Tuberculosis

PEMICU 3BBATUK

BERDARAH

Ronald Chrisbianto Gani405090223

FK UNTAR 2009

BLOKSISTEM RESPIRASI

TUBERCULOSIS

TUBERCULOSIS

• Caused by Mycobacterium Tuberculosis complex

• Usually affects lung, but in 1/3 case, can affect other organs

• Transmissions via droplet nuclei• If untreated, maybe fatal in 5 years in 50-65%

cases

Harrison’s Principle of Medicine17th ed Volume 1

ETIOLOGIC AGENT

• Caused by Mycobacterium Tuberculosis, the complex includes– M. Bovis (unpasteurized milk)– M. Caprae (related to M. Bovis)– M. Africanum (in West, East and Central Africa)– M. Microti– M. Pinnipedii– M. Canetii

• Rod shaped, non-spore, thin aerobic bacterium measured 0,5um – 3um. Often neutral in gram staining.


ETIOLOGIC AGENT


Mycobacterium Tuberculosis, Ziehl-Neelsen Staining

EPIDEMIOLOGY


EPIDEMIOLOGY

• Mostly in developing country• In US, TB usually associated with elderly, HIV-

infected, immigrants, and poor people• TB usually associated with poor hygiene and

ventilation


EPIDEMIOLOGY


RISK FACTORS

• HIV disease• Diabetes• Silicosis• Immunosupression• Gastrectomy• Malnutrition• Presence of fibrotic lesion


PATHOGENESIS• Droplet masuk ke saluran napas (10% ke paru, sisanya

disaring) netrofil makrofag kebanyakan mati dan dikeluarkan

• Bila menetap berkembang biak dalam sitoplasma makrofag membentuk fokus gohn limfangitis lokal + limfadenitis regional = kompleks primer (Ranke), setelah itu dapat:– Sembuh total tanpa bekas (kebanyakan)– Sembuh dengan meimbulkan bekas– Berkomplikasi dan menyebar melalui

• Per kontinuitatum• Bronkogen• Limfogen• hematogen Buku Ajar Ilmu Penyakit Dalam

Edisi V Jilid III

CLINICAL MANIFESTATIONS• Pulmonary

– Primary disease– Post–Primary Disease

• Extra Pulmonary– Tuberculous Lymphadenitis (>40%)– Pleural Tuberculosis (20%)– Tuberculosis of Upper Airways– Genitourinary Tuberculosis (15%)– Skeletal Tuberculosis (10%)– Tuberculous Meningitis and Tuberculoma (5%)– Percardial Tuberculosis– Miliary or Disseminated Tuberculosis


PULMONARYCLINICAL MANIFESTATIONS

• Primary Disease– Occurs soon after initial infection, often in children– Affects middle and lower lobes lung zones– May cause lesion that can heal spontaneously and later

seen as small calcified nodule (Gohn lesion)– In immunosupressed patients and children, disease may

progress with cavitation, pleural efusion, hematogenous dissemination

– Enlarged lymph nodes compress bronchi lobar collapse

– May develop miliary tuberculosis and/or tuberculosis meningitis Harrison’s Principle of Medicine

17th ed Volume 1

PULMONARYCLINICAL MANIFESTATIONS

• Post-Primary Disease– Also called adult-type, reactivation, secondary– Localized to the posterior segment of upper lobes and

superior segements of lower lobes– Early symptoms : fever, night sweats, weight loss,

anorexia, malaise– In majority cases : Cough and purulent sputum, often

with blood streaks– Pleuritic chest pain, rochi, pallor and clubbing finger

may occur in some cases– Hematologic findings : Mild Anemia and leukocytosis


EXTRAPULMONARYCLINICAL MANIFESTATIONS

• Lymphadenitis– Painless swelling of cervical and supraclavicular nodes (scrofula)– Fine needle aspiration or surgical biopsy for diagnosis (AFB smear

50%, culture 70-80%)– DD : infectious conditions, neoplastic diseases (lymphomas and

metastatic carcinomas), disorders (Kikuchi disease, Kimura disease, Castleman disease)

• Pleural Tuberculosis– Fluid is straw-colored and exudative, protein level >50%, Glucose

Level : Normal or Low, pH 7.3, MN cells common, PMN in early stages, Biopsy for diagnosis

– Empyema results from rupture of a cavityHarrison’s Principle of Medicine17th ed Volume 1


• Genitourinary – Urinary frequency, dysuria, nocturia– Urinalysis : pyuria and hematuria– Genital TB more common among women, Fallopian Tube and

uterine disease can cause infertility• Skeletal disease

– Most common in spine, hips, and knees– May cause collapse of vertebral bodies and become kyphosis and

gibbus• Meningitis

– Cranial nerve involvement may cause coma, hydrocephalus, and intracranial hypertension

– CSF may have High Lymphocyte, elevated protein level, low glucose. Culture (+) in 80% cases



• Gastrointestinal disease– Affects terminal ileum and ceccum abdominal pain and

diarrhea– Palpable mass on bowel may occur– TB peritonitis fever, abdominal pain, ascites exudative, need

peritoneal biopsy• Pericarditis

– Acute/subacute fever, dull retrosternal pain, friction rub, effusion is common, chronic fatal

• Miliary / disseminated tuberculosis– Lesion are small granulomas, non spesific– Hepatomegaly, splenomegaly, lymphadenopaty, choroidal

tubercles of the eye may occurHarrison’s Principle of Medicine17th ed Volume 1

DIAGNOSIS

• AFB Microscopy• Mycobacterial Culture• Nucleic Acid Amplification• Drug Suspectibility Testing• Radiographic Procedure• Additional Diagnostic Procedures• Serologic and other diagnostic test– Tuberculin Skin Test (TST)– IFN – Gamma Release Assays (IGRAs)


DIAGNOSIS

• AFB Microscopy– Smear of expectorated sputum or tissue– Most modern : auramine-rhodamine staining and

fluorescence microscopy– Traditional Method : Ziehl-neelsen staining– Three sputums preferaby in the morning

• Mycobacterial Culture– Agar-based medium, incubated at 37o C, 4-8 weeks– Biochemical test to speciate mycobacterial isolates– New methods : molecular method or high-pressure liquid of

chromatography of mycolic acid 2-3 weeks


DIAGNOSIS

• Nucleic Acid Amplification– Amplification of mycobacterial nucleic acid– Ready in several hours– High specificity and sensitivity

• Drug Suspectibility Testing– Tested for isoniazid, rifampin, and ethambutol

• Radiographic Procedures– Classic X-ray : infiltrates and cavities– CT-Scan : diagnose extrapulmonary TB– MRI : Diagnose intracranial TB Harrison’s Principle of Medicine

17th ed Volume 1

DIAGNOSIS

• Additional Diagnostic Procedures– Sputum induction by ultrasonic nebulization of hypertonic saline– Fiberoptic bronchoscopy– In children who cannot expectorate sputum, specimen from early

morning gastric lavage for culture• Serologic test

– Based on detection of antibodies– Marketed in developing countries, not in US

• TST– Skin test with Tuberculin PPD– False negative in immunosupressed pts– False positive in BCG vaccinated pts


DIAGNOSIS

• IGRAs– Measuring T cells release of IFN gamma in

response to stimulation with highly tuberculosis spesific antigents ESAT-6 and CFP-10

– More spesific and less cross reaction to BCG vaccine and non-tuberculosis mycobacteria

– Ex : QUANTIferon-TB Gold (ELISA) and T-SPOT.TB (ELISpot)





MANAGEMENTKATEGORI

DIAGNOSTIK TBREGIMEN PENGOBATAN TB

Fase Awal Fase Lanjutan

Kategori I Anjuran Utama2 HRZE

Anjuran Utama4HR atau 4(HR)3

Opsional2(HRZE)3 or 2HRZE

Opsional4(HR)3 or 6HE

Kategori II Anjuran Utama2HRZES / 1HRZE

Anjuran Utama5HRE

Opsional2(HRZE)3 / 1HRZE3

Opsional5(HRE)3

Kategori III Anjuran Utama2HRZE

Anjuran Utama4HR or4(HR)3

Opsional2(HRZE)3

Opsional4(HR)3 OR

6HEKategori IV Dirancang khusus

Farmakologi dan Terapi Edisi V

MANAGEMENT

• Kategori I– Pasien baru sputum BTA (+)– Pasien baru TB-paru BTA (-) dg infeksi parenkim paru berat

(ekstensif)– TB-Paru dg penyakit HIV atau TB ekstraPulmonal

• Kategori II– Pasien TB-Paru BTA (+) yg pernah diobati

• Kambuh• Pengobatan gagal

– Pasien kategori I yg gagal diobati dg• Program pengobatan yg adekuat• Data yang representatif mengenai TB-MDR menunjukkan angka tinggi

– Tersedia pengobatan IV


MANAGEMENT

• Kategori III– Pasien baru TB paru dengan BTA (-), selain kategori

I dan TB ektraparu ringan• Kategori IV– Kronik (Sputum BTA masih positif sesudah

pengobatan ulang)– Terbukti atau suspek kasus TB-MDR


MANAGEMENT

Katzung’s Basic & Clinical Pharmacology 11th ed

MANAGEMENT

Harrison’s Principle of Medicine 17th ed Volume 1

Documents

Tuberculosis