Tuberculosis
Breakdown of a Disease
1.Pathogenesis 2.Transmission 3.Symptoms 4.Screening 5.Diagnosis Treatment
IGRAs
A positive TB skin test or TB blood test only tells that a person has been infected with TB bacteria. It does NOT tell whether the person has latent TB infection (LTBI) or has progressed to TB disease. Other tests, such as a chest x-ray and a sample of sputum, are needed confirm TB disease (CDC, 2020) Can pick up any infection Quantefreon = is more Specific Weeds out false positvies, more confirmatory screen speIT - t spot. Not as specific but works together the two,.. sensitive
Mantoux Tuberculin Skin TestInterpreting the Reaction
All other people in higher risks Kids have blunted immune system Iife style if theres a lot of people
Medical History Red Flags
Along with risk factors
diff category graphic
An induration of 15 or more millimeters is considered positive in any person, including persons with no known risk factors for TB. However, targeted skin testing programs should only be conducted among high-risk groups. Cat 1 - high risk, HIV, undergoing cancer treamtnes Your immune system not as good, may not reach that well Cat2 - moderate risk, people you are exposed to, lifestyle Cat 3 - heatlhy immune syetm reaction, more reaction ,regular population Skin test require professional to see if patinetis screening pos Need knowledge to understand results correctly Want little reaction to be worried, because of blunted immune respsone Iif you do test every year, might develop bleb
Mantoux Tuberculin Skin Test Interpreting the Reaction
An induration of less than 5 millimeters (mm) is considered a negative test result. However, if you have symptoms, or you know you've been exposed to someone with TB, you may be advised to get another test later.
Mantoux Tuberculin Skin Test: Study Question What 2 factors determine the interpretation of a skin test reaction as positive or negative?
Answer: (1) Size of induration and (2) risk factors for TB
High-Risk Groups for TB Infection Special Settings
Approximately 4-6% of TB cases reported in the United States occur among people incarcerated at the time of diagnosis. The incarcerated population contains a high proportion of people at greater risk for TB than the overall population (CDC, 2020)
reported TB cases
CDC, 2019) Source: https://www.cdc.gov/tb/publications/factsheets/statistics/tbtrends.htm Better contact tracing Access Education Hardcroe efforts in center
Reading Results: Mantoux Tuberculin Skin Test (PPD)
If you have a positive PPD, it means you have been exposed to a person who has tuberculosis and you are now infected with the bacteria (mycobacterium tuberculosis) that causes the disease. Reading can be tricky Not the red part you read erythema, but the blister?
Chest X-Ray
Miliary TB is a potentially fatal form of TB that results from massive lymphohematogenous dissemination of Mycobacterium tuberculosis bacilli. The epidemiology of miliary TB has been altered by the emergence of the human immunodeficiency virus (HIV) infection and widespread use of immunosuppressive drugs (NIH.gov) Checking for lugns, listening to airway Make sure its clear May not hear wheeze , much more subtel unless severe
TB Transmission
Most people with active TB who've had appropriate drug treatment for at least two weeks are no longer contagious (Mayo Clinic, 2019) Dark dusty not well ventaliated How long exposed for Weaknign the bacteria through drugs
pathogenesis vs pathophysiology
Source: https://pediaa.com/what-is-the-difference-between-pathophysiology-and-pathogenesis/ Patho phys comes after gensis What is the chain of command that elads to disease
some side effects are extensife
Streptomycin Dephnis Watch out this, monitor hearing freq for kids, kidney and liver impairment **
TB Pathogenesis: LTBI (latent tuberculosis)
The TB infection may be cleared by the host immune system or suppressed into an inactive form called latent tuberculosis infection (LTBI), with resistant hosts controlling mycobacterial growth at distant foci before the development of active disease. Patients with LTBI cannot spread TB. Sometiems, we are exposed to Tb, and its strong to defend itself but not kill it What it does it creastes granulomas in the lungs and it keeps and contains the TB from growing , virulent, not contagious Latent TB , able to develop this granuloma and contain it
Progression to TB Disease
Treatmetn = 6 months long, Helps ID new cases
Chest X-Ray
Tuberculous cavities are common in superior segments of upper and lower lobes. When a cavity in anterior segment is encountered, a strong suspicion for lung cancer should be raised. TB and aspiration lung abscess are rare in anterior segments. Can see white (infiltrates) - collection of blood wbc trying to heal Cavity - space, air, circle
TB Overview
Video is the CDC Introduction to TB Disesae caused by bacteria, person to person through air Without treatment, can die High incidence of drug resistance Access to healthcare
Once coughed out by a person with TB, the bacilli can survive up to
six months outside the body if they are protected from direct sunlight. uOften will settle in dusty, dark areas. Can survive 6 months Dark dusty moist area Dirty basement Connections to poverty
TB Transmission
(CDC, 2020) tuberculosis is carried in airborne particles, called droplet nuclei, of 1- 5 microns in diameter. Infectious droplet nuclei are generated when persons who have pulmonary or laryngeal TB disease cough, sneeze, shout, or sing. TB is spread from person to person through the air. •remain suspended in air for long periods of time. •M. tuberculosis can exist in the air for up to six hours, during which time another person may inhale it. • • •We get it via droplet •N 95
race trends for TB
41.4 million people in the United States were black alone, which represents 12.7 percent of the total population. African Americans are the second largest minority population, following the Hispanic/Latino population. (Minority News, 2019) Depends where people are coming Most cases are from people moving to america
Mantoux Tuberculin Skin Test Interpreting the Reaction
An induration of 15 or more millimeters is considered positive in any person, including persons with no known risk factors for TB. However, targeted skin testing programs should only be conducted among high-risk groups. Everyone else
Mantoux Tuberculin Skin Test What can cause a False-Positive Reaction?
BCG, or bacille Calmette-Guerin, is a vaccine for tuberculosis (TB) disease. Many foreign-born persons have been BCG-vaccinated. BCG is used in many countries with a high prevalence of TB to prevent childhood tuberculous meningitis and miliary disease. Antigen is a toxin or other foreign substance which induces an immune response in the body, especially the production of antibodies. QuantiFERON-TB Gold (QFT) is a simple blood test that aids in the detection of Mycobacterium tuberculosis, the bacteria which causes tuberculosis (TB). QFT is an interferon-gamma (IFN-γ) release assay, commonly known as an IGRA, and is a modern alternative to the tuberculin skin test (TST, PPD or Mantoux). What is specificity, spT BCG vaccine - TB vax, don't want to do the test bec inflammatin
TB is typically NOT spread by
Coughed out, breathing it in Body unabl to kill it How ill you are
Medical Evaluation
Do history Risk factors How are youcategorizing them 1, 2 , 3 Trends Hot spots, travel history. Medical history Cough blod, 3 weeks more, classic sytmojs Rule out any microbacteria
Latent TB Infection**
Does latent TB need treatment? TB drug regimens are standardized globally, and include a combination of drugs given daily for six months. More than 95% of children are cured with this treatment. Giving anti-TB drugs twice- or thrice-weekly is more convenient to supervise than daily treatment but may not be as effective as daily treatment in curing children of TB. •Children, adolescents, and people infected with HIV who have latent TB infection need to take INH for 9 months. Don't need ot memorizethe durgs These three drugs though are for those with latent TB High priority treatment for latent to prevent active TB
Bacteriologic Examination Drug Susceptibility Testing
Drug susceptibility testing determines which drugs can kill TB (tubercle bacilli). If the tubercle bacilli are killed by a particular drug, they are susceptible to that drug Culture tells what is the right drug. Takes that sample , introduces the right drugs Makign sure that durg can kill that particular bacteria Checking fro resistant strains
IGRA Disadvantages and Limitations
Expensive Wbc are viable Need to dot it quick Limited data issues
TB Symptoms
Extrapulmonary sites of infection commonly include lymph nodes, pleura, and osteoarticular areas, although any organ can be involved. The diagnosis of extrapulmonary tuberculosis can be elusive, necessitating a high index of suspicion (source: https://www.aafp.org › afp)
Diagnostic MicrobiologySpecimen Collection
Gastric lavage, also commonly called gastric irrigation, is the process of cleaning out the contents of the stomach Induced - tap and make them cough loosen the secrations Bronchosopy - what else is there. Gastric washing - nurse drops NG tube into stomach, push air and listen for the woosh and see if youa re In the right place- inject normal ccs into stomach, syringe wil have different content. Swallow enough sputum to be able to pull out sample from STOMACH?
TB Pathogenesis: TB Active Disease
However, most people with active TB who've had appropriate drug treatment for at least two weeks are no longer contagious. 10-15 years kept, then illness decrsae immune, capsule breaks If good, immune system, body does good job in keeping it encapsulated
TB Pathogenesis: Active TB Disease
If TB bacteria become active in the body and multiply, the person will go from having latent TB infection to being sick with TB disease. ... People with TB disease usually have symptoms and may spread TB bacteria to others. A cough lasting 3 weeks or longer is a symptom of TB disease. How do you know if TB is active? Signs and symptoms of active TB include: •Coughing that lasts three or more weeks. •Coughing up blood. •Chest pain, or pain with breathing or coughing. •Unintentional weight loss. •Fatigue. •Fever. •Night sweats. •Chills. •Among other symptoms Someitmes our bodies break down and the granuloma breaks and the TB excapes, then we have active TB And we become contagious This happens bc of immune issue - like developing cncer and under chemo Or undercontrolled HIV Can be a time bomb depending what happens to immune system
High-Risk Groups for TB Infection Low-Income and Homeless
In the United States, 1% of the population experiences homelessness in a given year, but more than 5% of people with TB reported being homeless within the year prior to diagnosis (CDC. 2020) Low income and homeless
TB Pathogenesis: the TB bacilli are ingested by alveolar macrophages; luckily, majority of these bacilli are destroyed or inhibited (nih. gov)
Infection occurs when a person inhales droplet nuclei containing tubercle bacilli that reach the alveoli of the lungs. The TB bacilli are ingested by alveolar macrophages; luckily, majority of these bacilli are destroyed or inhibited. Vast majority, breathe it in, our macrophages eat it up and destroy it
Interferon-Gamma Release Assays (IGRAs)Let's Discuss the Blood Tests
Interferon-Gamma Release Assays (IGRAs) are whole-blood tests that can aid in diagnosing Mycobacterium tuberculosis infection. However, they do NOT help differentiate latent tuberculosis infection (LTBI) from tuberculosis disease.
Mantoux Tuberculin Skin Test Interpreting the Reaction
Mantoux Tuberculin Skin Test Interpreting the Reaction
TB: Types of Mycobacteria
Mycobacterium avium complex (MAC) is a group of bacteria related to tuberculosis. These germs are very common in food, water, and soil. Almost everyone has them in their bodies. When you have a strong immune system, they don't cause problems. MAC is related to the tuberculosis germ but is not contagious (the MAC microbes live in the environment). There is other bacteria that causes TB disase Cousin bactiera similar but not cause Tb
The Sites of TB Disease
Other Sites of TB Disease Lower CD4 count Young children 4, immature immune system Ptus them at risk for all kinds of infections Stature , smaller, people cough on them, play on the ground Hand to mouth
Pott's disease: TB outside the lungs
Pott disease, or Pott's disease, is a form of tuberculosis that occurs outside the lungs whereby disease is seen in the vertebrae. •Tuberculosis can affect several tissues outside the lungs including the spine, a kind of tuberculous arthritis of the intervertebral joints. •Approximately 1-2.2% of total tuberculosis cases are attributable to Pott disease. • Most of it is in the lymphatic system = like the neck But can be in the knee or different organs Extract abcess, seeing what it is
Drug-Resistant TB
Priamary resistance - you catch a primary resistant TB from another indv. Secondary - we didn't get the right drug routine, or pt wasn't taking it correctly. Not completing treatment
Drug-Resistant TB (CDC Link here)
Resistnat to about everything is the last one High restiatnce and worried person to person spread Worreid about cough retrurnign and other things Not multiresistance
Drug-Resistant TB
Restitnt to at least on e of the first line drugs
Progression to TB Disease Some conditions increase probability of LTBI progressing to TB disease
Silicosis is a progressive disease that belongs to a group of lung disorders called pneumoconiosis. Silicosis is marked by the formation of lumps (nodules) and fibrous scar tissue in the lungs. It is the oldest known occupational lung disease, and is caused by exposure to inhaled particles of silica, mostly from quartz in rocks, sand, and similar substances. Substance users - less nutrition, don't sleep as well , connection. Silicosis - rock dust breathing in DM - bacteria loves sugar, high blood sugar, higher incidence of infections Kidney diseae - nutrition deficient Low vit D, zinc
Mantoux Tuberculin Skin Test Let's Discuss the BCG Vaccine
TB blood tests (IGRAs), unlike the TB skin test, are NOT affected by prior BCG vaccination and are not expected to give a false-positive result in people who have received BCG. •TB blood tests are the preferred method of TB testing for people who have received the BCG vaccine (CDC, 2020)
Other High-Risk Groups for TB Infection Foreign-Born/Immigrants
TB disease in the United States is most common among people who were born in countries with high rates of TB. In 2018, a total of 70.2% of reported TB cases in the United States occurred among non-U.S.-born people. (CDC, 2020) Countries really struggling We share same diseases and same world
Mantoux Tuberculin Skin Test
The Mantoux tuberculin skin test (TST) is the standard method of determining whether a person is infected with Mycobacterium tuberculosis. Reliable administration and reading of the TST requires standardization of procedures, training, supervision, and practice (CDC, 2019) The TST is performed by injecting 0.1 ml of tuberculin purified protein derivative (PPD) into the inner surface of the forearm. The injection should be made with a tuberculin syringe, with the needle bevel facing upward. The TST is an intradermal injection. When placed correctly, the injection should produce a pale elevation of the skin (a wheal) 6 to 10 mm in diameter. At intradermal ,, at edge To shallow to burst skin
4. TB ScreeningAvailable Screening Tests
The QuantiFERON-TB Gold In-Tube is a blood test for use as an aid in diagnosing Mycobacterium tuberculosis infection, both latent tuberculosis infection and active tuberculosis disease. T-SPOT.TB is a type of ELISpot Assay used for tuberculosis diagnosis, which belongs to the group of interferon gamma release assays. •ELISpot Assay is the enzyme-linked immune absorbent spot is a type of assay that focuses on quantitatively measuring the frequency of cytokine secretion for a single cell. Skin test, can screw up administration and Less expensive One time Two blood tests One is more sensivie another is more specific T F
TB ScreeningMantoux tuberculin skin test (TST)A.K.A. the purified tuberculin protein (PPD)
The TB skin test, also known as the Mantoux tuberculin skin test, is the most common way to screen for tuberculosis. They'll inject a tiny amount of fluid called tuberculin just below the skin in your forearm. It contains some inactive TB protein. You should feel a small prick from the needle. Purified Protein Derivative (PPD) The PPD skin test is a method used to screen for silent (latent) tuberculosis (TB) infection. PPD stands for purified protein derivative
Treatment of Active TB Disease
These meds have a lot of side effects Preferred is the first column Cont phase - Intsenvie phase - then back off Differen toptions Different regimes besdies daily treamtnet
IGRA Advantages
They may have a positive reaction to a subsequent TST because the initial test stimulates their ability to react to the test. This is commonly referred to as the "booster phenomenon" and may incorrectly be interpreted as a skin test conversion (going from negative to positive). Why blood over skin?Because of BCG vaccine Requres single visit - don't need to come back
LTBI vs. TB Disease
Tuberculin skin tests (TST) are administered to detect the presence of Mycobacterium tuberculosis, the bacterium that causes tuberculosis (TB). The terms Mantoux, TB skin test, tuberculin skin test, and PPDs are often used interchangeably. •Mantoux refers to the technique for administering the test. • • Granule is too small to see in latent But in active, see it spreading. The inflammation and the graunles. Abnormal chest x ray Sputum smear = positive in an active case
TB Transmission Tends to settle in the anterior top portion of the lung
Where does it tend to land? Anterior portion of lungs, inflammation and granuloma of the lung Posterior, in the back of the lung, more frequently worry, assocatie that with cancer
2. TB Transmission
https://www.cdc.gov/tb/statistics/reports/2017/TBsurveillancereport-figures.html.
5. TB Diagnosis
•Erythrocyte sedimentation rate (ESR) •Polymerase chain reaction (PCR)-make DNA copies cxr - chest radiograph An acid-fast bacteria (AFB) culture is done to find out if you have tuberculosis (TB) or another mycobacterial infection. Besides TB, the other main mycobacterial infections are leprosy and a TB-like disease that affects people with HIV/AIDS. Do screenings (skin and blood test diagnos_? NO Never considered diagnsositc Gold standard = sputm culture Chest x ray , not diagnostic- telss if theres something there, but what type of pneumonia, might resemblecancer