PREPARED BY:- KISHOR R.

LALCHETA
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CONTENTS
GENERAL STRUCTURE OF M. TUBERCULOSIS

MORPHOLOGICAL CHARACTERISTICS
CHEMICAL COMPOSITION TRANSMISSION SYMPTOMS

LATENT TB INFECTION VS. TB DISEASE

PATHOGENESIS RISK FACTORS FOR THE DEVELOPING TB DISEASE DIAGNOSIS

TREATMENT
DOTS THERAPY REFERENCES RESEARCH PAPER
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What is Tuberculosis?
Tuberculosis (TB) is a potentially fatal contagious

disease that can affect almost any part of the body

but is mainly an infection of the lungs.

TB is caused by a bacterium called Mycobacterium

tuberculosis.

The History of TB ?
In 1994 tuberculosis bacilli were found in a 1000year-old mummy, in Chiribaya Alta, Peru.This mummy dated from before the time of Colombus. This negated the opinion that Europeans had introduced tuberculosis to that continent.

In 1997, DNA of M. tuberculosis was found in 3000 year old an Egyptian mummy from Thebes. It is possible that the bacterium originates from the one causing bovine tuberculosis. Some people claim that tuberculosis started to spread among humans after the domestication of cattle.

What is the Mycobacterium tuberculosis?

M.Tuberculosis is a pathogenic bacterial spp. in the genus Mycobacterium causative agent of TB. First discovered by Robert Koch in 1882, so called Kochs bacillus or Tubercle bacilli.(noble price) M. Tuberculosis has a waxy coating of on the cell surface. These organisms are very inactive compared with the organisms of typhoid

fever and diphtheria Means?

The organisms are slow grower taking 3 to 6 weeks for colony growth to appear.
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Morphological characteristics
The organisms are slender and straight. Staining may produce a granular or a bedded

appearance.
Often seen in palisade or V shape or L shape. It cant tolerate heat, but It can live in humid or dry or cold surroundings.

Chemical composition
The chemical composition of M. tuberculosis is somewhat differ from other

organisms.
Much of its pathogenicity is related to its antigenic activity and this in turn depends on its chemical composition. (No exotoxin or endotoxin) It consists of Lipid, Protein, and Carbohydrate.

Lipid fraction
Constitute approximately 50% of the organism. Form a waxy coated around the bacillus or interspersed throughout its substance. It is responsible for the following special features : (1) It makes the organism more difficult to stain , so that heat and a mordant are required and it is responsible for its acid fastness.
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(2) It provide the bacilli more resistant to therapeutic agents.

(3) It protects them against digestion when taken up by phagocytes.

(4) It is less irritating to the tissue than the surface of rapidly multiplying bacteria , so that the type of cellular response is less acute. (5) The lipid seems to be responsible for transforming the mononuclear and macrophages of the exudate into the epithelioid type of cell and thus for the formation of the tubercle which gives the disease its name.

Protein fraction
The protein fraction was origenally extracted by Koch , who name it Tuberculin. This protein is the active antigen responsible for producing the state of hypersensitivity of the tissues .
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It is notable that tuberculin itself does not have this power when injected

into an animal.

Carbohydrate fraction
The carbohydrate fraction , a polysaccharide , when injected it promotes the speedy accmulation of polymorphonuclear Leukocytes at the site of injection. Thus it may be noted that it is the first response of the tissues to invasion by the Tubercle bacillus.

Transmission
Tuberculosis spreads by droplet infection. This type of transmission means that when a TB patient exhales, coughs, or sneezes, tiny droplets of fluid containing Tubercle bacilli are released into the air. This mist or aerosol can be taken into the nasal passages and lungs of a susceptible person nearby. Tuberculosis is not, however, highly contagious compared to some other infectious diseases. Only about one in three close contacts of a TB patient,

and fewer than 15% of more remote contacts, are likely to become infected.
As a rule, close, frequent, or prolonged contact is needed to spread the disease.
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Transmission of TB. TB is spread from person to person through the air. The dots in the air represent droplet nuclei containing Tubercle bacilli.

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Latent TB Infection vs. TB Disease

Latent TB infection :
To be infected with TB means that Tubercle bacilli are in the body but are being kept in a dormant or latent state by the bodys immune system. The immune system does this by producing special immune cells that

surround the tubercle bacilli. The cells form a hard shell that keeps the
bacilli contained and under control. Because of the potential for the bacilli to become active, multiply, and lead to TB disease, individuals infected with M. tuberculosis are said to have latent TB infection (LTBI). TB infection is detected by the tuberculin skin test. Most people with LTBI have a positive reaction to the tuberculin skin test.(chest x-ray)

People who have LTBI, but not TB disease are NOT infectious in other
words, they cannot spread the infection to others.
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Active TB disease :
Some people with LTBI develop TB disease. TB disease develops when the immune system cannot keep the tubercle bacilli under control and the bacilli begin to multiply rapidly.

LTBI

TB Disease (in the lungs) Tubercle bacilli

Tuberculin skin test or -TB Gold test result usually positive Chest x-ray usually normal Sputum smears and cultures negative No symptoms Not infectious Not a case of TB Chest x-ray usually abnormal Sputum smears and cultures positive Symptoms such as cough, fever, weight loss Often infectious before treatment A case of TB
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Pathogenesis
Droplet nuclei are inhaled and pass down the bronchial tree and implant in a bronchiole OR alveolus. The bacillus may multiply here without resistance from the host.

Macrophages may slowly engulf organisms that may remain viable and
multyply within the cell.

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A general phenomena of the pathogenesis of TB

Droplet

nuclei

containing

tubercle

bacilli are inhaled, enter the lungs, and travel to the alveoli.

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Tubercle bacilli multiply in the alveoli.

A small number of tubercle bacilli enter the bloodstream and spread the body. throughout

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Within 2 to 10 weeks, the immune system produces special immune cells that surround the tubercle bacilli. The cells form a hard shell that keeps the bacilli contained and under control (LTBI).

If the immune system cannot keep the bacilli under control, the bacilli begin to

multiply rapidly (TB disease). This process

can occur in different places in the body such as the lungs, kidneys, brain, or bone.
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Human Immunity after infected Tubercle bacillus

Tubercle bacillus

Human immunity

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 The natural immunity of human to TB is nonspecific After infected or given BCG vaccine, tubercle human bacillus will is obtain specific immunity The cell- mediated immunity . The immunity of bacillus.

cellular immunity develops within 4 to 8 weeks after infected with

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Lesion formation in the lung

Are of two types.
exudative

Exudative lesions consist of a liquid exudate containing neutrophils & monocytes.

The lesions are formed by acute inflammatory response.

It may heal, progress to necrosis of local tissue, or develop into a tubercle.
productive

Consists of cells without exudate, organized around the bacilli.

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 The collection of cells and organisms is called a granuloma. In the center of the granuloma is a compact mass of giant cells. Surrounding this mass are epithelioid cells, lymphocytes, monocytes, and fibroblasts.

Eventually the tubercle will become a Ghon complex having a

fibrous outside and calcified inside. The organisms inside may die or survive for years.

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Two types of cells are essential in the formation of TB

Macrophages: Directly phagocytize TB and processing and presenting antigens to T lymphocyte

T lymphocytes(CD4+):
Induce protection through the production of lymphokines

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There are Four main events occur between the Immune system and the Pathogens:-

A. Phagocytosis
When the organisms enter into the lungs,tuberculosis-inducing mycobacteria are phagocytosed By alveolar macrophages. The phagocytosis is mainly receptor mediated.

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B. Special receptor mediated response :Some receptors (e.g., Toll-like receptors, TLR) recognize certain surface antigen pattern common to all prokaryons, whereas other are specific for mycobacterial antigens (e.g., the CD14 molecule, which is specific for lipoarabinomanan (LMN) antibodies). Antibodies and complement factor C3 bind to molecules on the surface

of the pathogen and are recognized by the corresponding receptors.

Since the alveolar macrophages cannot effectively kill the phagocytosed mycobacteria, the bacteria can survive intracellularly. In fact, they can even replicate by blocking phagosome maturation. The migration of alveolar macrophages to the nearest lymph nodes activates a T-cell mediated , specific immune response.
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3. Induction of specific immune response: M. Tuberculosis secretes proteins into the phagosome. Initially, these proteins are export proteins. They later form part of the cell wall and ultimately represent intracellular proteins. Processed fragments consisting of 10 20 amino acids are presented on class-2 MHC molecules. Peptides consisting of 8 10 amino acids are

presented on class 1 MHC molecules.

CD -1, a distant relative of class 1 MHC, presents bacterial lipoids that preferentially stimulate CD 4 and CD 8 double negative T cells. In addition, Gamma/Delta T cells are activated by mycobacterial antigens containing phosphate groups, no presenting molecule for this antigen group has yet been identified. It is assumed that the phospholigands are presented directly on the cell surface.
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4. Granuloma formation: Activated CD4+ Tcells secrete chemokines that attract circulating monocytes to the site of inflammation. They also secrete TNF alfa ,

which is responsible for Granuloma formation.

Complete intracellular killing of mycobacteria

within the granuloma can occur due to the cytokine

-mediated activation of macrophages.

In most cases, however, the pathogen becomes concentrated within the granuloma, which becomes sealed off from the surroundings. The reason for this is TNF alfa mediated thickenig and fibrosis of the granuloma wall and IL-4- induced coalescence of macrophages to form the Giant cells.
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In this case, the host is infected but does not develop tuberculosis because the mycobacteria and granulomas defense system are at balance.

Now, IFN- gamma activates Tuberculostatic macrophages, for example, by

promoting the synthesis of calcitriol,a substance that activates microbicidal effector function. The activated macrophages release O2 metabolites and proteases and thus cause necrosis in the centre of the granuloma . Activated CD8+ cytotoxic T cells induce the lysis of macrophages, which release their contents into the necrotic granuloma centre. The growth conditions there are less favorable for the mycobacteria because of the low O2 tension within the centre and because of the type of enzymes released.
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Uncontrolled cell destruction, on the other hand, leads to caseation of the granuloma, which results in extensive tissue damage. The mycobacteria

can now enter into the circulaion and create new colonies in virtually any
of the hosts organs.

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Risk Factors For The Developing TB Disease

Certain medical conditions increase the risk that LTBI will progress to TB disease. The risk may be about 3 times higher (as with diabetes) to more

than 100 times higher (as with HIV infection) .

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Some of these conditions are

HIV infection, Chest x-ray findings consistent with prior TB (in a person inadequately treated) Low body weight (10% or more below ideal) Recent infection (within the past 2 years) Silicosis Diabetes mellitus Chronic renal failure/hemodialysis Prolonged therapy with corticosteroids and other immunosuppressive agents Solid organ transplant Certain intestinal conditions (e.g., gastrectomy, jejunoileal bypass)
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Diagnosis
Latent TB infection(LTBI)

TB Disease

The Tuberculin Skin Test TB Gold Test (QFT-G)

Medical history Tuberculin skin test Chest x-ray Bacteriologic examination.

PCR and MIRP Microplate Alamar Blue Assay (MABA)

Adenosine deaminase
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 Diagnosis of Latent TB Infection

The Tuberculin Skin Test

The tuberculin skin test is used to determine whether a person has LTBI. In this test, a substance called tuberculin is injected into the skin.

In most people who have LTBI, the immune system will recognize the tuberculin because it is similar to the tubercle bacilli that caused the infection. This recognition generally will cause a reaction to the tuberculin skin test.

Different types of tuberculin tests are available, such as the Mantoux

tuberculin skin test and the multiple-puncture test.
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 Classification or Interpretation of TST Reactions Whether a reaction to the Mantoux tuberculin skin test is classified as positive depends on the size of induration and the persons risk factors for TB. 5 mm of induration is considered a positive reaction in:

HIV-infected persons
Organ transplant recipients

Close contacts of a person with infectious TB

Persons who have chest x-ray findings consistent with prior TB Persons who are immunosuppressed for other reasons (e.g., taking the equivalent of 15 mg/day of prednisone for 1 month or more
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10 mm of induration is considered a positive reaction in:

Recent immigrants (within last 5 years) from a high-prevalence country

Injection drug users (with unknown or HIV negative status)

Residents or employees of high-risk congregate settings (for example, nursing homes or correctional facilities
)

Mycobacteriology laboratory personnel Children <4 years of age, or children or adolescents exposed to adults at high risk People with other high-risk conditions such as diabetes
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15 mm of induration is considered a positive reaction in:

Persons with no known risk factors for TB

In most cases, people who have a very small reaction or no reaction to the tuberculin skin test probably do not have LTBI.

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Tuberculin skin test

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 TB Gold Test (QFT-G)

TB gold test (QFT-G) is a whole-blood test for detecting LTBI. The test measures the patients immune reactivity to M. tuberculosis. Blood samples are mixed with antigens. If the patient is infected with M. tuberculosis, the blood cells will recognize the tuberculin and release interferon-gamma (IFN-) in response. As with the tuberculin skin test, follow-up medical evaluation should be conducted on persons with positive test results to rule out TB disease.
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Diagnosis of TB Disease
Medical history
1. Exposure to TB 3. Previous TB infection or TB disease 2. Symptoms of TB disease 4. Risk factors for developing TB disease
Weight loss Fatigue Fever Night sweats HIV infection Low body weight Recent infection (within the past 2 years) Silicosis Diabetes mellitus Chronic renal failure/hemodialysis

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 Chest x-ray

The chest x-ray is useful for diagnosing TB disease. About 85% of TB patients have pulmonary TB. Usually, when a person has TB disease in the lungs, the chest x-ray appears abnormal. It may show infiltrates (collections of fluid and cells in the tissues of the lung) or cavities However, the results of a chest x-ray cannot confirm that a person has TB disease. A variety of illnesses may produce abnormalities whose appearance on a chest x-ray resembles TB.

Moreover, a chest x-ray cannot detect LTBI.

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Abnormal signs are appear in th chast x-ray of TB patient

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Tuberculous effusion
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 Bacteriologic examination
This is done in a laboratory that specifically deals with M. tuberculosis
and other Mycobacteria (a Mycobacteriology laboratory).

1. Obtaining a specimen 2. Examining the specimen under a microscope 3. Culturing the specimen 4. Conducting drug susceptibility testing
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1. Obtaining a specimen

Sputum

Bronchoscopy

2. Examining the specimen under a microscope

Acid-fast bacilli during AF staining.

3. Culturing the specimen

This can take from 4 days to 8 weeks, depending on the type of medium used. With the help of morphological characteristics it can be identify which type of mycobacteria is growing.

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Acid fast staining of T. bacillus

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4. Conducting drug susceptibility testing

Drug susceptibility tests, the final part of the bacteriologic examination, are done to determine which drugs will kill the tubercle bacilli that are causing TB disease in a particular patient. The drug susceptibility pattern of a strain of tubercle bacilli is the list of drugs to which the strain is susceptible and to which it is resistant. The results of drug susceptibility tests can help clinicians choose the appropriate drugs for each patient.

In addition, drug susceptibility tests should be repeated if a patient has

positive culture for M. tuberculosis after 2 months of treatment or if a patient does not seem to be getting better.
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TREATMENT
Treatment for Latent TB Infection Treatment for TB Disease

Treatment for Latent TB Infection

Treatment for latent TB infection (formerly known as preventive therapy or chemoprophylaxis) is recommended to prevent progression from LTBI to TB disease The usual treatment of LTBI infection is isoniazid (INH) given daily for 9 months for all persons. Patients should be evaluated every month for signs of hepatitis and other adverse reactions to INH. An alternate regimen is rifampin (RIF) for 4 months.
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Treatment for TB Disease

TB disease must be treated for at least 6 months and in some cases, treatment lasts even longer if sputum smears and cultures do not convert to negative First-line Drugs Second-line Drugs

Isoniazid, Rifampin, pyrazinamide, streptomycin,

Para-amino-salicylic acid, kanamycin, amikacin Ethambutol Cycloserine and etc.

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Targets of first line drugs on the M. tuberculosis

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DOTS Therapy (Directly Observed Treatment, short course)

The Stop TB Strategy, the Global Plan to Stop TB, 20062015 and targets for TB control In 2006, WHO launched the new Stop TB Strategy. The core of this strategy is DOTS, the TB control approach launched by WHO in 1995. Since its launch, 36 million patients have been treated under DOTS-

based services.
The new six-point strategy builds on this success, while recognizing the key challenges of TB/HIV and MDR-TB. It also responds to access, equity and quality constraints, and adopts evidence-based innovations in engaging with private health-care providers, empowering affected people and communities, to help strengthen health systems and promote research.
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Prevention

BCG Vaccination
In 1908 Albert Calmette, a pupil of Pasteur, and Camille Gurin discovered that Mycobacterium bovis is attenuated when it is cultured in vitro in a medium containing bovine bile. BCG was used for the first time in France in 1921, to vaccinate children. The vaccine is usually administered to the upper arm and often leaves a fibrous scar of 6-9 mm diameter. If the concentrations used are too high, if higher volumes are injected than indicated or if vaccination is subcutaneous, there may be local ulceration and complications (BCG adenitis).
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REFERENCES
I. An Essentials Of Diagnostic Microbiology 6th Edition, By- Lisa Shimeld

II. Textbook Of Pathology , 7th Edition, By- Willium Boyd. III. Color Atlas Of Immunology , By- G. R. Burmester and Antonio Pezzutto. IV. The Gale encyclopedia Of Medicine, 3rd edition, by- Jacqueline L. Longe V. Pulmonary Tuberculosis Page Down To The History, By- L. Rizza.