Mycobacterial Infection :

Marshel Tendean, MD
Department of Internal
Medicine UKRIDA Jakarta

Outline :
Epidemiology of Tuberculosis infection
Etiology & Pathogenesis
Classification of Tuberculosis :
Case definition Tuberculosis
Class classification
WHO classification

Diagnostics
Tuberculosis treatment :
Pulmonary Tuberculosis
Extrapulmonary Tuberculosis
MDR treatment

ISCTH recommendation

Introduction
A spesific pulmonary infection
caused by fast acid bacteria
Mycobacterium tuberculosis complex
Multiorgan system usually affects the
lungs, although other organs are
involved in up to one-third of cases.
If properly treated, TB caused by
drug-susceptible strains is curable in
virtually all cases

Course of disease
Exposure
Bronchoge
nic
Contact

Droplet nuclei
3000/ cough

Skin, Gi tract,
Plasenta

Clinical
Tuberculosis

Hematogenous

Definition :
Tb suspect: patients with objective
symptoms spesific for TB
TB confirmed by bacteriologi
examination
TB diagnosed by clinical examination
:
Negative smear TB
Extrapulmonary TB

Classifications
Tuberculosis with bacterial confirmation:
Anatomic location (pulmonary, non pulmonary)
Past medical history :
Nave case
Patient with prior medication :

Relalpse
Failure of treatment
After default (1 month exposure and 2 month loss) / lose to follow up
Other (Undocumented treatment history)
Transferred patients
Undetermined treatment history

Bacteriologic and drug resistency :

Diagnostif for minimal 1 smear or 2 smears

HIV status

Pre-emtive Tuberculosis
Treatment
Indicated in patients with promontent
symptoms for tuberculosis
Patients with urgent condition
warrant tuberculosis treatment TB
enignitis, Miliary TB, Tb in HIV
Patients with productive unexplained etiology should be
screened for pulmonary Tuberculosis.
Standart 1 International Standart for Tuberculosis care

Negative smear Tuberculosis :

1. Smear negative but positive culture for M.
Tuberculosis
2. Fulfill one of the following criteria :
Clinical decision to treat tuberculosis
Radiolgic finding compatible with active tuberculosis
AND
Strong indentification from laboratory examintion or
clinical manifestation. OR
If (-) HIV, unresposive to broad spectrum antibiotics.

. However undetermined AFB smear not

categorized as negative smear, but not

Tuberculosis due to HIV

status:
Tuberculosis coinfected with HIV:
patients is proven positive for HIV
serologic test or HIV registry and
initiated with ARV
Tuberculosis with negative HIV
Tuberculosis with undetermined HIC

Pathogenesis :
Primary tuberculosis :
Hallmark by the presence of initial infection
(the Ghon focus) is usually peripheral and
accompanied by transient hilar or paratracheal
lymphadenopathy (Ghon Complex)

Secondary tuberculosis :
Mainly adult form
Caused by endogenous activation of previous
or latent infection
Affected apical and posteriot lobe

Sign and Symptoms :

Mainly insidious nonspesific sign of
fever, night sweat, weight loss,
general malaise, anoreksia and
weakness.
Most common symptoms cough
(90%), with productive, some have
blood streaking.
Hemoptysis (mild or masive) in 20%
patients caused by ruptured of
rasmussen aneurysm later on

Diagnosis :
Proven diagnosis is established by a
minimum of 1 positive smear or
hystology of TB or spesific symptoms
and radiologic findings of
tuberculosis

Patients with consideraton of Tuberculosis should be examined by

minimum of 2 AFB smear (1 morning smear) or Patients with Xray
I
suspected tuberculosis also determenied for AFB smear
Standart 2 and 4 International Standart for Tuberculosis care

Severity :

Cavitary
Smear +
Extrapumonary

Other TEST :
IGRA (Gama Interferon)
Tuberculin test
Fast TB determination kit

Treatment :
Goals :
Tuberculosis care and maintain quality of
live
Prevent death due to active tuberculosis
Limit transmission

DOTS (Directly Observed Treatment Short Course)

approach.
ISTC(International Standarts for Diagnosis Care) standart.
All Patients diagnosed as nave Tuberculosis should
be treated with standart regiment for tuberculosis
consist of initial phase 2 months and 4 months
extended phase INH and rifampisin or with fixed dose
combination
Standart 8 International Standart for Tuberculosis care

Tuberculosis Treatment :
Category I. 2RHZE / 4 RH
Category II. Will be depend with the facility to determine
drug resistency
If no facility for rapid detection available, start empiric
treatment and followed by culture result 2 RHZES / RHZE /
5 RHE

Treatment monitoring :
Should be done within 2 months
category 1 and 3 months category 2
Same directions for smear negative
TB

DOTS

Tuberculosis in special
population :

 Negative smear TB are more

common
Other determination from Gene
Xpert, urine LAM, Culture (better
sensitivity)
Should be treated with anti
tuberculosis prior of giving ARV to
prevent IRIS

 Latent TB :
Could be diagnosed with tuberculine
tesst
Not always amenable for treatment

Tb in Pregnancy:
Antituberculosis is given during pregnancy
and breastfeeding
Patients given rifampicin had risk for
hypoprotrombinemia and should be given
vit K 1 x 10 mg
Offspring should also initiated with INH
profilaxis dose for 6 month continued with
Vaccination
Strepromycin and fluoloquinolone are
contraindicated for pregnancy

Tb With Liver Probem

Most of drug are considered hepatotoxic
except streptomycin and etambutol
If initial ALT > 3X UNL, this protocol should be
considered:
Two hepatotoxic drug :
9 months INF + RIF + ETB
2 months INH + RIF + ETB + Strep + 6 Months INH + RIF

One hepatotoxic drug :

2 months INH + ETB + Strep + 6 Months

Without hepatotoxic drug :

18-24 months of streptomysin, ETB, quinolone

Drug Induced Hepatitis :

Determined by elevation level of
bilirubin and ALT
IF Bilirubin >2 Stop antituberculosis
If ALT > 5 UNN stop antituberculosis
IF ALT > 3 close monitoring

Extrapulmonary
Tuberculosis:

Lymph node
Pleura
Bones and joints
Meninges
Peritoneum
Pericardium

 Lymph node :
The most common extrapulmonary manifestation in
HIV seropositive and seronegative (35%).
Commonly in supraclavicula and posterior cervical
sites (scrofula).
Could be discrete, matted or fistulous.

Pleura :
Occurs in 20%, manifested as pleural effusion 1 side
Diagnosed by exudatiyve and (+) AFB smear (25%),
Culture in (75% cases)
Y-Ifn, lysozime may helpful, diagnosis proven by (+)
granuloma or AFB at pleural biopsy.

 Genitourinary tuberculosis :
Difficult to determine (unspesific
symptoms and findings)
Deffinite diagnosis by :

Microscopic
Culture
Tissue biopsy
PCR
Spesific radiologic findings

 Tuberculosis requiring steroid :

Pericarditis tuberculosis
Meningitis tuberculosis
Miliary tuberculosis

 Milliary tuberculosis :

MDR (Multi Drug Resistance)

MDR
XDR
TDR
Treatment are considered with 2nd
line treatment and comprise as
culture results.