Tuberculosis

Transmission, Prevention and Control

 Mycobacterium tuberculosis

Morphology
1 Straight or slightly curved thin rod shaped bacilli

2 Non-sporing, non-motile, non-capsulated bacteria.

3 Acid fast bacilli, neither gram +ve nor gram –ve.

4 During acid fast stain, they appear bright red to intensive purple with green/blue background.

5 They measure 0.5 µm x 3 µm. Acid fast :bacteria that

cannot be decolorised
6 Appears in single, in pairs or small clumps. with acid after staining

7 High content of mycolic acid (50 to 60 %).

8 Cell wall is rich in lipids and waxes.

Mycolic acids: are long fatty acids
found in the cell walls of the Mycolata
9 They are wrapped together due to presence of fatty acids. taxon, a group of bacteria that
includes Mycobacterium tuberculosis
10Capable of intracellular growth.

11 They are resistance to disinfectants, detergents, common antibiotics, dyes, stains, osmotic lysis, lethal
oxidation, etc.
Habitat

1 Human is only the known reservoir.

2 Usually found in the lungs but can also live in any part of the body.

3 They may be obligate pathogen, facultative or opportunistic pathogens or

free living.

4 Usually infect the mono-nuclear phagocytes.

5 Can also be infected by the consumption of unpasteurized milk.

6 Can survive for weeks in dust, on carpets or clothes, for months in sputum.

7 They are also found in soil and water.

 contagious,

Droplet Infection
It is spread through the air:
when a person with TB (whose lungs are affected) coughs,
sneezes,
spits,
laughs, or
talks.
• the active stage and

• the inactive stage.

cough, fever, night sweats, weight loss, etc.
Commonest sites of Miliary Tuberculosis
1 Liver
2 Spleen
3 Kidney
4 Adrenals
5 Fallopian Tubes
6 Epididymis
7 Meninges
8 Bones and Joints
Cough Etiquette
It is spread through the air when a person with TB (whose lungs are affected) coughs,
sneezes, spits, laughs, or talks.

TB is contagious, but it is not easy to catch. The chances of catching TB from

someone you live or work with are much higher than from a stranger. Most people with
active TB who have received appropriate treatment for at least 2 weeks are no longer
contagious.

Since antibiotics began to be used to fight TB, some strains have become resistant to
drugs. Multidrug-resistant TB (MDR-TB) arises when an antibiotic fails to kill all of the
bacteria, with the surviving bacteria developing resistance to that antibiotic and often
others at the same time.

Tuberculosis commonly known as TB is classified in two

stages:

• the active stage and

• the inactive stage.

On becoming infected by these bacteria, it will invade the bloodstream, then into the lymph nodes
and spreads to any other organs in the body. Latent TB - the bacteria remain in the
This bacterium is generally found in the lung when detected. body in an inactive state. They cause
no symptoms and are not contagious,
Tuberculosis commonly known as TB is classified in two stages: but they can become active.
• the active stage and
Active TB - the bacteria do cause
• the inactive stage. symptoms and can be transmitted to
others.
In the inactive stage of tuberculosis or latent tuberculosis; means it will be in the body and stays
dormant.
There are no signs that the individual has the disease, and it is not in an infectious state.
Persons will live for long periods without having any symptoms.
An inactive stage of tuberculosis can become active if the immune system is compromised, if the
person contracts HIV or if the person is elderly, babies and or children. These individuals will
become susceptible to the disease becoming active.
When the bacteria become active it will cause death to the tissues or organs which are infected.

Active tuberculosis is when the bacteria in the body actively invaded the organs; namely the
lung. This state occurs when the body’s immune system is low and it is unable to fight the
bacteria so the lungs become infected.
The symptoms of active tuberculosis are:
• coughing up blood,
• a terrible cough and
• chest pains.

For persons who have developed active tuberculosis, the bacteria will infect the lung in such a
way as to even cause a rupture or tear in the lung.
Risk Factors for Tuberculosis
Risk factors for tuberculosis include anything that weakens a person's immune system or
puts someone in frequent, close contact with people who have active TB.
In the United States, some of the main risk factors for tuberculosis include:
• Poverty
• HIV infection
• Homelessness
• Being in jail or prison
• Substance abuse
• Having a weakened immune system for reasons other than HIV, such as chronic steroid
use, patients on dialysis, and those who have had organ transplants and take drugs to
prevent rejection
Symptoms of tuberculosis
While latent TB is symptomless, the symptoms of active TB include the following:
• A bad cough that lasts 3 weeks or longer
• Coughing, sometimes with mucus or blood
• Pain in your chest
• Chills
• Fatigue
• Fever
• Unexplained Loss of weight
• Loss of appetite
• Night sweats

Tuberculosis usually affects the lungs, but can also affect other parts of the body.
When TB occurs outside of the lungs, the symptoms vary accordingly. Without treatment, TB can spread to
other parts of the body through the bloodstream:
• TB infecting the bones can lead to spinal pain and joint destruction
• TB infecting the brain can cause meningitis
• TB infecting the liver and kidneys can impair their waste filtration functions and lead to blood in the urine
• TB infecting the heart can impair the heart's ability to pump blood, resulting in a condition called cardiac
tamponade that can be fatal
Tuberculosis is unlike most bacterial infections in that it usually doesn't cause symptoms immediately.

Most commonly, tuberculosis (TB) goes through three stages:

• Primary TB infection
• Latent TB infection
• Active TB

Primary TB Infection
Infection with Mycobacterium tuberculosis begins when a person breathes in airborne bacteria.

This is more likely to happen if a person is in close contact with one or more infected people with active TB
who are coughing or sneezing.
In many people, any inhaled bacteria are killed immediately by the immune system.
In others, the TB bacteria are engulfed by macrophages, a type of white blood cell, and enter a dormant
state.
This is called latent infection, and this stage can last for years or even for life.
However, in certain populations, including infants, the elderly, those with recently acquired TB infection, and
people with weakened immune systems, symptoms of active tuberculosis may start within weeks of primary
infection.

Latent TB Infection
In latent tuberculosis, the bacteria are dormant. A person has no symptoms and is not infectious.
However, a tuberculin skin test or blood test for TB — called the interferon-gamma release assay, or IGRA —
will be positive, showing that the person has not only been exposed to tuberculosis, but has latent (or
"occult") infection with the bacteria that causes tuberculosis.
Treatment of latent infection, if discovered, is recommended in certain individuals at high risk to prevent that
person from developing active disease and to prevent the further spread of tuberculosis.
People at high risk of TB infection (such as those who work in hospitals) may be screened, sometimes annually, for
latent infection.
People who plan to start chemotherapy for cancer or an immunosuppressive drug — to treat an autoimmune
condition, for example — may also be screened for latent tuberculosis
In people without HIV infection, the risk of latent infection becoming active disease has been estimated at 10
percent over a lifetime.
But for people infected with HIV, the risk increases significantly.

Active Tuberculosis
In active tuberculosis, the bacteria multiply in the body, causing symptoms and physical changes.
The most common kind of tuberculosis, pulmonary tuberculosis, typically causes the following symptoms:

• Breathing difficulty
• Chest pain
• Coughing, sometimes with phlegm
• Fatigue
• Fever
• Night sweats
• Weakness
• Weight loss
• Wheezing

In addition to the lungs, tuberculosis can affect other parts of the body including the lymph nodes, other
internal organs, bones and joints, or the brain.
This form of the disease, called extrapulmonary tuberculosis, also causes fatigue, fever, night sweats,
weakness, and weight loss, and may also cause other symptoms, depending on what body parts are affected.
The bacteria that cause tuberculosis (TB) multiply very slowly, so the symptoms of the disease also develop
slowly, usually over months to years.
And because many of the symptoms are vague and can have other causes, they are often not recognized as early
symptoms of tuberculosis.
The classic symptoms of active tuberculosis are:

• A general sense of being unwell

• Loss of weight and appetite
• Night sweats
• Intermittent fever
• Generalized body aches
• Fatigue
Tuberculosis most commonly affects the lungs, a condition called pulmonary tuberculosis.
When it affects parts of the body besides the lungs, it is called extrapulmonary tuberculosis.

Pulmonary Tuberculosis
Pulmonary tuberculosis typically causes a persistent cough that may produce yellow or green sputum first thing in
the morning.
Over time, the sputum may be streaked with blood, although large amounts of blood are unusual.
The cough is often blamed on smoking, asthma, or a recent illness, rather than being recognized as a symptom of
TB.
Pulmonary tuberculosis can also cause night sweats, in which a person wakes up drenched in sweat. It may or
may not cause a fever.
As the infection progresses, people feel tired and generally unwell. They may lose weight because of a loss of
appetite.

Two other common symptoms of pulmonary tuberculosis are chest pain and shortness of breath.

These symptoms may result from pleural effusion — an accumulation of fluid between the thin membranes (the
pleura) that cover the lungs and line the inside of the chest wall.
Or they can be a sign of a pneumothorax, the presence of air between the pleura.
Extrapulmonary Tuberculosis
Extrapulmonary tuberculosis may result from pulmonary TB that has spread via the bloodstream.
It causes a variety of symptoms, depending on where the active disease is located:
• Abdominal cavity: Swelling, tenderness
• Bladder: Painful or frequent urination, blood in urine
• Bones: Pain, tenderness
• Head: Headache, nausea, drowsiness, mental changes, or a stiff neck
• Joints: Pain, stiffness, swelling
• Kidneys: Pain, blood in urine, frequent urination
• Lymph nodes: Redness, swelling
• Pericardium (the membrane around the heart): Enlarged neck veins, shortness of breath, chest
pain
• Reproductive organs (men): Lump in scrotum
• Reproductive organs (women): Infertility, pelvic pain, abnormal bleeding
• Spine: Pain, spinal deformity, paralysis of the legs
Extrapulmonary tuberculosis can be difficult to diagnose, and is often mistaken for another condition
or illness initially.

Miliary TB
Miliary tuberculosis, or "disseminated tuberculosis," is a potentially life-threatening form of TB in
which large numbers of tuberculosis bacteria spread throughout the body via the bloodstream.

It's more common in people with a weakened immune system.

The symptoms of miliary TB are the same as those seen in other types — fatigue, weight loss, fever,
chills, weakness, and difficulty breathing — making it difficult to diagnose.

Late in the disease, a chest x-ray of miliary TB shows millions of tiny spots throughout the lungs.
Miliary Tuberculosis Symptoms and Signs
1 Gradual onset of vague ill-health Miliary Tuberculosis Treatment
2 Loss of weight Miliary TB is treated using the same
drug regimens as pulmonary TB but
3 Fever treatment is generally extended for joint
4 Generalized lymphadenopathy (in about 40%) and bone tuberculosis (6 to 9 months)
and TB meningitis (9 to 12 months)
5 Pancreatitis with the duration of treatment
6 Adrenal insufficiency determined individually based upon
clinical response. Steroids are used
7 Drenching night sweats when there is meningitis or adrenal
8 Tachycardia (increased heart rate) i n s u f fi c i e n c y. T h e r e s p o n s e t o
treatment is judged based on the
9 Progressive anemia clinical and radiologic findings.
10 There may be cough and breathlessness
11 Miliary Tuberculosis may present as tuberculous meningitis
12 Usually there are no abnormal physical signs in the early stages of miliary TB but the liver and
spleen eventually become enlarged
13 Presence of Choroidal tubercles in the eyes (these choroidal tubercles are about one-quarter
of the diameter of the optic disc and are yellowish and slightly shiny and raised in nature, later
becoming white in the center. They may occur singly or multiple in each eye.
 Prevention
stop the transmission of TB from one adult to another:

identifying people with active TB, and then curing them through the provision of drug treatment

If someone is not on treatment, then precautions such as cough etiquette, must be taken to prevent TB
spreading from one adult to another.Cough etiquette means that if you have TB, or you might have TB,
then when you cough you should cover your mouth and nose with a tissue. You should put your used
tissue in a bin. If you don’t have a tissue then you should cough or sneeze into your upper sleeve or
elbow. You should not cough into your hands. After you have coughed you should wash your hands.

Another main part of TB prevention is to prevent people with latent TB from developing active, and
infectious, TB disease.

The final part of TB prevention is TB infection control. This means preventing the transmission of TB in
such settings as hospitals & prisons.

masks

The pasteurization of milk also helps to prevent humans from getting bovine TB
TB prevention – the BCG vaccine The vaccine called Bacillus Calmette-Guerin (BCG) was first developed in the 1920s.
The BCG vaccine has been shown to provide children with excellent protection against the disseminated forms of TB
Preventing TB transmission in households, masks:
• Houses should be adequately ventilated;
• Anyone who coughs should be educated on cough etiquette and respiratory hygiene, and
should follow such practice at all times;
• While smear positive, TB patients should:
◦ Spend as much time as possible outdoors;
◦ If possible, sleep alone in a separate, adequately ventilated room;
◦ Spend as little time as possible on public transport;
◦ Spend as little time as possible in places where large numbers of people gather together.
TB treatment as TB prevention
TB drug treatment for the prevention of TB k/a chemoprophylaxis,

Isoniazid is one of the drugs used to prevent latent TB from progressing to active TB or TB disease

• Improving the ventilation in indoor spaces so there are fewer bacteria in the air
• Using germicidal ultraviolet lamps to kill airborne bacteria in buildings where people at high risk of
tuberculosis live or congregate
• Treating latent infection before it becomes active
• Using directly observed therapy (DOT) in people with diagnosed tuberculosis (latent or active) to raise
the likelihood of the disease being cured

Avoiding other people by not going to school or work, or sleeping in the same room as someone, will help to
minimize the risk of germs from reaching anyone else.
Wearing a mask, covering the mouth, and ventilating rooms can also limit the spread of bacteria.

Diagnosis of tuberculosis

The most common diagnostic test for TB is a skin test where a small injection of PPD tuberculin, an extract of the
TB bacterium, is made just below the inside forearm.
The injection site should be checked after 2-3 days, and, if a hard, red bump has swollen up to a specific size, then
it is likely that TB is present.

However, there are other tests that are available to diagnose TB. Blood tests, chest X-rays, and sputum tests can
all be used to test for the presence of TB bacteria and may be used alongside a skin test.
 Treating Tuberculosis
can be treated with antibiotics effectively.
This was discovered in the early 1950s.
This is not so easy now as the bacteria have become immune to the treatment of antibiotic.
A new and more stubborn strain of the disease has surfaced which is classified as multi-drug resistant TB or
drug resistant TB.
Because of this new development and the resistance of the bacteria to the commonly used drugs it has
become more difficult to treat.
This status is become a problem worldwide and has kept the medical fraternity on their toes where treatment
is concerned.

Most common TB drugs

If you have latent tuberculosis, you may need to take just one type of TB drug. Active tuberculosis,
particularly if it's a drug-resistant strain, will require several drugs at once The most common medications
used to treat tuberculosis include:
• Isoniazid
• Rifampin (Rifadin, Rimactane)
• Ethambutol (Myambutol)
• Pyrazinamide

If you have drug-resistant TB, a combination of antibiotics called fluoroquinolones and injectable
medications, such as amikacin, kanamycin or capreomycin, are generally used for 20 to 30 months. Some
types of TB are developing resistance to these medications as well.
A number of new drugs are being looked at as add-on therapy to the current drug-resistant combination
treatment, including:
• Bedaquiline
• Linezolid
 The precise type and length of antibiotic treatment depend on a person's age, overall health,
potential resistance to drugs, whether the TB is latent or active, and the location of infection (i.e.,
the lungs, brain, kidneys).
People with latent TB may need just one kind of TB antibiotics, whereas people with active TB
(particularly MDR-TB) will often require a prescription of multiple drugs.
Antibiotics are usually required to be taken for a relatively long time. The standard length of time for
a course of TB antibiotics is about 6 months.

It is important for any course of treatment to be completed fully, even if the TB symptoms have
gone away. Any bacteria that have survived the treatment could become resistant to the
medication that has been prescribed and could lead to developing MDR-TB in the future.
Directly observed therapy (DOT) may be recommended. This involves a healthcare worker
administering the TB medication to ensure that the course of treatment is completed.