TB lecture DBS 1204

Views:
 
Category: Entertainment
     
 

Presentation Description

No description available.

Comments

Presentation Transcript

Slide 1: 

2/16/2011 1 Darmawan B Setyanto Respirology Division, Department of Pediatric Faculty of Medicine, University of Indonesia Pediatric TB lecture

Introduction : 

2/16/2011 2 Introduction

Definition : 

2/16/2011 3 Definition Tuberculosis is a disease due to Mycobacterium tuberculosis infection with systemic spread thus can affect almost all organs, and the most frequent site is in the lung, which usually as the site of primary infection

Tuberculosis : 

2/16/2011 4 Tuberculosis The reaction of the tissues of the human host to the presence and multiplication of Mycobacterium tuberculosis or Mycobacterium bovis

History : 

2/16/2011 5 History ancient Egypt : gibbus 1882, Koch, identification management : sanatorium, collapse treatment Chemotherapy : PAS – 1943 – Lehmann Streptomycine – 1945 - Waksman & Schats Isoniazid – 1952 – Domagk Rifampicine - 1957

Magnitude of problem : 

2/16/2011 6 Magnitude of problem TB one of the oldest diseases of human remains one of the deadliest diseases in the world 8 million of new cases yearly 3 million death yearly 20-40% population is infected reemergence, global emergency

The secret : 

2/16/2011 7 The secret Why TB is so strong & robust? the secret: specific characters of the bacilli special issues: hematogenic spread infection vs disease primary vs post-primary

The main problems : 

2/16/2011 8 The main problems Diagnosis Clinical manifestations : not specific  both over/under diagnosis & over/under treatment diagnostic specimen : difficult to obtain TB infection or TB disease ?  no diagnostic tool to distinguish Adherence / compliance Drug discontinuation  treatment failure

Etiology : 

2/16/2011 9 Etiology

The bacilli : 

2/16/2011 10 The bacilli Mycobacterium tuberculosis Mycobacterium bovis features: slender, often slightly curved, rods aerobic, non-motile, non-spore forming acid fail to wash the stain out  acid fast bacilli Mycobacteria : found in environments, some strictly human pathogen (M tb, bovis), others animal pathogen and opportunistic pathogens in human (atypical mycobacteria)

TB bacilli : 

2/16/2011 11 TB bacilli

M tuberculosis : 

2/16/2011 12 M tuberculosis Unique characteristics : live in weeks in dry condition no endotoxins, no exotoxins hematogenic spread grows slowly (24-32 hr) non specific clinical manifestation aerob, organ predilection - lung wide spectrum of replication: dormant

Transmission : 

2/16/2011 13 Transmission

Transmission ... : 

2/16/2011 14 Transmission ... airborne human to human transmission by droplet nuclei adult pulmonary TB: cough, sneeze, speak, or sing droplet nuclei : contain 2-3 bacilli, small size (1-5) keep in the air for long period inhalation, reach alveoli middle and lower lobes

TB droplet nuclei : 

2/16/2011 15 TB droplet nuclei

Transmission factors: : 

2/16/2011 16 Transmission factors: doses / numbers concentration in the air virulence exposure duration host immune state

Infection source : 

2/16/2011 17 Infection source Known source of infection, has diagnostic value Shaw (1954), transmission rate: AFB (+) : 62.5 % AFB (-), M tb (+) : 26.8 % AFB (-), M tb (-) : 17.6 %

Transmission rate (Shaw ’54) : 

2/16/2011 18 Transmission rate (Shaw ’54) adult TB patient AFB(+) AFB(-) culture(+) culture(-) CXR (+) 65% 26% 17%

Pathogenesis : 

2/16/2011 19 Pathogenesis

Location of primary focus in 2,114 cases, 1909-1928 : 

2/16/2011 20 Location of primary focus in 2,114 cases, 1909-1928 Location % Lung 95.93 Intestine 1.14 Skin 0.14 Nose 0.09 Tonsil 0.09 Middle ear (Eustachian tube) 0.09 Parotid 0.05 Conjunctiva 0.05 Undetermined 2.41

Slide 21: 

2/16/2011 21 Figure. Pathogenesis of primary tuberculosis droplet nuclei inhalation alveoli ingestion by PAM’S intracellular replication of bacilli destruction of bacilli destruction of PAM’S Tubercle formation Hilar lymph nodes hematogenic spread multiple organs remote foci Lymphogenic spread disseminated primary TB acute hematogenic spread occult hematogenic spread primary focus lymphangitis lymphadenitis primary complex CMI

Incubation period : 

2/16/2011 22 Incubation period first implantation  primary complex 4-6 weeks (2-12 weeks)  incubation period first weeks: logaritmic growth, : 103-104  elicit cellular response end of incubation period: primary complex formation cell mediated immunity tuberculin sensitivity  PrimaryTB infection has established

Slide 23: 

2/16/2011 23 lymphadenitis lymphangitis primary focus Pathogenesis ...

Hematogenous spread : 

2/16/2011 24 Hematogenous spread during incubation period, before TB infection establishment: lymphogenic spread hematogenic spread hematogenic spread (HS): occult HS acute generalized HS

Occult HS : 

2/16/2011 25 Occult HS most common sporadic, small number no immediate clinical manifestation remote foci in almost every organ rich vascularization: brain, liver, bones & joints, kidney including: lung – apex region CMI (+): silent foci - dormant, potential for reactivation

TB hematogenous spread : 

2/16/2011 26 TB hematogenous spread

Acute HS : 

2/16/2011 27 Acute HS less common large number immediate clinical manifestation: disseminated TB milliary TB, meningitis TB tubercle in same size, special appearance in CXR

Miliary TB : 

2/16/2011 28 Miliary TB

Primary complex : 

2/16/2011 29 Primary complex end of incubation period TB infection establishment tuberculin sensitivity (DTH) cell mediated immunity end of hematogenic spread end of TB bacilli proliferation small amount, live dormant in granuloma new exogenous TB bacilli: destroyed / localized

Tuberculin skin test : 

2/16/2011 30 Tuberculin skin test

Tuberculin test : 

2/16/2011 31 Tuberculin test TB infection cellular immunity delayed type hypersensitivity tuberculin reaction

Tuberculin : 

2/16/2011 32 Tuberculin

Tuberculin delivery : 

2/16/2011 33 Tuberculin delivery 1. Mantoux : intradermal injection 2. Multiple puncture : Heaf, special apparatus with 6 needles Tine, disposable, 4 needles 3. Patch test

Tuberculin : 

2/16/2011 34 Tuberculin Mantoux 0.1 ml PPD intermediate strength location : volar lower arm reading time : 48-72 h post injection measurement : palpation, marked, measure report : in millimeter, even ‘0 mm’ Induration diameter : 0 - 5 mm : negative 5 - 9 mm : doubt > 10 mm : positive

Mantoux tuberculin skin test : 

2/16/2011 35 Mantoux tuberculin skin test

Tuberculin positive : 

2/16/2011 36 Tuberculin positive 1. TB infection : infection without disease / latent TB infection infection AND disease disease, post therapy 2. BCG immunization 3. Infection of Mycobacterium atypic

Tuberculin negative : 

2/16/2011 37 Tuberculin negative No TB infection Anergy Incubation period

Anergy : 

2/16/2011 38 Anergy Patient with primary complex do not give reaction to TST due to supression of CMI : Severe TB: miliary TB, TB meningitis Severe malnutrition Steroid, long term use Certain viral infection: morbili, varicella Severe bacterial infection: typhus abdominalis, diphteria, pertussis Viral vaccination: morbili, polio Malignancy: Hodgkin, leukemia, ...

TB infection & TB disease : 

2/16/2011 39 TB infection & TB disease TB infection: CMI can control infection primary complex (+) cell mediated immunity (+) tuberculin sensitivity (DTH) (+) limited amount of TB bacilli no clinical or radiological manifestation TB disease: CMI failed to control TB infection TB infection + clinical and/or radiological manifestation

TB classification (ATS/CDC modified) : 

2/16/2011 40 TB classification (ATS/CDC modified)

TB natural history overview : 

2/16/2011 41 TB natural history overview primary TB infection primary TB disease latent TB infection no disease post primary TB respiratory TB non respir TB new infection

Prognostic factors : 

2/16/2011 42 Prognostic factors TB bacilli : virulence infection dose Patient : general condition age nutritional state coinfection: morbili, pertussis genetic stress; physically (trauma, surgery) or mentally

Pathology : 

2/16/2011 43 Pathology

Pathology : 

2/16/2011 44 Pathology complicated pathogenesis varied pathology clinical manifestation radiologic appearance lung represent tubercle, granuloma, tuberculoma, fibrosis, fistula, cavity, atelectasis complication of primary focus: so many possibilities

Lesions of pulmonary TB : 

2/16/2011 45 Lesions of pulmonary TB Parenchym: primary focus, pneumonia, atelectasis, tuberculoma, cavitary Lymph node: hilar, paratracheal, mediastinal Airway: air trapping, endobronchial TB, bronchial stenosis, fistula, bronchiectasis Pleura: effusion, fistula, empyema, pneumothorax, hemothorax Blood vessels: milliary, hemorrhage

Slide 46: 

2/16/2011 46 tubercle formation resolution primary focus calcification 2nd lung lesions caseation liquefaction granuloma Pathology jungle remote foci reg lymph node tuberculoma cavity milliary seed erodes airway compresses airway rupt to pleura rupt to airway bronchiectasis fibrosis br pl fistula

Clinical : 

2/16/2011 47 Clinical

Clinical types of pediatric TB : 

2/16/2011 48 Clinical types of pediatric TB Infection: TST (+), clinical (-), radiographic (-) Disease: Pulmonary: primary pulmonary TB milliary TB pleuritis TB progr primary pulm TB: pneumonia, endobr TB Extrapulmonary: lymph nodes brain & meninges bone & joint gastrointestinal other organs

Clinical manifestation : 

2/16/2011 49 Clinical manifestation vary, wide spectrum factors: TB bacilli: numbers, virulence host: age, immune state clinical manifestation general manifestation organ specific manifestation

General manifestation : 

2/16/2011 50 General manifestation chronic fever, subfebrile anorexia weight loss malnutrition malaise chronic recurrent cough, think asthma! chronic recurrent diarrhea others

Slide 51: 

2/16/2011 51 Fever of Onset Tuberculin Test Positive Primary pulmonary TB TB Meningitis Miliary TB TB Pleural effusion Osteo-articular TB Renal TB Phlyctenular conjunctivitis Erythema nodosum 2 – 3 months 3 – 12 months 6 – 24 months > 5 years Time after primary infection Clinical Manifestation Figure 5. The Timetable of Tuberculosis Donald PR et.al. In: Madkour MM, ed. Tuberculosis. Berlin; Springer;2003.p.243-64

Slide 52: 

2/16/2011 52 Miller FJW. Tuberculosis in children, 1982 Timetable of untreated primary TB in children A minority of children experience : 1. Febrile illness 2. Erythema Nodosum 3. Phlyctenular Conjunctivitis Complications of focus 1. Effusion 2. Cavitation 3. Coin shadow Complications of nodes 1. Extension to bronchus 2. Consolidation 3. Hyperinflation MENINGITIS OR MILIARY in 4% of children infected under 5 years of age LATE COMPLICATIONS Renal & Skin Most after 5 years 1 2 3 4 5 6 BONE LESION Most within 3 years 24 months Resistance reduced : 1. Early infection (esp. in first year) 2. Malnutrition 3. Repeated infections : measles, whooping cough streptococcal infections 4. Steroid therapy infection BRONCHIAL EROSION Most children become tuberculin sensitive 12 months DIMINISHING RISK But still possible 90% in first 2 years GREATEST RISK OF LOCAL & DISEMINATED LESIONS Development Of Complex 4-8 weeks 3-4 weeks fever of onset PRIMARY COMPLEX Progressive Healing Most cases Uncommon under 5 years of age 25% of cases within 3 months 75% of cases within 6 months 3-9 months Incidence decreases As age increased

Organ specific : 

2/16/2011 53 Organ specific Respiratory : cough, wheezing, dyspnea Neurology : convulsion, neck stiffness, SOL manifestation Orthopedic : gibbus, crippled Lymph node : enlarge, scrofuloderma Gastrointestinal: chronic diarrhea Others

Microbiology : 

2/16/2011 54 Microbiology culture (Lowenstein Jensen) confirm the diagnosis negative result do not rule out TB positive result : 10 - 62 % (old method) methods: old method radiometric (Bactec) PCR

Polymerase chain reaction : 

2/16/2011 55 Polymerase chain reaction PCR from gastric aspirate  diagnosis of TB in children Sensitivity: 44 – 90% Specificity: 94 – 96,8% Compared to MTB culture Lodha R et.al. Indian J Pediatr 2004;71:221-7. PCR technique using primer containing IS6110  better results Khan EA and Starke JR. Emerg Infect Dis 1995;1:115-23. May help in early detection of resistant strain of MTB Lodha R et.al. Indian J Pediatr 2004;71:221-7.

Radiology, serology , ... : 

2/16/2011 56 Radiology, serology , ...

Imaging diagnostic : 

2/16/2011 57 Imaging diagnostic routine : chest X ray on indication : bone, joint, abdomen majority of CXR non suggestive TB pitfall in TB diagnostic

Radiographic picture : 

2/16/2011 58 Radiographic picture primary complex: lymph node enlargement milliary atelectasis cavity tuberculoma pneumonia air trapping - hyperinflation pleural effusion honeycombs – bronchiectasis calcification, fibrosis

Radiographic picture : 

2/16/2011 59 do not always help, particularly in small children at times can be confusing some cases: extensive disease from radiography  clinical exam revealed little or nothing more confusingsuperadded bacterial pneumonia Osborne CM et.al. Arch Dis Child 1995;72:369-74 Radiographic picture

Radiographic picture : 

2/16/2011 60 No radiographic picture is typical of TB Many lung diseases have similar radiographic appearances mimicking PTB Cannot distinguish active pulmonary TB – inactive PTB – previously treated TB May not detect early stages of TB disease under-reading over-reading intra-individual inconsistency Vijayan VK. Indian J Clin Biochem 2002;17(2):96-100. Radiographic picture

Radiographic picture : 

2/16/2011 61 Commonly found: enlargement of hilar/ paratracheal nodes  sometimes difficult to interpret  requires thorax CT with contrast Thorax CT reveals enlargement of lymph node in 60% children with TB infection and normal Chest röntgenogram Delacourt C et.al. Arch Dis Child 1993;69:430-2. Radiographic picture

Slide 62: 

2/16/2011 62 Over diagnosis TB by CXR Over- diagnosis

Serology : 

2/16/2011 63 Sensitivity: 19 – 68% Specificity: 40 – 98% Disadvantages results affected by factors such as - age - history of BCG vaccination - exposure to atypical Mycobacteria - unable to differentiate between infection and disease Khan EA and Starke JR. Emerg Infect Dis 1995;1:115-23. Depends on: Type of antigen used Type of infection Serology

Interferon γ : 

2/16/2011 64 Detection of interferon- γ (QuantiFERON-TB) comparable with TST to detect latent TB infection Advantages - less affected by BCG vaccination - can discriminates responses due to nontuberculous mycobacteria - avoids variability and subjectivity associated with placing and reading TST The utility of QFT in predicting the progression to active TB has not been evaluated Mazurek GH et.al. MMWR Dispatch 2002;51. Interferon γ

Diagnosis : 

2/16/2011 65 Diagnosis

The main problems : 

2/16/2011 66 The main problems Diagnosis Clinical manifestations : not specific  both over/under diagnosis & over/under treatment diagnostic specimen : difficult to obtain No other definitive diagnostic tools TB infection or TB disease ?  no diagnostic tool to distinguish Adherence / compliance Drug discontinuation  treatment failure

Diagnosis : 

2/16/2011 67 Diagnosis Tuberculin skin test Chest X ray Clinical manifestation Microbiologic Pathology Hematological Known infection source Others : serologic, lung function, bronchoscopy

Clinical setting management : 

2/16/2011 68 Clinical setting management Suspect TB proveTB infection Mantoux test positive negative not TB Seek other etiologies completed: Ro, lab Diagnosis TB treatment

Practical clinical approach to Ped TB : 

2/16/2011 69 Practical clinical approach to Ped TB Scoring system Stegen, 1969 Smith, Marquis, 1981 Migliori dkk, 1992 WHO, 1994 Algorithm IDAI: 1998, 2002

Algorithm for Early Detection and Referral for Childhood Tuberculosis in Indonesia : 

2/16/2011 70 Algorithm for Early Detection and Referral for Childhood Tuberculosis in Indonesia Suspected TB: Close contact with adult with AFB sputum (+) Early reaction of BCG (in 3-7 days) Weight loss with no apparent cause, or underweight with no improvement in 1 month with adequate nutritional support (failure to thrive) Prolonged/recurrent fever with no apparent cause Cough more than 3 weeks Specific enlargement of superficial lymph node Scrofuloderma Flychten conjunctivitis Tuberculin test positive (> 10 mm) Radiological findings suggestive TB If > 3 positive Next page

Slide 71: 

2/16/2011 71 Considered TB Give anti-TB therapy Observation in 2 months Clinical response (+) No clinical response/worsening TB Continue anti-TB therapy Not TB MDR TB Refer to hospital Reevaluation in Referral Hospital: Clinical signs Tuberculin test Radiological findings Microbiology and serology examination Histopatology examination Diagnostic procedure and therapy according to each hospital’s protocol ATTENTION Presence of any dangerous signs: Seizure Decreased level of consciousness Neck stiffness Or signs such as: Spinal tumor/lump Limping Dam board phenomenon  Send to hospital UKK Pulmonologi –IDAI. Jakarta;2002.

Encountered problem : 

2/16/2011 72 Encountered problem Increasing demands of TB drugs for Pediatric TB Increasing diagnosis of Pediatric TB using the IDAI algorhitm Over diagnosis !? Need improvement  IDAI scoring system

Proposed IDAI scoring system : 

2/16/2011 73 Proposed IDAI scoring system

Notes for IDAI scoring system : 

2/16/2011 74 Notes for IDAI scoring system Diagnosis by doctor BW assessement at present Fever & cough no respons to standard tx CXR is NOT a main diagnostic tool in children All accelerated BCG reaction should be evaluated with scoring system TB diagnosis total score >5 Score 4 in under5 child or strong suspicion, refer to hospital INH prophylaxis for AFB(+) contact with score <5

Diagnosis of TB in children : 

2/16/2011 75 Diagnosis of TB in children If you find the diagnosis of TB in children easy, you probably overdiagnosing TB If you find the diagnosis of TB in children difficult, you are not alone It is easy to over-diagnose TB in children It is also easy to miss TB in children Carefully assess all the evidence, before making the diagnosis Anthony Harries & Dermot Maher, 1997

Treatment : 

2/16/2011 76 Treatment

Objectives of treatment : 

2/16/2011 77 Objectives of treatment Rapid reduction of the number of bacilli Preventing acquired drug resistance Sterilization to prevent relapses

Treatment principles : 

2/16/2011 78 Treatment principles Drug combination, not single drug risk of fall and rise phenomenon each TB drug has special action to certain TB bacilli population Two phases : Initial phase (2 months) – intensive, bactericidal effect Maintenance phase (4 months / more) – ‘sterilizing’ effect, prevent relaps

Slide 79: 

2/16/2011 79 Smear + Culture + Smear - Culture + Smear - Culture - 108 107 106 105 104 103 102 101 100 Start of treatment (isoniazid alone) Weeks of treatment 0 3 6 9 12 15 18 WHO 78351 Sensitive organisms Resistant organisms Number of bacilli per ml of sputum Toman K, Tuberculosis, WHO, 1979 The ‘fall and rise’ phenomenon

Treatment principles : 

2/16/2011 80 Treatment principles Long duration  problem of adherence (compliance) Other aspects : Nutrition improvement prevent / search & treat other disease

Hypothetical model of TB therapy : 

2/16/2011 81 Hypothetical model of TB therapy A B C Bacteridal activity & ‘sterilizing’ effect 0 1 2 3 4 5 6 Pop A = rapidly multiplying (caseum) Pop B = slowly multiplying (acidic) Pop C = sporadically multiplying Months of therapy

Slide 82: 

2/16/2011 82 Drugs Daily dose (mg/Kg/day) Adverse reactions 2 Time/week dose (mg/Kg/dose)) Isoniazid (INH) 5-15 (300 mg)) Hepatitis, peripheral neuritis, hypersensitivity 15-40 (900 mg)) Rifampicin (RIF) 10-15 (600 mg)) Gastrointestinal upset,skin reaction, hepatitis, thrombocytopenia, hepatic enzymes, including orange discolouraution of secretions 10-20 (600 mg) Pyrazinamide (PZA) 15 - 40 (2 g) Hepatotoxicity, hyperuricamia, arthralgia, gastrointestinal upset 50-70 (4 g) Ethambutol (EMB) 15-25 (2,5 g) Optic neuritis, decreased visual acuity, decreased red-green colour discrimination, hypersensitivity, gastrointestinal upset 50 (2,5 g) Streptomycin (SM) 15 - 40 (1 g) Ototoxicity nephrotoxicity 25-40 (1,5 g) When INH and RIF are used concurrently, the daily doses of the drugs are reduced National consensus of tuberculosis in children, 2001 Dosage of antituberculosis drug

TB bacilli population : 

2/16/2011 83 RIF, INH neutral TB bacilli population cavity, extra cell caseous mass intra macrophage TB amount 107 - 109 104 - 105 104 - 105 Metabolism & replication Active slowly / intermittent slowly pH neutral / base acid Most effective drug (consecutively) INH, RIF, STREP PZA, RIF, INH

Drug activities upon TB pop : 

2/16/2011 84 Drug activities upon TB pop

TB therapy regimen : 

2/16/2011 85 TB therapy regimen 2 mo 6 mo 9 mo 12mo INH RIF PZA EMB SM PRED DOT.S !

Corticosteroid : 

2/16/2011 86 Corticosteroid Anti inflammation prednison : oral, 1-2mg/kgBW/day, tid 2-4 weeks, tap off Indications : Miliary TB Meningitis TB Pleuritis TB with effusion

Treatment evaluation : 

2/16/2011 87 Treatment evaluation Clear improvement in clinical and supporting examination, especially in the first 2 month Main : clinical supporting exam as adjuvant

Treatment evaluation : 

2/16/2011 88 Treatment evaluation Clinical improvement : Increased body weight Increased appetite Diminished / reduced symptoms (fever, cough, etc) Supporting examination : Chest X rays : 2 / 6 month (on indication) Blood : BSR Tuberculin test : once positive, do not needed to repeat !

Treatment failure : 

2/16/2011 89 Treatment failure Inadequate response, despite adequate therapy : Review the diagnosis, not a TB case ? Review other aspects : nutrition, other disease MDR – rarely in children Treatment discontinuation

Treatment problems : 

2/16/2011 90 Treatment problems The main : compliance / adherence The factors : Long duration Drug side effect Initial improvement – misinterpreted by patients / parents Inconvenient health service Socio-economic-cultural factors The following : drug resistance

Treament problem solution : 

2/16/2011 91 Treament problem solution DOTS : Directly Observe Treatment Shortcourse FDC : Fixed dose combination i.e. >2 drugs in one tablet in a fixed dose formulation

DOTS with a SMILE : 

2/16/2011 92 DOTS with a SMILE S : Supervised M : Medication I : In L : a Loving E : Environment (Grange JM, Int J Tuberc Lung Dis 1999; 3:360-362)

Fixed Dose Combination : 

2/16/2011 93 Fixed Dose Combination FDC: >2 drugs in one tablet in a fixed dose formulation simple dosing patient friendly, doctor friendly increase adherence reduce MDR easier drug supplying easier drug monitoring

Slide 94: 

2/16/2011 94

FDC tablet formulation : 

2/16/2011 95 FDC tablet formulation WHO H : 30 mg R : 60 mg Z : 150 mg IDAI H : 50 mg R : 75 mg Z : 150 mg

WHO FDC (H/R/Z:30/60/150 & H/R:30/60) : 

2/16/2011 96 WHO FDC (H/R/Z:30/60/150 & H/R:30/60)

IDAI FDC (H/R/Z:50/75/150 & H/R:50/75) : 

2/16/2011 97 IDAI FDC (H/R/Z:50/75/150 & H/R:50/75) Note: BW < 5kg should be referred and need tailored dosing

WHO vs IDAI fdc formulation : 

2/16/2011 98 WHO vs IDAI fdc formulation WHO: INH: 4-6 mg/kgBW BW grouping: too many not practical hard to remember a gap for BW 30-33 kg IDAI INH: 5-10 mg/kgBW simple BW grouping more friendly both for doctor and patient

Trace : 

2/16/2011 99 Trace Child TB patient Adult TB patient centri- petal centri- fugal

Case finding : 

2/16/2011 100 Case finding centripetal trace the source adult people close contact by chest X ray centrifugal trace other ‘victims’ children close contact by tuberculin

Prevention : 

2/16/2011 101 Prevention socio-economic improvement chemoprophylaxis BCG immunization

Primary prophylaxis : 

2/16/2011 102 Primary prophylaxis to prevent TB infection in TB Class 1 person exposure (+), infection (-)  tuberculin negative drug: INH 5 - 10 mg/kgBW/day as long as contact take place, the source should be treated at least for 3 months repeat TST: negative: success, stop INH positive: fail, become TB Class 2 continue as 2nd proph

Secondary prophylaxis : 

2/16/2011 103 Secondary prophylaxis to prevent TB disease in TB Class 2 person (exposure (+), infection (+), disease (-) and person with tuberculin conversion certain high risk population under five, puberty long term use of steroid malignancy certain infection: morbili, pertussis drug: INH 5 - 10 mg/kgBW/day during the higher risk of TB disease development: 6-12 month

BCG immunization : 

2/16/2011 104 BCG immunization mimicking the TB pathogenesis with attenuated TB bacilli without hematogenic spread and/or without establishment of remote foci CMI (+)  DTH (+)  TST (+) older neonate (>2 month not vaccinated)  TST first mass immunization : BCG without TST first accelerated BCG reaction: help the screening

Thank you : 

2/16/2011 105 Thank you

authorStream Live Help