover, but then responds to a
previously acquired opportunistic infection with
an overwhelming inﬂammatory response that
paradoxically makes the symptoms of infection
worse.

Infections most commonly associated with IRIS
include Mycobacterium tuberculosis and
cryptococcal meningitis.
Persons living with AIDS are more at risk for IRIS if
they are starting HAART for the ﬁrst time, or if they
have recently been treated for an opportunistic
infection

J
• J

References
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2.
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4.
World Health Organization. WHO
consolidated guidelines on drug-resistant
tuberculosis treatment. 2019.
Xu P, Chen H, Xu J, Wu M, Zhu X, Wang F,
et al. Moxiﬂoxacin is an effective and safe
candidate agent for the tuberculosis
treatment: a meta-analysis. Int J Infect Dis.
2015 Oct 16.
NTLP(uganda) manual 3rd edition march
2017.
Davidson's principles and practice of
medicine 21st edition part 2 chapter 19 page
688 - 695.

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