CLINICAL FEATURES OF TB AND INVESTIGATIONS 8 APR10.

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By: sachinkate (29 month(s) ago)

myself dr sachin kate doig PG in tb &chest.go thru ur ppt i like it.i wnna dwnld it for my acedemic purpse so kindly allow me thnx

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CLINICAL FEATURES OF TB AND INVESTIGATIONS:

CLINICAL FEATURES OF TB AND INVESTIGATIONS DR AMOL DIWAN ASST. PROFESSOR DEPT OF TB & CHEST SKNMC

Clinical Manifestation:

Clinical Manifestation Pulmonary Tuberculosis primary or postprimary (secondary) Extrapulmonary Tuberculosis Lymph-node tuberculosis ( tuberculous lymphadenitis) Pleural tuberculosis Tuberculosis of the upper airways Genitourinary tuberculosis Skeletal tuberculosis Tuberculosis meningitis and tuberculoma Gastrointestinal tuberculosis Pericardial tuberculosis Miliary or disseminated tuberculosis HIV-associated tuberculosis

Pulmonary Tuberculosis:

Pulmonary Tuberculosis Constitutional Symptoms Low grade evening rise fever Night sweats Weight loss Malaise Tiredness Headache Loss of appetite

Pulmonary Tuberculosis:

Pulmonary Tuberculosis Systemic Symptoms Most common symptom is cough for more than two weeks (dry or productive) Expectoration can be mucoid , muco -purulent or blood tinged Chest pain – dull aching – usually due to pleural involvement Dyspnoea - not common but can be caused by pleural effusion, pneumothorax , collapse , fibrosis in advanced disease or global parenchymal destruction Haemoptysis – from blood streaked to massive -generally caused by erosion of Rasmussen’s aneurysms (bronchial circulation) Hoarseness - when the larynx is affected

Lymph Node Tuberculosis:

Lymph Node Tuberculosis Usually present with slowly enlarging lymph nodes in cervical, axillary,inguinal area The lymph nodes may be of varying sizes , discrete or maeetd Firm or cystic in consistency Usually nontender unless sec. infection sets in(Abscess develops) Abscess may burst open leading to chronic nonhealing sinus and ulcer

LYMPH NODE TB:

LYMPH NODE TB Usually in young females Slowly enlarging lymph nodes otherwise asymptomatic ( alongwith constitutional symptoms) Stage I – Enlarged firm mobile discrete nodes stageII – large rubbery nodes fixed to surrounding tissues ( periadenitis ) Stage III – central softening due to abscess formation Stage IV – collarstud abscess Stage V – sinus tract formation

Abdominal Tuberculosis:

Abdominal Tuberculosis Abdominal pain is most common symptom Located in rt or lt lower quadrant or central epigastric region Colicky or cramp like character Diarrhoea – liquid to semisolid stools mixed with mucus or blood passed 6 to 8 times per day Some pts. may have diarrhoea alternating with contipation Malabsorption is also common upto 70% pts. Other symptoms include anorexia, nausea, vomitting , malaena

Neurological Tuberculosis:

Neurological Tuberculosis Tuberculous Meningitis – usually starts with history of vague ill health,apathy, irritability, anorexia and behavioral changes Fever, headache and vomitting can be troublesome Focal neurological deficits and features of raised intracranial pressure may be present Rarely convulsions and cranial nerve palsies most commonly sixth nerve may occur If untreated, progressive deterioration of conciousness, pupillary abnormalities and pyramidal signs may be seen due to increasing hydrocephalus and tentorial herniation.

SKELETAL TUBERCULOSIS:

SKELETAL TUBERCULOSIS CONSTITUTIONAL SYMPTOMS PRESENT CLOD ABCESSES – NECK , CHEST WALL, GRION, INGUINAL AREA, AND THIGHS GIBBUS OR KYPHOSIS – COMMON IN THORACIC SPINE PARAPLEGIA – STARTS WITH TWITCHING OF MUSCLES AND CLUMSINESS IN WALKING- PROGRESSES THROUGH MS WEAKNESS, SPASTICITY INCOORDINATION, WITH DIFFICULTY IN WALKING IN ORDER SPINE>HIP>KNEE>ANKLE>SHOULDER>ELBOW> SMALL JOINTS OF HANDS AND FEET

CUTANEOUS TUBERCULOSIS:

CUTANEOUS TUBERCULOSIS Previously not exposed to M tuberculosis – Tuberculosis chancre or milliary tb of skin Previously sensitised to M tuberculosis – Lupus vulgaris, Scrofuloderma, Tuberculosis verrucosa cutis Tuberculids – Lichen scrofuosorum, Papulonecrotic tuberculid, Erythema induratum, Ertythema nodosum

Complication of pulmonary tuberculosis:

Complication of pulmonary tuberculosis Pleurisy Bronchiectasis •Systemic Fungus ball Respi . failure Hemoptysis cor pulmonale Empyema sec. amylodosis Open negative syndrome Bronchial stenosis Pneumothorax Dissemination Sec. pyogenic infection

PowerPoint Presentation:

INVESTIGATIONS Types of specimens: 1.Pulmonary specimens -Sputum. -Gastric lavage - Transtracheal aspirations - Bronchoscopy -Laryngeal swabbing 2.Urine specimens 3.Tissue and body fluid specimens (SEROUS FLUIDS) 4.Blood specimens 5.Wounds, skin lesions, and aspirates

Sputum collection :

Sputum collection Sputum collected in the morning before any meal Should not use oral antiseptics 2 sputum samples Sputum is not available then . Laryngeal swabs . Bronchial washings . In small children gastric Lavage

Observe to identify Sputum from Saliva.:

Observe to identify Sputum from Saliva. SPUTUM Specimens appear mucoid even, blood stained. Contains many Polymorphoneutrophils. <10 epithelial cells >25 neutrophils SALIVA Appears clear, watery, and frothy. Contains many squamous epithelial cells Absence of Polymorphoneutrophils.

Laboratory diagnosis:

Laboratory diagnosis Microscopy Culture Animal inoculation Nucleic acid amplification technology Allergic tests

Investigations for tuberculosis:

Investigations for tuberculosis CBC with ESR Liver function tests Chest x-ray Ultrasonography e.g. thorax, abdomen and pelvis, neck, scrotum CT Scan chest, abdomen, brain ,spine MRI Spine

Laboratory Diagnosis:

Laboratory Diagnosis 1- Sputum smears stained by Z-N stain Two morning successive mucopurulent sputum samples are needed to diagnose pulmonary TB . Advantage : - cheap – rapid - Easy to perform Disadvantages: - sputum ( need to contain 5000-10000 AFB/ ml.) - Young children, elderly & HIV infected persons may not produce cavities & sputum containing AFB.

Limitation of Microscopy for Tuberculosis.:

Limitation of Microscopy for Tuberculosis. Repeated sample examinations. load on technical staff. Training and dedication of Microscopist . The load of bacilli must be more than 10,000 / 1 ml of sputum. Low in sensitivity < 50 % Repeated requests for samples High drop out by patients, for repeated samples. Not dependable in pediatric age group.

MICROSCOPY:

MICROSCOPY

What is Smear Positivity WHO:

What is Smear Positivity WHO All patients who have submitted two Specimens and found to be positive for identification of AFB

Grading :

Grading If the slide has Result Grading No. of fields to be examined More than 10 AFB /oil immersion field pos 3+ 20 1-10 AFB/ oil immersion field pos 2+ 50 10-99 AFB/100 oil immersion field pos 1+ 100 1-9 AFB/100 oil immersion field pos Scanty* 100 No AFB in 100 oil immersion field neg 100 *record actual number of bacilli seen in 100 fields

PowerPoint Presentation:

2- Detecting AFB by fluorochrome stain using fluorescence microscopy: The smear may be stained by auramine-O dye. In this method the TB bacilli are stained yellow against dark background & easily visualized using florescent microscope . Advantages: - More sensitive - Rapid Disadvantages: - Hazards of dye toxicity - more expensive - must be confirmed by Z-N stain

Acid Fast Bacilli as seen under Fluorescent Microscope:

Acid Fast Bacilli as seen under Fluorescent Microscope

Processing specimens:

Processing specimens Sputum Microscopy can be improved with Sputum liquefaction, concentration and gravity sedimentation. Popular solvents Sodium hypochlorite. Sodium hydroxide. Ammonium sulphate N-acetyl-L-cysteine –sodium hydroxide.

Culture methods:

Culture methods Rapid culture methods • BACTEC system • MycobactGrowth Indicator Tube(MGIT) • MB/BacT system (Alert 3d) • Septi-check AFB method • ESP culture system II (VersaTREK) • Microscopic observation of broth/slide

Culturing Mycobacterium:

Culturing Mycobacterium Culturing for isolation of Mycobacterium spp continues to be a Gold standard , particularly in Developing countries. Need only 10 – 100 bacilli / 1 ml of sputum.

Recent facts on Culturing:

Recent facts on Culturing Useful in HIV infected patients with Tuberculosis. As even few bacilli can be grown in spite of smear negativity. But the specimens to be incubated for longer time as few bacilli are present.

Solid media:

Solid media Agar based 1. Middlebrook 7H10 and Middle brook 7H10 selective 2.Middlebrook 7H11 and Middlebrook 7H11 selective 3. Middlebrook biplate (7H10/7H11Sagar)

Solid media:

Solid media EGG BASED Lowenstein-Jensen (L-J) L-J with pyruvic acid L-J with iron

Solid media:

Solid media Cultures incubated at 35 °c in the dark in an atmosphere of 5% to 10% co2 and high humidity Cultures are examined weekly for growth Most isolates appear between 3 and 6 weeks a few isolates appear after 7 or 8 weeks After 8 wks of incubation negative cultures are reported

Mycobacterium tuberculosis:

Mycobacterium tuberculosis Dry , Rough , Raised , irregular colonies with wrinkled surface They are creamy white becoming yellowish or buff coloured on further incubation

Eight Week Growth of Mycobacterium tuberculosis on Lowenstein-Jensen Agar :

Eight Week Growth of Mycobacterium tuberculosis on Lowenstein-Jensen Agar

Commonly used liquid media systems to culture and detect the growth of mycobacterium:

Commonly used liquid media systems to culture and detect the growth of mycobacterium BACTEC 460 Mycobacteria growth indicator tube (MGIT) BACTEC MGIT 960 ( continuous growth monitoring systems)

Liquid media :

Liquid media Use of liquid media system reduces the turn-around time for isolation of acid-fast bacilli to approximately 10 days compared with 17 days or longer in conventional methods Once growth is detected in the liquid media , an acid fast stain is performed to confirm the presence of acid-fast bacilli

Recent Methods for Diagnosis:

Recent Methods for Diagnosis BACTEC 460 ( rapid radiometric culture system ) specimens are cultured in a liquid medium (Middle brook7H9 broth base )containing C 14 – labelled palmitic acid & PANTA (polymyxin,amphoB,nalidixic acid,trimethoprim,azlocillin ) antibiotic mixture. Growing mycobacteria utilize the acid, releasing radioactive CO 2 which is measured as growth index (GI) in the BACTEC instrument. The daily increase in GI output is directly proportional to the rate & amount of growth in the medium.

Advantages : :

Advantages : - Rapid (mycobacteria can be detected within 12 days.) - Determining drug susceptibility. - Specificity is very high Disadvantages: - Expensive - Hazards of using radioactive material.

II Mycobacteria Growth Indicator Tube (MGIT):

II Mycobacteria Growth Indicator Tube (MGIT) Tube contains modified Middlebrook 7H9 broth base with middlebrook OADC enrichment & PANTA (polymyxin, amphoB, nalidixic acid, trimethoprim, azlocillin) antibiotic mixture. All types of clinical specimens, pulmonary as well as extra-pulmonary ( except blood ) could be cultured on this type of media.

Principle of the procedure: :

Principle of the procedure: A fluorescent compound – ruthenium salt (which is sensitive to O 2 ) is embeded in silicone on the bottom of the tube. The actively respiring microorganisms consume the oxygen & allow the fluorescence to be observed using UV trans-illuminator lamp.

The MGIT 960 System:

The MGIT 960 System The MGIT 960 system is a non-radiometric automated system that uses the MGIT media & sensors to detect the fluorescence. Advantages: -The system holds 960 plastic tubes which are continuously monitored. Early detection as the machine monitoring & reading the tubes every hour. Non radiometric

PowerPoint Presentation:

ESP II Myco system (versaTREK) • Changes in gas pressure in a sealed culture broth bottle by gas production/consumption • Reliable & less labour intensive • Used in combination with solid medium not stand alone

MB/BacT System:

MB/BacT System MB/ BacT system ( Alert 3d system ) • Non radiometric continuous monitoring system • Automated • Based on colorimetric detection of CO2 • Slightly longer time than BACTEC system (11.6 days vs 13.7 days) • Prone to contamination

Approach to identification :

Approach to identification Growth on solid or liquid media perform a acid-fast stain Several colonies on solid media are inoculated to middle brook 7H9 broth 5ml and incubated at 35 °c for 5 to 7 days with daily agitation to enhance the growth Either this broth or growth in primary liquid culture are inoculated all test media including biochemical tests and pigmentation and growth rate determinations

Biochemical tests:

Biochemical tests Niacin test P=Human tubercle bacilli: N=Bovine Aryl sulphatase test P= Atypical Mycobacteria Catalase – Peroxidase test Differentiate between typical and atypical Mycobacteria Nitrate reduction test P= M.tuberculosis N= M.bovis Adenosine deaminase activity useful in tuberculous serositis e.g. pleural,peritoneal,meningeal,pericardial Bromide partition test(Radioactive) Useful in TB meningitis (<1.6)

Nucleic acid probes commercially available:

Nucleic acid probes commercially available M. tuberculosis complex M. avium complex M. avium M. intercellulare M. kansasii M. gordonae

PowerPoint Presentation:

M. tuberculosis antigens with serodiagnostic potential can be divided into six categories based on the type of TB they preferentially detect 1) Antigens that can be used to detect latently infected patients or household contacts: 16-kDa (a- crystallin ),14-kDa and 6-kDa antigens. 2 )Antigens that can be used to detect TB patients at an early stage of disease: MTB81, MPT51, MPT32 and Ag85C (Table 3). 3) Antigens that can be used to detect TB patients co-infected with HIV: TB9.7, TB15.3, TB16.3, TB51,MTB81, MPT32 and Ag85B

PowerPoint Presentation:

4 ) Antigens that can be used to detect antibodies in sera of patients with extrapulmonary TB: DAT, TAT, SL-I, cord factor, GST-822, ESAT-6, MTB11 (CFP-10), TB9.7, TB15.3, TB16.3, TB51 and 38-kDa tigen . IgA antibodies to MPT64 have been studied in pleural effusions MPT64 is also readily detected in tissues of TB patients using immunohistochemistry 5) A combination of recombinant proteins and a fusion polyprotein which may detect different forms of TB (caused by different strains and in different host populations): 38-kDa antigen, MTB8, MTB11, MTB48,MTB81, DPEP, TB9.7 and TB16.3

Serologic tests:

Serologic tests Serologic tests • Applied mainly for smear & culture negative pulm & EPTB at inaccessible body sites • Extensive antigenic sharing between diff. sps. Of mycobacteria ---complicates the diagnostic value of serological tests •Multideterminant nature of Ag. – Single Ag. Molecule may possess epitope sp. For M.tb . , it may also bear non specific ones. • ELISA based methods for the detection of mycobacteria antigen in body fluids • Positive test may perhaps “rule in” a diagnosis, but a negative test cannot “rule out” a diagnosis of tuberculosis • Used as supportive evidence along with conventional tests

Serologic tests - limitations:

Serologic tests - limitations • Great individual variability in the number and type of reactive antibodies • Affected by BCG vaccination, previous infection and environmental NTM exposure • Persistence of antibodies leads to difficulty in distinguishing between infection and disease • Low sensitivity in smear negative, HIV co-infection, and disease endemic countries • Expensive • Requires trained personnel

Chromatographic analysis:

Chromatographic analysis Analysis of Mycobacterial lipids by chromatographic methods 1. Gas-liquid chromatography 2. Reverse – phase high performance liquid chromatography

III Polymerase Chain Reaction (PCR) & Gene probe:

III Polymerase Chain Reaction (PCR) & Gene probe Nucleic acid probes & nucleic acid amplification tests in which polymerase enzymes are used to amplify ( make many copies of specific DNA or RNA sequences extracted from Mycobacterial cells. Targets for PCR • IS6110 • IS1081( nested PCR developed by CDFD) • 65 kDa protein gene • 16S r DNA gene • MPB64 gene • 35 kDa protein gene •TRC 4

Advantages: :

Advantages : Rapid procedure ( 3 – 4 hours) - High sensitivity (1-10) bacilli / ml sputum) Disadvantages : - Very expensive. - Require specialist training & equipments. - False positive results. - Can not differentiate between living & dead bacilli.

PCR ASSAY:

PCR ASSAY Types of PCR •DNA PCR •RT PCR • NESTED •INVERSE •IN SITU COMMERCIAL OR IN HOUSE

Emerging Rapid Methods.:

Emerging Rapid Methods. 1. Fast Plaque TB uses phage amplification technology. 2. ELISA ( QuantiFERON – TB ) 3. Enzyme-Linked immunospot ( ELISPOT ) ELISPOT proved highly useful to detect active tuberculosis in Adults and children.

FAST plaque TB Test :

FAST plaque TB Test - Patient’ s sputum is mixed with myco-bacteriophage . - A virucide is added which destroy any phages outside the TB bacilli. - Lysis of cells & release of phages after replication within the tubercle bacilli. - Non-pathogenic mycobacteria are added & the sample incorporated in agar mixture( over night incubation) - Zones of clearing indicate that patient’ s sputum contained viable M. tuberculosis.

T Cell Interferon –γ Tests:

T Cell Interferon – γ Tests In vitro T-cell-based assays tests for diagnosis of latent TB infection : - QuantiFERON TB gold Test - T-Spot Test. These whole-blood assays measure IFN- γ production by previously sensitised lymphocytes in response to M.tuberculosis-specific protein antigens ESAT6 and CFP-10

Methods to determine susceptibility of M.tuberculosis to anti-Mycobacterial agents:

Methods to determine susceptibility of M.tuberculosis to anti-Mycobacterial agents Absolute concentration method Resistance is expressed as the lowest concentration of drug that inhibits all or almost all of the growth , that is the minimum inhibitory concentration

Susceptibility testing:

Susceptibility testing Resistance ratio method Resistance is expressed as the ratio of the MIC of the test strain divided by the MIC for the standard strain for each drug Proportion method The extent of growth in the absence or presence of drug is compared and expressed as percentage If growth at the crictical concentration of drug is >1% , the isolate is considered clinically resistant

Newer methods:

Newer methods Line probe assay for rapid detection of Rifampicin mutations High density DNA probes Luciferase gene technique

Method of PPD skin test:

Method of PPD skin test Mantoux test 1) Intradermal injection 5TU of PPD-S = 2 TU of RT-23 PPD 2) In 48-72 hrs 3) Read induration

Nonspecific tests Tuberculin Test ( Mantoux Test ):

Nonspecific tests Tuberculin Test ( Mantoux Test ) Test to be interpreted in relation to clinical evaluation. Even the induration of 5 mm to be considered positive when tested on HIV patients. Lacks specificity.

Allergic test:

Allergic test 1. Mantoux test . 0.1 ml of PPD containing 5 TU is injected intradermally on flexor aspect of fore arm . Examine after 48 – 72 hrs . In duration of diameter 10 mm –p 5mm or less – N

Allergic test:

Allergic test 2. Multiple Heaf test 3. Tine test Disposable prongs carrying dried PPD Test become positive 4- 6 wks after infection or immunization Allergy wanes gradually and disappears after 4-5 yrs Skin tests • TB MPB 64 patch test- Specific MTB antigen, becomes positive in 3-4 days and remains for a week • Sens 98.1% and spec 100% • Requires further evaluation

uses:

uses In diagnosis of tuberculosis in infants and young children Measure of prevelance of infection Select the susceptibles (contact screening)

Fungus ball:

Fungus ball

Hypertrophied bronchial artery:

Hypertrophied bronchial artery hemoptysis

Rasmussen aneurysm:

Rasmussen aneurysm

Bronchial stenosis:

Bronchial stenosis