Complications and Presentations of Tuberculosis: A Detailed Overview by Dr. Ruchi Dua
TUBERCULOSIS(Part 2)
Dr Ruchi Dua
Associate Professor(MD,DNB)
Department of Pulmonary Medicine
Aiims Rishikesh
MCQ & Revision of Part 1
OBJECTIVES
•
What are complications of tuberculosis?
•
What are various presentations of EPTB?
•
Drug resistant tuberculosis
•
DOTS & RNTCP
COMPLICATIONS
C
O
M
P
L
I
C
A
T
I
O
N
S
•
Local-
•
ARDS/respiratory failure
•
Bronchiectasis/PTOAD
•
aspergilloma
•
haemoptysis (symp )
•
Pleural -Empyema/pneumo
•
Extensive lung destruction
•
Rt middle lobe syndrome
•
Scar ca
•
Systemic-
•
shock
•
amyloidosis
•
disseminated tb-(laryngeal tb)
•
Cor-pulmonale
EPTB
•
Common sites:LN,PE
•
Any site
•
Diagnosis:more difficult
LN TB
•
LN-site
•
painless enlargement
,systemic symptoms<50%
•
Matting
•
Sinus/fistula
•
FNAC/Bx/NAAT/smear/culture
Pleural Effusion
•
Pain/dyspnea/cough
•
Fever/dec appetite
•
Radiology
•
Pleural fluid analysis
SKELETAL TB
•
Site
•
Pain/joint swelling/dec
range of motion.
•
Draining sinuses and
abscesses
•
Systemic symptoms
•
Radiographic changes
m/b nonspecific
CNS TB
•
Tuberculous meningitis(MC), intracranial tuberculomas, , cranial
nerve palsies and communicating hydrocephalus , cranial vasculitis
may lead to focal neurologic deficits.
•
Malaise, headache, fever, or personality change,A/S,seizures/focal
defects
•
CSF –lymphocytic,increased protein,ADA,CB NAAT
Koch’s abdomen
•
Site-gut/peritoneum/LN
•
pain,nausea/vomitting
•
altered bowel habbits
•
Distension
•
Diagnosis:ascetic fluid
analysis/LN
sampling/radiology
Miliary
•
Fever/dec appetite/wt loss/vague-elderly
•
Haematogenous
•
Fulminant disease -septic shock, ARDS,MOF
•
CXR/Liver/spleen BX/BM
•
Haematological-anaemia(NCNC),hyponatremia
PRESENTATION(Extra-Pulmonary)
•
Genitourinary-infertility, urinary difficulties
•
CVS-pericarditis(pain/dyspnea)
CLINICAL CLUES-EPTB
•
A
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s
•
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MANAGEMENT
Principles of chemotherapy
•
Variable bacilli population:rapid growers,slow growers,dormant
•
Longer duration
•
2 phases of treatment
•
Need for multiple drugs to treat(spontaneous resistance)
TREATMENT REGIMENS
R;rifampicin,H:isoniazid,E:ethambutal,Z:pyrazinamide,S:streptomyci
n
Intermittent regimens
are being changed to
daily regimens under
RNTCP in India
•
New case:CAT 1
•
Smear positive
•
Smear negative
•
EPTB
•
Retreatment:CAT 2
•
Relapse
•
Defaulter
•
failure
•
CAT 4 :MDR
•
CAT 5:XDR
•
Definitions
•
MDR:R and H
•
XDR:R and H,any FQ,any injectables(kanamycin,amikacin,capreomycin)
•
Primary & acquired resistance
•
Mono/poly drug resistance:DRTB
Drug Resistance:Magnitude
•
3% Primary
•
12% Acquired
•
XDR 4-20% of MDR
Dx in drug resistant Tb
•
MDR-TB:
•
Rapid Molecular Test ( LPA/ CB-NAAT)
•
Liquid Culture & DST
•
Solid Culture & DST
•
XDR-TB:
•
Liquid Culture & DST
•
Solid Culture & DST
•
LPA(Genotypic methods)
Changed to
daily
OLD
Grouping of antiTb drugs(2017 ,RNTCP
guidelines)
RNTCP 2017
DR TB:Principles of Treatment
•
MDR:4 second line drugs /not used
•
XDR:7 drugs
•
Duration:24(MDR),36(XDR)
DOTS plus previously
Second line drugs
•
Treatment longer
•
Toxic
•
Expensive
•
Stress:emergence rather than treatment of DRTb
more
Newer ATT
•
Bedaquiline
•
Delaminid
•
protaminid
MCQ
•
A pt on ATT C/O burning soles
•
A pt on ATT C/O loss of appetite & vomittings
•
A pt on ATT C/O dec vision
DOTS & RNTCP
Advantages
•
Directly observed
•
Standardised treatment
•
Free of cost
TB & HIV
•
Increased chances of reactivation/relapse
•
Atypical presentations
•
Higher ADR/drug interactions
•
Priorty to treat Tb first and then ART
TB & DM
•
Higher risk
•
Glycemic control must for cure
•
Higher chances of ADR
This presentation by Dr. Ruchi Dua, Associate Professor at Aiims Rishikesh, delves into the complications of tuberculosis including local and systemic effects, as well as various presentations of extrapulmonary TB. Topics covered include common complications like respiratory failure, pleural effusion, and systemic shock, alongside presentations of TB in different body systems such as skeletal, CNS, and abdominal involvement. The slides also touch upon drug-resistant tuberculosis, DOTS, RNTCP, and highlight the challenges in diagnosing extrapulmonary TB.
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Presentation Transcript
TUBERCULOSIS(Part 2) Dr Ruchi Dua Associate Professor(MD,DNB) Department of Pulmonary Medicine Aiims Rishikesh
OBJECTIVES What are complications of tuberculosis? What are various presentations of EPTB? Drug resistant tuberculosis DOTS & RNTCP
COMPLICATIONS COMPLICATIONS Local- ARDS/respiratory failure Bronchiectasis/PTOAD aspergilloma haemoptysis (symp ) Pleural -Empyema/pneumo Extensive lung destruction Rt middle lobe syndrome Scar ca
Systemic- shock amyloidosis disseminated tb-(laryngeal tb) Cor-pulmonale
EPTB Common sites:LN,PE Any site Diagnosis:more difficult
LN TB LN-site painless enlargement ,systemic symptoms<50% Matting Sinus/fistula FNAC/Bx/NAAT/smear/culture
Pleural Effusion Pain/dyspnea/cough Fever/dec appetite Radiology Pleural fluid analysis
SKELETAL TB Site Pain/joint swelling/dec range of motion. Draining sinuses and abscesses Systemic symptoms Radiographic changes m/b nonspecific
CNS TB Tuberculous meningitis(MC), intracranial tuberculomas, , cranial nerve palsies and communicating hydrocephalus , cranial vasculitis may lead to focal neurologic deficits. Malaise, headache, fever, or personality change,A/S,seizures/focal defects CSF lymphocytic,increased protein,ADA,CB NAAT
Kochs abdomen Site-gut/peritoneum/LN pain,nausea/vomitting altered bowel habbits Distension Diagnosis:ascetic fluid analysis/LN sampling/radiology
Miliary Fever/dec appetite/wt loss/vague-elderly Haematogenous Fulminant disease -septic shock, ARDS,MOF CXR/Liver/spleen BX/BM Haematological-anaemia(NCNC),hyponatremia
PRESENTATION(Extra-Pulmonary) Genitourinary-infertility, urinary difficulties CVS-pericarditis(pain/dyspnea)
CLINICAL CLUES-EPTB Ascites -lymphocyte predominance and negative bacterial cultures Chronic lymphadenopathy (especially cervical) CSF -lymphocytic pleocytosis / elevated protein /low glucose Pleural effusion -Exudative / lymphocyte predominance/negative bacterial cultures Joint inflammation (monoarticular) with negative bacterial cultures Persistent sterile pyuria Unexplained pericardial effusion, constrictive pericarditis, or pericardial calcification/Vertebral osteomyelitis involving the thoracic spine
Principles of chemotherapy Variable bacilli population:rapid growers,slow growers,dormant Longer duration 2 phases of treatment Need for multiple drugs to treat(spontaneous resistance)
TREATMENT REGIMENS Type of TB case Intensive Phase Continuation Phase New(CAT 1) 2RHEZ 4RHE Retreatment(CAT 2) 2SHREZ/1RHEZ Intermittent regimens are being changed to daily regimens under RNTCP in India 5RHE R;rifampicin,H:isoniazid,E:ethambutal,Z:pyrazinamide,S:streptomyci n
New case:CAT 1 Smear positive Smear negative EPTB Retreatment:CAT 2 Relapse Defaulter failure
CAT 4 :MDR CAT 5:XDR Definitions MDR:R and H XDR:R and H,any FQ,any injectables(kanamycin,amikacin,capreomycin) Primary & acquired resistance Mono/poly drug resistance:DRTB
Drug Resistance:Magnitude 3% Primary 12% Acquired XDR 4-20% of MDR
Dx in drug resistant Tb MDR-TB: Rapid Molecular Test ( LPA/ CB-NAAT) Liquid Culture & DST Solid Culture & DST XDR-TB: Liquid Culture & DST Solid Culture & DST LPA(Genotypic methods)
Changed to daily
Grouping of antiTb drugs(2017 ,RNTCP guidelines) FQ Levo/moxi/gati Injectable agents K/A/C Other second line drugs Etio/prothio/cycloserine/linezolid Add on drugs D1:Z/E/H high dose,D2:Bedaquiline/delaminid D3:PAS,Amoxy-clav,Meropenem,imipenem cilastatin
DR TB:Principles of Treatment MDR:4 second line drugs /not used XDR:7 drugs Duration:24(MDR),36(XDR) DOTS plus previously
Second line drugs Treatment longer Toxic Expensive more Stress:emergence rather than treatment of DRTb
Newer ATT Bedaquiline Delaminid protaminid
MCQ A pt on ATT C/O burning soles A pt on ATT C/O loss of appetite & vomittings A pt on ATT C/O dec vision
Advantages Directly observed Standardised treatment Free of cost
TB & HIV Increased chances of reactivation/relapse Atypical presentations Higher ADR/drug interactions Priorty to treat Tb first and then ART
TB & DM Higher risk Glycemic control must for cure Higher chances of ADR
