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Diagnosis of Tb
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Dr.T.V.Rao
DIAGNOSIS OF DIAGNOSIS OF TUBERCULOSISTUBERCULOSIS
Emerging TrendsEmerging Trends
Dr.T.V.Rao, MD.Dr.T.V.Rao, MD.
Dr.T.V.RaoDr.T.V.Rao
Robert Koch Discovers Robert Koch Discovers MycobacteriumMycobacterium
Dr.T.V.Rao
A Global EmergencyA Global Emergency
The Tuberculosis in the The Tuberculosis in the beginning of the 21beginning of the 21stst Century Century declared as Global Emergency declared as Global Emergency
(WHO)(WHO)
Dr.T.V.RaoDr.T.V.Rao
Why Tuberculosis is a Important Why Tuberculosis is a Important Disease.Disease.
Tuberculosis continues to be a Tuberculosis continues to be a Important communicable disease.Important communicable disease.
A leading cause of morbidity and A leading cause of morbidity and mortality in Developing world. mortality in Developing world.
Most Important communicable Most Important communicable disease in Bangladesh, China, disease in Bangladesh, China, Indonesia, Africa, and Pakistan.Indonesia, Africa, and Pakistan.
But it is Curable DiseaseBut it is Curable Disease
Dr.T.V.RaoDr.T.V.Rao
Tuberculosis is a Global ProblemTuberculosis is a Global Problem
Dr.T.V.RaoDr.T.V.Rao
Tuberculosis - Important Tuberculosis - Important communicable disease spread by communicable disease spread by
Respiratory routeRespiratory route
Dr.T.V.RaoDr.T.V.Rao
Why Everybody Concerned.Why Everybody Concerned.
Tuberculosis kills young adults.Tuberculosis kills young adults. Premature death of the infected a Premature death of the infected a
prominent future.prominent future. Today many are co infected with HIV.Today many are co infected with HIV. The open cases of Tuberculosis infects a The open cases of Tuberculosis infects a
few around his/her environment.few around his/her environment. A social burden to the family, society and A social burden to the family, society and
Nations.Nations.
Dr.T.V.RaoDr.T.V.Rao
Tuberculosis in the era ofTuberculosis in the era ofHIV / AIDS.HIV / AIDS.
HIV / AIDS epidemic led to large HIV / AIDS epidemic led to large increase of Smear negative pulmonary increase of Smear negative pulmonary
tuberculosis which in turn has led to tuberculosis which in turn has led to poor treatment out comes, and early poor treatment out comes, and early
mortalitymortality
Frequently involves Lower lobes of Frequently involves Lower lobes of Lungs.Lungs.
Dr.T.V.RaoDr.T.V.Rao
Why we fail to Diagnose Why we fail to Diagnose Tuberculosis.Tuberculosis.
Lack of health infrastructure.Lack of health infrastructure. Control is plagued with lack ofControl is plagued with lack of
Accurate,Accurate,
Robust,Robust,
and Rapidand Rapid
Diagnostic methods,Diagnostic methods,
Technologies.Technologies.
Dr.T.V.RaoDr.T.V.Rao
Why we failed ( Cont )Why we failed ( Cont )
Diagnostic services are poor, and so we Diagnostic services are poor, and so we failed at Individual and community failed at Individual and community levels.levels.
Patients are diagnosed late.Patients are diagnosed late. Many patients are never diagnosed Many patients are never diagnosed
before death.before death.
Early deaths are burden to Social Early deaths are burden to Social Infrastructure and Economic loss. Infrastructure and Economic loss.
Dr.T.V.RaoDr.T.V.Rao
Importance of Clinical servicesImportance of Clinical services
Early diagnosis rests with clinicians, Early diagnosis rests with clinicians, whose contribution is immense in whose contribution is immense in
prompt treatment.prompt treatment.
A clinicians knowledge, proper A clinicians knowledge, proper documentation are immense help in documentation are immense help in
Developing countries.Developing countries.
Dr.T.V.RaoDr.T.V.Rao
When to suspect TuberculosisWhen to suspect Tuberculosis
Cough longer than 3 weeks.Cough longer than 3 weeks. Fever for 1 month, or both.Fever for 1 month, or both. Blood stained sputum.Blood stained sputum. Night sweats, weight lossNight sweats, weight loss Age between 14 and 70 years Age between 14 and 70 years
( ( Correlates National Tuberculosis Correlates National Tuberculosis Programme ).Programme ).
Dr.T.V.Rao
DIAGNOSTIC METHODSDIAGNOSTIC METHODS
Dr.T.V.RaoDr.T.V.Rao
Diagnosis.Diagnosis.
Tuberculosis is a diversified disease.Tuberculosis is a diversified disease. Any organs can be involved.Any organs can be involved. Any age group, gender no bar for Any age group, gender no bar for
Tuberculosis.Tuberculosis. Involvement of Lungs contribute to Involvement of Lungs contribute to
majority of tuberculosis.majority of tuberculosis. And involvement of Lungs is designated as And involvement of Lungs is designated as
Pulmonary tuberculosis.Pulmonary tuberculosis.
Dr.T.V.RaoDr.T.V.Rao
Diagnosis of Pulmonary Diagnosis of Pulmonary TuberculosisTuberculosis
Majority of Adults suffer with pulmonary Majority of Adults suffer with pulmonary tuberculosis.tuberculosis.
Microbiological examination of Sputum Microbiological examination of Sputum continues to be a Gold standard in proving continues to be a Gold standard in proving the Diagnosis.the Diagnosis.
Sputum examination in Children is not Sputum examination in Children is not sensitive in Diagnosis.sensitive in Diagnosis.
Radiological examination of Lungs, most Radiological examination of Lungs, most commonly prescribed investigation.commonly prescribed investigation.
Dr.T.V.RaoDr.T.V.Rao
X - ray examination of chest most X - ray examination of chest most easily available Investigation.easily available Investigation.
Dr.T.V.Rao
Microbiological Microbiological Investigations are essential Investigations are essential for definitive Diagnosis of for definitive Diagnosis of
Tuberculosis.Tuberculosis.
Dr.T.V.RaoDr.T.V.Rao
Importance of Optimal SpecimensImportance of Optimal Specimens
Pulmonary Tuberculosis is the Pulmonary Tuberculosis is the commonest presentation of Tuberculosiscommonest presentation of Tuberculosis
Sputum is the Most important specimen Sputum is the Most important specimen for identification and isolation of Acid for identification and isolation of Acid fast bacilli.fast bacilli.
The developing countries suffers the most The developing countries suffers the most important step in getting an ideal important step in getting an ideal sample.sample.
Dr.T.V.Rao
Sputum specimensSputum specimens
Train the staff to obtain the appropriate Train the staff to obtain the appropriate specimenspecimen
A few minutes of education to patients on A few minutes of education to patients on importance of ideal sample make a great importance of ideal sample make a great difference and improves the Diagnosis.difference and improves the Diagnosis.
Dr.T.V.RaoDr.T.V.Rao
Observe to identify Sputum from Observe to identify Sputum from Saliva.Saliva.
SPUTUMSPUTUM
Specimens appear mucoid Specimens appear mucoid even, blood stained. even, blood stained.
Contains many Contains many Polymorphoneutrophils.Polymorphoneutrophils.
SALIVASALIVA
Appears clear, watery, Appears clear, watery, and frothy.and frothy.
Contains many Contains many squamous epithelial squamous epithelial cellscells
Absence of Absence of Polymorphoneutrophils.Polymorphoneutrophils.
Dr.T.V.RaoDr.T.V.Rao
Role of Microscopy in Tuberculosis.Role of Microscopy in Tuberculosis.
Microscopy for Diagnosis of Tuberculosis is Microscopy for Diagnosis of Tuberculosis is initiated in 1880initiated in 1880
The conceptions have not changed since The conceptions have not changed since then.then.
Best efforts should be put to obtain Best efforts should be put to obtain sputum,sputum,
Processing of saliva loses all valuable Processing of saliva loses all valuable clues to diagnose.clues to diagnose.
Dr.T.V.RaoDr.T.V.Rao
Microscopy and TuberculosisMicroscopy and Tuberculosis
Microscopy with Microscopy with Ziehl – Neelsen’s Ziehl – Neelsen’s stainingstaining
A century old A century old
procedureprocedure
Dr.T.V.RaoDr.T.V.Rao
Why MicroscopyWhy Microscopy
Only we need Microscope, and few Only we need Microscope, and few stains.stains.
Most rapid, economical,Most rapid, economical, Can detect bacterial load.Can detect bacterial load. A Diagnostic, and Prognostic tool.A Diagnostic, and Prognostic tool. A little of sputum 0.2 µl is adequate.A little of sputum 0.2 µl is adequate. A prompt diagnosis after searching A prompt diagnosis after searching
as few as 100 fields.as few as 100 fields.
Dr.T.V.RaoDr.T.V.Rao
Limitation of Microscopy for Limitation of Microscopy for Tuberculosis.Tuberculosis.
Repeated sample examinations. load on Repeated sample examinations. load on technical staff.technical staff.
Training and dedication of Microscopist.Training and dedication of Microscopist. The load of bacilli must be more than The load of bacilli must be more than
10,000 / 1 ml of sputum.10,000 / 1 ml of sputum. Low in sensitivity < 50 %Low in sensitivity < 50 % Repeated requests for samplesRepeated requests for samples High drop out by patients, for repeated High drop out by patients, for repeated
samples.samples. Not dependable in pediatric age group.Not dependable in pediatric age group.
Dr.T.V.RaoDr.T.V.Rao
Smear showing Acid Fast Bacilli.Smear showing Acid Fast Bacilli.
Dr.T.V.RaoDr.T.V.Rao
What is Smear PositivityWhat is Smear PositivityWHOWHO
All patients who have submitted All patients who have submitted twotwo
Specimens and found to be Specimens and found to be positivepositive
for identification of AFBfor identification of AFB
Dr.T.V.RaoDr.T.V.Rao
Processing Direct smear negative Processing Direct smear negative specimensspecimens
Sputum Microscopy can be improved with Sputum Microscopy can be improved with Sputum liquefaction, concentration and Sputum liquefaction, concentration and gravity sedimentation.gravity sedimentation.
Popular solvents Popular solvents Sodium hypochlorite.Sodium hypochlorite. Sodium hydroxide.Sodium hydroxide. Ammonium sulphateAmmonium sulphate N-acetyl-L-cysteine –sodium N-acetyl-L-cysteine –sodium
hydroxide.hydroxide.
Dr.T.V.RaoDr.T.V.Rao
Benefits of Liquefaction and Benefits of Liquefaction and ConcentrationConcentration
Major studies showed processing of Major studies showed processing of sputum with chemicals and centrifugation sputum with chemicals and centrifugation improved sensitivity up to 18 %.improved sensitivity up to 18 %.
Incremental yield ( positive with bleach Incremental yield ( positive with bleach minus positives with Ziehl – Neelsen stain) minus positives with Ziehl – Neelsen stain) up to 9 %.up to 9 %.
Treating specimens with Sodium Treating specimens with Sodium hypochlorite is Mycobactericidal and also hypochlorite is Mycobactericidal and also kills HIV and improves the safety and kills HIV and improves the safety and acceptability by technical staff.acceptability by technical staff.
Dr.T.V.RaoDr.T.V.Rao
When Microscopy failsWhen Microscopy fails
Smear negative tuberculosis.Smear negative tuberculosis. In HIV infected patients, on many In HIV infected patients, on many
occasions prove negative. in spite of occasions prove negative. in spite of presence of bacilli, ( as few bacilli are presence of bacilli, ( as few bacilli are expectorated).expectorated).
Needs concentration and liquefaction Needs concentration and liquefaction with chemicals.with chemicals.
Time consuming, needs more Time consuming, needs more technical manpowertechnical manpower
Dr.T.V.RaoDr.T.V.Rao
Growing role ofGrowing role ofFluorescent MicroscopyFluorescent Microscopy
There is a growing need for screening for There is a growing need for screening for AFB by Florescent Microscopy.AFB by Florescent Microscopy.
Several studies prove, Florescent Several studies prove, Florescent Microscopy in Diagnosis of Tuberculosis is Microscopy in Diagnosis of Tuberculosis is a priority,a priority,
Developing world should opt and initiate Developing world should opt and initiate florescent microscopy.florescent microscopy.
Dr.T.V.RaoDr.T.V.Rao
Acid Fast Bacilli as seen under Acid Fast Bacilli as seen under Fluorescent MicroscopeFluorescent Microscope
Dr.T.V.RaoDr.T.V.Rao
Why we need Florescent Why we need Florescent MicroscopyMicroscopy
Useful when few bacilli are present.Useful when few bacilli are present. Increases the sensitivity in HIV patients with Increases the sensitivity in HIV patients with
tuberculosis.tuberculosis. Reduces the time needed for testing.Reduces the time needed for testing. About 15 times as many fields of view can be About 15 times as many fields of view can be
scanned by fluorescent microscopy than by Ziehl scanned by fluorescent microscopy than by Ziehl – Neelsen’method in the same period.– Neelsen’method in the same period.
Increases the sensitivity by 10 %Increases the sensitivity by 10 % Better conclusions with one or two specimens, Better conclusions with one or two specimens,
unlike Ziehl Neelsen’s method needing 3 or > 3 unlike Ziehl Neelsen’s method needing 3 or > 3 specimens.specimens.
Dr.T.V.RaoDr.T.V.Rao
Culturing MycobacteriumCulturing Mycobacterium
Culturing for isolation of Culturing for isolation of Mycobacterium spp continues to be a Mycobacterium spp continues to be a Gold standard, particularly in Gold standard, particularly in Developing countries.Developing countries.
Need only 10 – 100 bacilli / 1 ml of Need only 10 – 100 bacilli / 1 ml of sputum.sputum.
Dr.T.V.RaoDr.T.V.Rao
Culturing Culturing Most useful inMost useful in
Surveillance,Surveillance, Drug sensitivity testing patterns.Drug sensitivity testing patterns. Identify treatment failures.Identify treatment failures. Useful in Patients presenting with Useful in Patients presenting with
respiratory symptoms, X- ray’s respiratory symptoms, X- ray’s suggestive, but smear negative. Can prove suggestive, but smear negative. Can prove culture positive.culture positive.
Cultures remain suggestive and helpful in Cultures remain suggestive and helpful in early treatment periods, failed drug early treatment periods, failed drug regimes.regimes.
Dr.T.V.RaoDr.T.V.Rao
Methods of Culturing.Methods of Culturing.
Culturing on Lowenstein Jenson’s Culturing on Lowenstein Jenson’s culture medium remain the culture medium remain the affordable ,economical method in affordable ,economical method in developing world.developing world.
Dr.T.V.RaoDr.T.V.Rao
Limitation in CulturingLimitation in Culturing
Mycobacterium spp are slow Mycobacterium spp are slow growing.growing.
Need 6 – 8 weeks for growing.Need 6 – 8 weeks for growing. Specimens can be contaminated Specimens can be contaminated
while growing, needs repeated while growing, needs repeated specimens, in turn patients loose specimens, in turn patients loose confidence in Laboratories.confidence in Laboratories.
Dr.T.V.RaoDr.T.V.Rao
Recent facts on CulturingRecent facts on Culturing
Useful in HIV infected patients with Useful in HIV infected patients with Tuberculosis.Tuberculosis.
As even few bacilli can be grown in As even few bacilli can be grown in spite of smear negativity.spite of smear negativity.
But the specimens to be incubated But the specimens to be incubated for longer time as few bacilli are for longer time as few bacilli are present.present.
Dr.T.V.RaoDr.T.V.Rao
Pitfalls in CulturingPitfalls in Culturing
Specificity is lost due to Specificity is lost due to contamination.contamination.
Can yield false positive results in 1 – Can yield false positive results in 1 – 4 % of the cases.4 % of the cases.
Cultures may be negative in spite of Cultures may be negative in spite of x rays are suggestive of tuberculosis.x rays are suggestive of tuberculosis.
Dr.T.V.RaoDr.T.V.Rao
Growth of Acid fast bacilli on Growth of Acid fast bacilli on L J Medium.L J Medium.
Dr.T.V.Rao
ADVANCES IN ADVANCES IN CULTURING CULTURING
TECHNIQUES.TECHNIQUES.There are emerging Modern Media There are emerging Modern Media
with accurate detection, are with accurate detection, are replacing the Egg and Agar based replacing the Egg and Agar based
medium.medium.
Dr.T.V.RaoDr.T.V.Rao
Emerging methods in CulturingEmerging methods in Culturing
MGIT – Mycobacterium growth MGIT – Mycobacterium growth incubator tube method.incubator tube method.
Growth occurs in shorter than egg Growth occurs in shorter than egg medium.medium.
Usefulness in HIV patients established.Usefulness in HIV patients established. Contamination is lessContamination is less But expensive to people in Developing But expensive to people in Developing
world.world.
Dr.T.V.RaoDr.T.V.Rao
Blood culturing for MycobacteriumBlood culturing for Mycobacterium
Useful in HIV patients, and children.Useful in HIV patients, and children. Effective in isolation of Atypical Effective in isolation of Atypical
mycobacterium.mycobacterium. But not cost effective.But not cost effective. May be important tool in future for May be important tool in future for
diagnosing Tuberculosis in HIV diagnosing Tuberculosis in HIV infected.infected.
Dr.T.V.Rao
Molecular Methods in Molecular Methods in Diagnosis of TuberculosisDiagnosis of Tuberculosis
Several methods are Several methods are available, mainly used as available, mainly used as
Research toolsResearch tools
Dr.T.V.RaoDr.T.V.Rao
Real Time PCR replacing older Real Time PCR replacing older MethodsMethods
Dr.T.V.RaoDr.T.V.Rao
PCR How useful to our Patients?PCR How useful to our Patients?
PCR ( Polymerase chain reaction ) used by PCR ( Polymerase chain reaction ) used by several investigators.several investigators.
However most cases can be diagnosed However most cases can be diagnosed with simple methods if effectively used.with simple methods if effectively used.
The definite role of PCR continues to be The definite role of PCR continues to be controversial controversial
Above all not cost effective to Developing Above all not cost effective to Developing countries.countries.
Dr.T.V.Rao
Rapid Diagnostic Methods Rapid Diagnostic Methods in Tuberculosisin Tuberculosis
Past decade has seen several Past decade has seen several emerging technologiesemerging technologies
How far practicable ?How far practicable ?
Dr.T.V.RaoDr.T.V.Rao
Emerging Rapid Methods.Emerging Rapid Methods.
1. Fast Plaque TB uses phage amplification 1. Fast Plaque TB uses phage amplification technology.technology.
2. ELISA ( QuantiFERON – TB )2. ELISA ( QuantiFERON – TB )
3. Enzyme-Linked immunospot 3. Enzyme-Linked immunospot ( ELISPOT ) ( ELISPOT ) ELISPOT proved highly useful to detect active ELISPOT proved highly useful to detect active tuberculosis in Adults and children. tuberculosis in Adults and children.
Dr.T.V.RaoDr.T.V.Rao
Emerging TechnologyEmerging TechnologyMODSMODS
Microscopic observation drug susceptibility Microscopic observation drug susceptibility assay. ( MODS )assay. ( MODS )
A new method gained importance in A new method gained importance in several reviews.several reviews.
Use a tissue culture plate based assay Use a tissue culture plate based assay with use of Middle Brook 7HG.with use of Middle Brook 7HG.
Needs a inverted light microscope.Needs a inverted light microscope. Even the drug resistance can be tested Even the drug resistance can be tested
with Rifampicin,and Isoniazid.with Rifampicin,and Isoniazid. Safe to work with cultures.Safe to work with cultures.
Dr.T.V.Rao
Non Specific TestsNon Specific Tests
Tuberculin testTuberculin test
( Mantoux Test )( Mantoux Test )
Dr.T.V.RaoDr.T.V.Rao
Tuberculin TestTuberculin Test( Mantoux Test )( Mantoux Test )
Test to be interpreted Test to be interpreted in relation to clinical in relation to clinical evaluation.evaluation.
Even the induration of Even the induration of 5 mm to be 5 mm to be considered positive considered positive when tested on HIV when tested on HIV patients.patients.
Lacks specificity.Lacks specificity.
Dr.T.V.RaoDr.T.V.Rao
Serology in Tuberculosis.Serology in Tuberculosis.
Several serological methods were Several serological methods were evaluated.evaluated.
But never gained the acceptance of But never gained the acceptance of the majority of the clinicians.the majority of the clinicians.
Serological tests are low sensitivity.Serological tests are low sensitivity. Many physicians depend on serology Many physicians depend on serology
in extra pulmonary tuberculosis.in extra pulmonary tuberculosis.
Dr.T.V.Rao
Dealing with Tuberculosis Dealing with Tuberculosis in HIV / AIDS patients.in HIV / AIDS patients.
Diagnosing Tuberculosis in Diagnosing Tuberculosis in HIV infected is a priority and HIV infected is a priority and
improve quality of Lifeimprove quality of Life
Dr.T.V.RaoDr.T.V.Rao
HIV/AIDS HIV/AIDS - - TuberculosisTuberculosis
Consider the HIV statusConsider the HIV status Identify the severity of Tuberculosis.Identify the severity of Tuberculosis. Early use of chest radiography.Early use of chest radiography. Maximal number of sputum smear Maximal number of sputum smear
examinations.examinations. Sputum concentration methods to be Sputum concentration methods to be
encouraged even by smaller laboratories.encouraged even by smaller laboratories. Explore the use of Florescent Microscopy.Explore the use of Florescent Microscopy. All smear negative specimens should be All smear negative specimens should be
cultured. cultured.
Dr.T.V.RaoDr.T.V.Rao
Limitations of Rapid TestsLimitations of Rapid Tests
The testing needs advanced and The testing needs advanced and sophisticated infrastructure.sophisticated infrastructure.
These tests are known for their These tests are known for their inability to diagnose between active inability to diagnose between active disease and latent infection.disease and latent infection.
Exclusively used in Developed Exclusively used in Developed nations.nations.
Dr.T.V.Rao
Extra pulmonary Extra pulmonary TuberculosisTuberculosis
Poses several challenges, Yet Poses several challenges, Yet no optimal, specific diagnostic no optimal, specific diagnostic
methodsmethods
Dr.T.V.RaoDr.T.V.Rao
Extra pulmonary TuberculosisExtra pulmonary Tuberculosis
A real challenge to Clinicians and A real challenge to Clinicians and Laboratories.Laboratories.
Optimal specimen collection a priority,Optimal specimen collection a priority, Molecular Methods are growing need.Molecular Methods are growing need. Clinicians start drug regimes on empirical Clinicians start drug regimes on empirical
basis.basis. Several serological tests for antibody Several serological tests for antibody
determinations are evaluated.determinations are evaluated.
Dr.T.V.Rao
Identification of Atypical Identification of Atypical MycobacteriumMycobacterium
A growing concern on infections with A growing concern on infections with less known, uncommon Mycobacterium less known, uncommon Mycobacterium
in immunosupreesed, an emerging in immunosupreesed, an emerging infectious disease probleminfectious disease problem
Dr.T.V.RaoDr.T.V.Rao
Atypical MycobacteriumAtypical Mycobacterium
Needs the help of reference Needs the help of reference laboratories.laboratories.
Needs different drug regimes, unlike Needs different drug regimes, unlike typical Mycobacterium isolates.typical Mycobacterium isolates.
Now a gowning concern in the era of Now a gowning concern in the era of AIDS.AIDS.
Dr.T.V.RaoDr.T.V.Rao
Future perceptionsFuture perceptions It is highly essential to explore and discover It is highly essential to explore and discover
rapid, simple, and accurate tuberculosis rapid, simple, and accurate tuberculosis diagnostic tools.diagnostic tools.
A massive investment, greater scientific interest, A massive investment, greater scientific interest, political commitment a top priority,political commitment a top priority,
Man power development, Human resource Man power development, Human resource utilization a greater concern.utilization a greater concern.
Microscopy and Florescent Microscopy utilization Microscopy and Florescent Microscopy utilization should be immediate concern, and strengthening should be immediate concern, and strengthening of treatment initiation protocols.of treatment initiation protocols.
Effective methods in diagnosing smear negative Effective methods in diagnosing smear negative patients a growing priority.patients a growing priority.
Dr.T.V.RaoDr.T.V.Rao
Microscopy in TuberculosisMicroscopy in TuberculosisTODAYTODAY
In spite of several In spite of several scientific, and scientific, and
molecular molecular advances advances
Microscopy in Microscopy in Tuberculosis Tuberculosis
continues to be continues to be back bone in back bone in Diagnosis.Diagnosis.
Dr.T.V.Rao
Specific detection of active Specific detection of active Tuberculosis cases in Tuberculosis cases in
patients with HIV infection or patients with HIV infection or AIDS is feasible and AIDS is feasible and
improves the rate of early improves the rate of early diagnosis and successful diagnosis and successful treatment of Tuberculosis.treatment of Tuberculosis.
Dr.T.V.RaoDr.T.V.Rao
Dr.T.V.RaoDr.T.V.Rao
Created for Medical graduates and Created for Medical graduates and Health care workers in Developing worldHealth care workers in Developing world
Dr.T.V.Rao, MD.Dr.T.V.Rao, MD.
e mail; e mail; doctortvrao@gmail.comdoctortvrao@gmail.com
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