Tuberculosis

Paul Salandanan, MD, FPCP, FPSMID

Endymion Tan, PTRP, MD, FPCP, FAMP, DPSMID
Mary Clare Carmelle F. Coronel, MD

TUBERCULOSIS  Crowding in poorly ventilated rooms is one of the most

 Caused by Mycobacterium tuberculosis complex important risk factors in the transmission of tubercle bacilli
 One of the oldest disease known to affect human worldwide  Virulence of the transmitted organism is important in
 Commonly affects the lungs but can also affect other organs establishing infection
in 1/3 of cases
 It is curable if properly treated but can also be fatal within 5 What other co-morbidities will you consider for you to be
years in 50-65% of the cases if untreated susceptible to TB?
 Transmission is usually airborne spread of droplet nuclei - B & T cell Deficiency, Cancer patient going on
by patients with infectious pulmonary TB Chemotherapy, Diabetic patient, patient undergoing
hemodialysis
ETIOLOGIC AGENT Ano yung pinaka important MOT in TB?
 Pathogenic species belong to M. tuberculosis complex, - MOT is mostly inhalation of droplet nuclein so you have
which comprises 8 distinct subgroups to practice airborne precaution
o Most important agent: M. tuberculosis (sensu What is the size of the small droplet of nuclei?
stricto) - 0.5 micrometer (sobrang liit). It is so small that it can
 Zoonotic members such as M. bovis- a tubercle bacillus that enter the alveoli
is resistant to pyrazinamide, was once an important cause of
TB transmitted by unpasteurized milk and is currently
responsible for 150,000 human cases worldwide. FROM INFECTION TO DISEASE
 Mycobacterium tuberculosis
o Rod shaped, non- spore- forming, thin aerobic
bacterium Acid fast bacilli- high content of
mycolic acid that is why it cannot be decolorized by
acid alcohol in gram stain
o Cell wall is linked by arabinogalactan and
peptidoglycan- low permeability of cell wall that
reduces the effectiveness of most antibiotics
o Lipoarabinomannan- pathogen- host interaction,
facilitates the survival of the organism within
macrophages

EPIDEMIOLOGY
 In 2016, estimated 10.4 million (88-12.2 million) new cases
occurred worldwide
o 95%: Asia (6.5 million), Africa (2.6 million), Middle
East (0.77 million), Latin America (0.26 million)
o Seven countries accounted for 64% of all new
cases: India, Indonesia, China, Philippines,
Pakistan, Nigeria and South Africa ,
 2/3 of the cases occurred in males
 In that same year, estimated 1.7 million (1.5-1.8 million)
deaths which included 0.37 million people with HIV infection.
 500,000 cases of multidrug- resistant TB (MDR-TB) and
100,000 cases of rifampin- resistant TB (RR-TB) occurred in
2016
o 240,000 people with MDR/RR-TB died that year  The risk of developing disease after being infected
depends on endogenous factors
FROM EXPOSURE TO INFECTION o innate immunologic and nonimmunologic defenses
 M. tuberculosis is commonly transmitted from a person with o cell mediated immunity function
infectious pulmonary TB by droplet nuclei through  Primary TB- children in first few years of life and
coughing, sneezing or speaking immunocompromised persons
 3000 infectious nuclei per cough o May be severe and disseminated, but it is not
 Risk of transmission is determined by exogenous associated with high level of transmissibility
factors:  Bacilli may persist for years before reactivating to produce
o Probability of contact with a person who has an secondary (or postprimary) TB
infectious form of TB o More infectious because of frequent cavitation
o Intimacy and duration of contact  It is estimated that 10% of infected persons will develop
o Degree of infectiousness of the case active TB in their lifetime
o Shared environment in which the contact takes o Risk is much higher among HIV infected
place persons- suppresses cellular immunity
 TB patients whose sputum contains AFB sputum smear  Age is an important determinant of the risk of disease after
positive case are most likely to transmit the infection infection
 Most infectious patients: o Highest among late adolescence and early
o Cavitary pulmonary disease adulthood
o Laryngeal TB

TRANSCRIBERS Trisha Faye Oberio, Kristine Jean Navarro, Aisle Paler 1 of 14

  In women, it peaks at 25-34 years of age whereas at older
ages, it is most common in men
 The risk also increases in elderly because of waning
immunity and comorbidity
 
Where to suspect a case of TB?
- For Primary TB, the most common lesion will be found in
 Perihilar Lymph nodes.
In children, Primary TB ay hindi nakakahawa because the
 is in perihilar lymph node kasi di naman nila dinadahak
lesion

palabras pero kapag sa adult nagkakaroon ng recurrence.
For TB, macocnsider na adult yung patient, if the patient is
15 years old and above. In TB, as long as the patient is 15
yrs old manifesting with fever, cough, hemoptysis or any
nonspecific constituitional signs and symptoms , nag-chills
lang siya, pinapawisan like afternoon fever. You should have
high index of suspicion that this might be TB
PATHOGENESIS AND IMMUNITY
INFECTION AND MACROPHAGE INVASION
 Inhalation of droplet nuclei containing M. tuberculosis
 10% of the inhaled bacilli reached the alveoli
 Alveolar macrophages that have not been activated
phagocytose the bacilli
 Adhesion and phagocytosis of alveolar macrophage
 Phagocytosis is enhanced by complement activation leading
to opsonization of bacilli with C3 activation products such as
C3b and C3bi
o Bacilli are resistant to complement- mediated
lysis
 Binding of alveolar macrophage mannose receptor for the
regulation of phagosome- lysosome fusion and inflammatory
cytokine production
 A complex of series of events is generated by the bacterial
cell- wall lipoglycan lipoarabinomannan (ManLAM)
o It inhibits intracellular increase of Ca2+ thus,
Ca2+/calmodulin pathway (that leads
phagosome- lysosome fusion) is impaired making
the bacilli survive within the phagosome
 If the bacilli are successful in arresting phagosome
maturation, then replication begins and the macrophage
eventually ruptures and releases its bacillary contents
 Other uninfected phagocytic cells are then recruited to
continue the infection cycle by ingesting dying macrophages
and their bacillary content, thus in turn becoming infected
themselves and expanding the infection, infection cycle
continues.
In the pathogenesis, what is important is the macrophages,
sila yung mag-phgocytose. Unactivated kasi naïve sila ee. May
alveolar macrophages. ( In short know the Pathogenesis)
 In areas with high transmission, this may be often seen in
children
 Most commonly involved areas: middle and lower lung
zones
Ghon focus- lesion forming after initial infection
o usually peripheral accompanied by transient hilar
or paratracheal lymphadenopathy which may or
may not be seen on CXR
o when it is accompanied with or without overylying
pleural reaction, thickening and regional
lymphadenopathy- Ghon complex
 Some patients develop erythema nodosum on the legs or
phlyctenular conjunctivitis
 Majority of the cases heal spontaneously and becomes
evident as small calcified nodule
 In young children with immature cell mediated immunity and
those who have impaired immunity this may progress to
clinical illness  the lesion can increase in size and can
evolve in many ways
o Pleural effusion- penetration of bacilli into the
pleural space from an adjacent subpleural focus
o Progressive primary TB- primary site rapidly
enlarges, the central portion undergoes necrosis
and cavitation develops
 TB in young children,
o Hilar or paratracheal lymphadenopathy- spread of
bacilli from lung parenchyma through lymphatic
spread
o Enlarged lymph nodes compress bronchi
 total obstruction with distal collapse
 partial obstruction with large airway
wheezing
 ball- valve effect with segmental/lobar
hyperinflation
o lymph nodes rupture  it can reach the airway 
pneumonia often with areas of necrosis and
cavitation
 Other manifestations:
o Bronchiectasis
to
o Occult hematogenous dissemination
o Disseminated or miliary disease- infection from an
insufficient acquired immune response
o Small granulomatous lesions  tuberculous
meningitis (very young children and
immunocompromised persons)

CLINICAL MANIFESTATIONS
 TB is classified as pulmonary, extrapulmonary or both
 Depending on several factors linked to different populations
and bacterial strains, extrapulmonary TB may occur in 10-
40% of the patient
 Up to 2/3 of HIV- infected patients with TB may have both
pulmonary and extrapulmonary TB or extrapulmonary TB
alone

PULMONARY TB
Primary Disease
 Occurs soon after the initial infection with tubercle bacilli
 It may be asymptomatic or may present with fever and
occasionally pleuritic chest pain

TUBERCULOSIS 2 of 14
Post primary (Adult- type) Disease
 Also referred as, reactivation or secondary TB
 Adult type- result from endogenous reactivation of distant
LTBI or recent infection
 Usually localized to the apical and posterior segments of
the upper lobes—higher mean oxygen tension that favors
mycobacterial growth
 Superior segments of the lower lobe are also more
frequently involved
 The extent of lung parenchymal involvement depends
on
o Small infiltrates
o Extensive cavitary disease
 Liquefied necrotic contents  airways 
bronchogenic spread  satellite lesions
 cavitation
o Caseating pneumonia
 Massive involvement of pulmonary
segments
 “Galloping consumption” of the past- 1/3 of untreated
patients succumb to severe pulmonary TB within few
months after onset
 “Consumption” or phthisis- chronic, progressively
debilitating course
 In earlier course of the disease, s/ sx are nonspecific and
insidious: diurnal fever and night sweats, weight loss,
anorexia, general malaise and weakness
 90% of the cases- cough develops- initially, non-
productive and limited in the morning and subsequently
accompanied by purulent sputum with blood streaks
 20-30% hemoptysis, if massive can be because of:
o Erosion of blood vessel in the wall of a cavity
o Rupture of dilated blood vessel in a cavity
(Rasmussen’s aneurysm)
o Aspergilloma formation in an old cavity
 Pleuritic chest pain
o Patients with subpleural parenchymal lesions or
pleural disease
 Dyspnea- in extensive diseases, rarely can cause adult
respiratory distress syndrome
 Physical findings:
o Detectable rales during inspiration especially after
coughing
o Rhonchi due to partial bronchial obstruction
o Classic amphoric breath sounds in areas with
large cavities
o In some cases, pallor and finger clubbing
 Hematologic findings:
o Mild anemia
o Leukocytosis
o Thrombocytosis
o Slightly elevated erythrocyte sedimentation rate
and C- reactive protein level
 Hyponatremia due to SIADH has also been reported
EXTRAPULMONARY TB
TUBERCULOSIS
 In descending order extrapulmonary sites that are most
commonly involved:
o Lymph nodes  pleura  genitourinary tract 
bones and joints  meninges  peritoneum 
pericardium
What is the most common Extrapulmonary site of TB?
- LYMPH nodes.
Anong Lymph node ang pinaka common?
- Cervical Lymph node
Kung Pulmonary TB ang lesions ay nasa lungs, may
sputum production
Pag normal chest xray tapos walang kaubo ubo, walang
cough, walang pulmonary symptoms pero enlarged ang lymph
nodes, meron siyang infection sa brain. Basta anything na
wala sa baga, ang tawag don ay extrapulmonary TB.
Lymph Node TB (Tuberculous Lymphadenitis)
 Most common presentation in both HIV- seronegative
individuals and HIV- infected patients
 Presents as: painless swelling of the lymph nodes-
posterior cervical and supraclavicular sites (scrofula)
 Usually discrete in earlier disease but develops into a matted
nontender mass over time  fistulous tract that drains
caseous material
 <50% of the cases presents with associated pulmonary
disease
 Systemic symptoms are uncommon EXCEPT in HIV
infected patients
 Dx:
o fine needle aspiration biopsy
o surgical excision biopsy
o bacteriologic confirmation
 AFBs
 Culture
 In HIV- infected patients, granulomas are less well-
organized and are frequently absent entirely but bacterial
loads are heavier
 D/Dx:
o Lymphomas or metastatic carcinomas
o Kikuchi’s disease (necrotizing histiocytic
lymphadenitis)
o Kimura’s disease
o Castleman’s disease
Pleural TB
 Accounts for 20% of cases in US
 Isolated pleural effusion reflects recent primary infection
 Collection of fluid in pleural space represents a
hypersensitivity response to mycobacterial antigens
 Depending on the extent, it can be small and resolve
spontaneously or it can be large to cause symptoms like
fever, pleuritic chest pain and dyspnea
 Physical findings in pleural effusion:
o Dullness in percussion
o Absence of breath sounds
o CXR reveals effusion, can also show parenchymal
lesion
 Thoracentesis:
o Straw colored fluid, sometimes hemorrhagic
o Exudate, protein concentration >50% of that in
serum
o Normal to low glucose concentration
o pH= ~7.3
o Detectable WBCs (500-6000)/uL)
o Neutrophils predominate in early stage but
lymphocytes in latter stage
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  Needle biopsy
o Required for diagnosis
o Reveals granulomas
o Positive culture in 80% of cases
 Tuberculous empyema- less common complication
o Rupture of a cavity  spillage of large number of
organisms in pleural space  bronchopleural
fistula
o CXR reveals hydropneumothorax with an air fluid
level
o Pleural fluid is purulent and thick and has a lot of
lymphocytes
o AFBs and culture are positive
o Surgical drainage- adjunct to chemotherapy
o Can result to: pleural fibrosis and restrictive lung
disease
o Decortication or removal of thickened visceral
pleura improves lung function
TB of upper airways
 May involve the larynx, pharynx and epiglottis
 Symptoms: hoarseness, dysphonia, dysphagia and chronic
productive cough
 Findings depends on the site involvement
 Ulcerations are seen in laryngoscopy
 AFB is positive but biopsy is needed to establish diagnosis
 Carcinoma of the larynx has same manifestations but is
usually painless
Genitourinary TB
 Common presentations include: urinary frequency, dysuria,
nocturia, hematuria and flank abdominal pain
 Patients may be asymptomatic and can be discovered after
severe destruction of the kidneys
 Documentation of culture- negative pyuria in acidic
urine can increase the suspicion of TB
 Culture of three morning urine specimens yields a
definitve diagnosis
 Diagnosed mostly in females
o Affects the fallopian tubes and endometrium 
infertility, pelvic pain and menstrual abnormalities
o Diagnosis is through biopsy or culture of
specimens obtained by dilation and curettage
 In males, affects epididymis  slight tender mass that may
drain externally through a fistulous tract; orchitis and
prostatitis
 Genitourinary tract TB responds well in chemotherapy
TUBERCULOSIS
Skeletal TB
 Related to reactivation of hematogenous foci or to spread
from adjacent paravertebral lymph node
 Commonly affected: weigh bearing joints (40% spine, 13%
hips, 10% knees)
 Spinal TB (Pott’s disease or tuberculous spondylitis)-
involves two or more adjacent vertebral bodies
 Common site:
o Upper thoracic spine- children
o Lower thoracic and upper lumbar- adults
 Advanced disease results kyphosis (gibbus)
 Complications:
o Paraplegia
o Paraparesis
o Pain- TB of hip joints (head of femur)
o Pain and swelling- TB of knee
 Aspiration of abscess or bone biopsy confirms
tuberculous etiology
 Dx:
o Examination of synovial fluid: thick in appearance
with high protein concentration and a variable cell
count
o Biopsy and culture is necessary to establish
diagnosis
 Responds to chemotherapy but in severe cases may
require surgery
Tuberculous Meningitis and Tuberculoma
 Most often seen in young children but can also be seen in
adults, especially those with HIV
 Results from hematogenous spread of primary or post
primary pulmonary TB or from rupture of a subependymal
tubercle into the subarachnoid space
 Often presents as: headache, slight mental changes, low
grade fever, malaise, anorexia, irritability
o If not recognized can progress to severe
headache, confusion, lethargy, altered sensorium
and neck rigidity
 Paresis of cranial nerves (ocular nerves)- meningeal
involvement at the base of the brain
 Focal ischemia- involvement of cerebral arteries
o Evolve to coma with hydrocephalus and
intracranial hypertension
 Dx: Lumbar puncture
o High leukocyte count
o Predominant leukocytes (early stage: neutrophils)
o Protein content (1-8 g/L)
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 o Low glucose concentration
 CSF is diagnostic up to 80% and remains the gold standard
 Responds to chemotherapy but neurologic sequelae are
documented in 25% of cases with delayed diagnosis
 WHO recommends adjuvant glucocorticoid therapy
(dexamethasone or prednisolone) tapered over 6-8 weeks
 Tuberculoma- uncommon manifestation  seizures and
focal signs
Gastrointestinal TB
 Uncommon
 Swallowing of sputum with direct seeding, hematogenous
spread or ingestion of milk from cows affected by bovine TB
 Most common sites: terminal ileum and cecum
 Common presentations: abdominal pain (associated with
appendicitis), swelling, obstruction, hematochezia, palpable
mass, fever, weight loss, anorexia and night sweats
 Since surgery is required in most cases, dx can be
established by histologic examination and culture of
specimen obtained intraoperatively
Pericardial TB (Tuberculous Pericarditis)
 Either from direct extension from adjacent mediastinal or
hilar lymph nodes or hematogenous spread
 Onset may be subacute but acute presentation includes:
dyspnea, fever, dull retrosternal pain and pericardial friction
rub
 Definitive diagnosis: pericardiocentesis guided with
echocardiography
o Effusion is exudative in nature with high count of
lymphocytes and monocytes
o Hemorrhagic effusion is common
o Pericardial biopsy is high yield than culture
 Without treatment it can be fatal and even with treatment it
can develop complications like: Chronic constrictive
pericarditis with thickening of pericardium, fibrosis and
calcification
 WHO recommends adjuvant glucocorticoid therapy may
be used but the 2016 guidelines of the American Thoracic
Society (ATS), CDC, and Infectious Disease Society of
America (IDSA) suggest that glucocorticoid therapy should
not be administered
Miliary or Disseminated TB
 Due to hematogenous spread
 In children often caused by primary infection but in adults it
is due to reactivation or recent infection
 Lesions are usually yellowish granulomas 1-2mm
 Clinical manifestations are nonspecific: fever, night
sweats, anorexia, weakness and weight loss
 Physical findings:
o Hepatomegaly
o Splenomegaly
o Lymphadenopathy
o Eye exam reveals choroid tubercles-
pathognomonic of miliary TB in 30% of cases
o Meningismus- 10%
 Hematologic findings:
o Anemia
o Leukopenia
o Lymphopenia
o Neutrophilic leukocytosis
o Leukemoid reactions
o Polycythemia
 If unrecognized, can be lethal
 Glucocorticoid therapy has no benefit
 Cryptic miliary TB- elderly with chronic course of mild
TUBERCULOSIS
intermittent fever, anemia, meningeal involvement, death
 Nonreactive miliary TB- rare, due to hematogenous
dissemination of tubercle baciili
o Pancytopenia is common
HIV- associated TB
 Most common and main cause of death among HIV- infected
persons
 A new TB infection may evolve into weeks
 It can appear at any stage of HIV infection
o When cell mediated is only partially compromised,
pulmonary TB presents as upper- lobe infiltrates
and cavitation and without significant
lymphadenopathy or pleural effusion
o In late stages (CD4+ count is <200/uL)- diffuse
interstitial and subtle infiltrates, little or no
cavitation, pleural effusion and intrathoracic
lymphadenopathy
 Most common extrapulmonary TB in HIV infected patients
o Lymphatic
o Disseminated
o Pleural
o Pericardial
 Xpert MTB/RIF assay is preferred initial diagnostic option
 Culture remains the gold standard
 Immune reconstitution inflammatory syndrome (IRIS) or
TB immune reconstitution disease
o Exacerbations in systemic manifestations or
respiratory rigns as well as radiographic and lab
manifestations of TB
o Associated with administration of ART
o Earlier ART is started and lower the baseline CD4+
count, greater risk
o No diagnostic test
o Can result to neurologic complications or death in
pxs with CNS TB
o ART should not be initiated during the first 8 weeks
of TB tx in pxs with TB meningitis
o Glucocorticoids can be used; prednisolone
given for 4 weeks at low dosage (1.5 mg/kg/day
for 2 weeks and half that dose for remaining 2
weeks)
DIAGNOSIS
“GOD DAMN IT ANG HIRAP NG
MEDISINA, YOU CAN QUOTE ON ME
ON THAT”
5 of 14
PRESUMPTIVE TB
TB culture with Drug Susceptibility Testing (DST)
Xpert MTB/ RIF
Chest x-ray
 “Classic picture”- upper lobe infiltrates and cavities, but in
the era of HIV/ AIDS there is no pathognomonic radiographic
pattern
 Presumptive TB- patient with CXR findings suggestive of
PTB w/ or w/o symptoms
 Although a good screening test to identify presumptive TB, a
single CXR cannot accurately confirm active PTB by this
modality alone
 Clinical correlation and bacteriologic confirmation should still
be done
BACTERIOLOGICALLY CONFIRMED TB
Direct Sputum Smear Microscopy (DSSM)
 Primary diagnostic test for diagnosing TB
 Sputum should be collected through spontaneous
expectoration
 Fluorescent light emitting diode (LED-FM) microscopy is
preferred over light microscopy (bacilli- neon green)
 For the diagnostic evaluation of PTB, two (2) sputum
specimens should be obtained
 Collect the first specimen (ie. spot) at the time of first
consultation. Collect the second spot specimen after at least
an hour, or the following morning. If the second specimen is
not submitted within three days from the first specimen, a
new set of two (2) sputum specimens should be collected
unless the first specimen tests positive for AFB
 At least (1) sputum smear positive is confirmed
bacteriologically confirmed TB
 Mucus from nose and throat and saliva from the mouth are
NOT good specimens
 Procedure:
o Clean the mouth by thoroughly rinsing with water.
o Breathe deeply, inhale 3 times, on the third inhale,
deep dapat then ibuga mo na lahat ng sputum na
lalabas, bawal saliva kasi walang mababasa
o Cough strongly after inhaling deeply for the third
time and try to bring the sputum from deep within
the lungs
o Expectorate the sputum in the sputum cup or
conical tube
o Collect at least 1 teaspoonful (5-10 mL) for
DSSM, for Xpert MTB/ RIF, sputum sample
should not be less than 1 mL
o Collect the first specimen (spot- spot technique)
at the time of the first consultation and the second
spot specimen at least an hour or the following
morning
TUBERCULOSIS
o TB culture
 If available, requested in the diagnostic work up of TB cases,
specifically in ruling out non tuberculous Mycobacteria
 Culture- positive for Mycobacterium tuberculosis is
considered bacteriologically confirmed PTB
 Limitation: long turnaround time of results, limited access
and cost of test
 Remains as the gold standard and reference for bacterial
confirmation
 Should be performed for the following:
o Retreatment cases
o Treatment failure
o Contacts of known drug resistant TB cases
 DST should not be routinely performed among new cases of
PTB
 WHO- approved rapid diagnostic test for TB
 Employs molecular techniques for the diagnosis of TB
 It has been introduced globally and is expected to replace
conventional bacteriology for diagnosis in many settings
 Unlike DSSM, it does not indicate the level of infectiousness
of TB case.
Presumptive TB – suspicion of TB because of the
presence of symptoms. Wala ka pang treatment
It is either bacteriologically confirmed or clinically
diagnosed kapag you decided to treat the patient
How many of those Bacteriologically confirming test
should be positive for you to say to say that this is
Bacteriologically confirmed case? 1 lang.
Bacteriologically Confirmed – At least 1 lang mag-positive
ditto (DSSM or AFB), pwede rin na TB culture (LJ medium or
Ogawa Medium) and Rapid Diagnostic Test (Gene Xpert)
- But the culture, it will take 6-8 weeks before the
results are out unlike in smear microscopy which is
fast
- Theoretically Rapid Gene Xpert tst is 45 mins TAT
(Turnaround Time) pero ditto sa Phils. Ay 1 week.
Ano ang advantage ng Rapid Test?
- The TB gene xpert will tell you if the px has or does
not have TB. (Presence or Absence of TB)
- It would also tell you if the patient is resistant or
sensitive to rifampicin.
What are the three ways to detect bacteriologically
confirmed TB?
- Culture, Smear microscopy, Gene Xpert. Kapag 1 sa
kanila nag positive ay bacteriologically confirmed.
Pina- Ultrasound mo, nakita sa ultrasound meron siyang
caseation necrosis. Chronic granulomatous inflammation,
mukhang TB to kaya lang di mo naman siya maidahak dahak.
Is this clinically diagnosed or bacteriologically confirmed?
- Clinically diagnosed kasi wala ka naman na
microscopy, ultrasound lang, so maski ultrasound
findings, biopsy findings, inflammation, caseation
necrosois. Clinically diagnosed pa rin yun.
You can do the sputum testing 1 day only with 1 hr apart
or pwede mong gawin na mag spit ka today then tomorrow
morning balik ka to spit.
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 TREATMENT  Low rate of induction of drug resistance by selection of
Two main aims of TB treatment: mutant bacilli
a) To prevent morbidity and death by curing TB while
preventing the emergence of drug resistance Because of lower degree of effectiveness and higher degree of
b) To interrupt transmission by rendering patients noninfectious intolerability and toxicity, several classes of second-line drugs
to others. are used for drug resistant TB:

DRUGS Second-line Drugs

A Fluoroquinolones
Four major drugs are considered first-line agents for treatment of TB:
Kanamycin
1. Isoniazid Second-line injectable
Amikacin
2. Rifampin B aminoglycosides
Streptomycin
3. Pyrazinamide Injectable polypeptide Capreomycin
4. Ethambutol Ethionamide
 These drugs are well absorbed after oral administration. Prothionamide
 Peak serum level: 2-4h Cycloserine
C Other oral agents
Terizidone
 Elimination within 24 h
Linezolid
Clofazimine
Pyrzinamide
D D1 (First line drugs) Ethambutol
High-dose Isoniazid
Bedaquiline
D2 (Two new drugs)
Delamanid
PAS
Imipenem-cilastatin
D3 Meropenem
Amoxicillin-clavulanate
Amithiozone [thiacetazone]

 Streptomycin, formerly first-line, is now rarely used for

Table taken from 2016 MOP
So you just have to remember that it’s 5,10,25 and 15 for
patients. We can use this as a guide to compute kung ilang
tablets per day ang papainom mo sa kanila.
Ex. Isoniazid, you give 5mg per kg. Kung si patient ay 60
kg. So 60 times 5 ay 300 mg (60 kg x5 mg/kg = 300 mg) of
isoniazid per day so that is 1 tab per day.
Remember the corresponding letter (H- Isoniazid, R-
Rifampicin, Z- Pyrazinamide, E- Ethambutol, S- Streptomycin)
***Sabi ni Doc Coronel she might give computation sa exam.
So tandaan yung 5, 10, 25, 15
*** Sabi ni Doc Tan, just remember the dose in mg/kg ,kahit di
na yung maximum dose
drug-resistant TB
o resistance levels worldwide are high
o more toxic than the other drugs in the same class
o however, level of cross-resistance with other agents is
not complete
 Fluoroquinolones: later-generation agents such as
levofloxacin (high-dose) and moxifloxacin are recommended
o Gatifloxacin considered as good alternative w/ proper
selection and careful monitoring
 Group D2: [phase 2 clinical trials] increase chances of cure
among people with MDR-TB; must be used in accordance
with international recommendations
o [phase 3 clinical trials] Delamanid suggests that
treatment success is similar to that of optimized
background regimen with lower than previously
observed cardiac toxicity; role remains elucidated.
 Group D3: efficacy in MDR-TB regimens is not clearly
defined
o Used in treatment of patients with TB resistant to most
first- and second-line agents
o Amithiozone is used very rarely because associated
with severe and fatal skin reactions, including Stevens-
Johnson syndrome, among HIV-infected patients

“YOU KNOW WHAT IS INFINITELY BETTER

 Except for ethambutol, these agents are recommended on
the basis of their bactericidal activity (ability to rapidly
THAN SEX?
reduce the number of viable organisms and render px “READING. READING BETWEEN THE LINES. IF
noninfectious) YOU READ BETWEEN THE LINES AND YOU’LL
 Has also sterilizing activity (ability to kill all bacilli and thus UNDERSTAND THIS”
sterilize the affected tissues, measured in ability to prevent
relapses)

TUBERCULOSIS 7 of 14
REGIMENS  Cases are assigned a registration group based:
 See Appendix Table 173-3. o History of previous treatment
o Classification based on anatomical site
Based on DOH- National Tuberculosis Control Program, MOP 5th o Bacteriologic confirmation
ed.:  Necessary in determining correct treatment regimen.
 All retreatment patients should be screened for MDR-TB
TB Disease Registration Group before initiating Category II treatment regimen. Initiating
Question/Issue 2106 CPG Category II treatment regimen without MDR-TB screening
Pre-treatment Baseline serum ALT and creatinine. (Strong can only be done in areas where access to PMDT services
screening recommendation, moderate quality evidence) is not possible.
tests Provider initiated counseling and testing (PICT)  A patient’s anti-TB regimen shall be comprised of at least
for HIV for all patients with TB (Strong four (4) first-line drugs. Fixed dose combination (FDC)
recommendation, moderate quality evidence) should be used – except in children unable to take tablet
Screening for DM using FBS, RBS or 75 g OGTT formulations.
for all patients with TB (Strong  Out-patient treatment shall be the preferred mode of care.
recommendation, moderate quality evidence), However, patients with life-threatening conditions shall be
HBA1c not routinely recommended. recommended for hospitalization.
Serum uric acid testing NOT routinely  Treatment response of PTB patients shall be monitored
recommended (Strong recommendation, through follow-up DSSM and clinical signs and
moderate quality evidence) symptoms. All adverse drug reactions (ADRs), whether
minor or major, shall be reported using the offi cial reporting
form of the FDA
Registration Group Definition of Terms  All registered TB patients in Category A and B sites, shall be
Patient who has never had treatment for offered PICT
New TB* or who has taken anti-TB drugs for less  All confirmed drug-resistant TB cases shall be offered PICT.
than 1 month.
 Inform patient that he/she has TB disease and motivate to
Retreatment Patient who received 1 month or more of
undergo treatment. For patients <18 years old, talk to the
anti-TB drugs in the past (excluding
parent/guardian regarding the need to undergo treatment.
prophylaxis or treatment for latent TB
Provide key information:
infection.
o At least 6-8 months supervised, well-documented TB
Relapse Patient previously treated for TB, who has
been declared cured or treatment
treatment with good compliance
completed in their most recent treatment o Free anti-TB drugs in a DOTS program
episode, and is presently diagnosed with o Public health facilities offer free bacteriology services
bacteriologically-confirmed or clinically- o Schedule of follow-up DSSM monitoring
diagnosed TB. o Tracing mechanism
Treatment After Patient who has been previously treated for o How to address possible adverse drug reactions
Failure TB and whose treatment failed at the end of o Relevance of contact investigation
their most recent course. o Cough etiquette and other pertinent control measures
Retreatment

Includes:
 Patient whose sputum smear or culture Recommended Treatment Regimen for Adults and Children
is (+) at 5 months or later during Category of Classification and Registration Treatment
treatment. Treatment Group Regimen
 Clinically-diagnosed patient (child or
Pulmonary TB, new
EPTB) for whom sputum examination
(bacteriologically-confirmed or
can’t be done and who does not show
clinically-diagnosed)
clinical improvement anytime during
treatment. Category I 2HRZE/4HR
Extra-pulmonary TB, new (whether
Treatment After Patient who was previously treated for TB bacteriologically-confirmed or
Lost to Follow-up who was lost to follow-up for 2 months or clinically-diagnosed) except
(TALF) more in their most recent course of treatment CNS/bones or joints
and is currently diagnosed with either
bacteriologically-confirmed or clinically- Extra-pulmonary TB, new
Category Ia 2HRZE/10HR
diagnosed TB. (CNS/bones or joints)
Pulmonary or extra-pulmonary,
Previous Patients who have been previously treated
Previously treated drug-susceptible 2HRZES/1HR
Treatment for TB whose outcomes after their most Category II
Outcome TB (whether bacteriologically- ZE/5HRE
recent course of treatment are unknown or
Unknown (PTOU) confirmed or clinically-diagnosed)
undocumented.
Patients who don’t fit into any of the
Other
categories listed above.
*Prophylaxis and treatment for latent TB infection (LTBI) are not counted as anti-TB treatment

TUBERCULOSIS 8 of 14
 Extra-pulmonary, previously treated
Practice:
drug-susceptible TB (whether
2HRZES/1HR  A 30 yr old man no previous history of TB manifest with
Category IIa bacteriologically-confirmed or cough, with weight loss and fever, chest x ray is positive
ZE/9HRE
clinically-diagnosed – CNS/bones or for infiltrates in apex, sputum negative, diagnosis?
joints) - Category 1, Pulmonary TB, Clinically Diagnosed
ZKmLfxPtoC - Treatment: 6months.
s - Regimen: 2 months of Intensive phase, 4 months of
 Individualize Maintenance phase
Standard
d once DST  A 20 yr old female, no cough, no colds kaya lang may
Regimen enlarged lymph nodes sa inguinal area. On biopsy there
Rifampicin-resistant TB or Multidrug- result is
Drug- is caseation necrosis, no previous TB treatment.
resistant TB available
Resistant - Category 1, Extra Pulmonary TB (Site : Inguinal
 Treatment Lymph node), Clinically Diagnosed (Biopsy lang
(SRDR)
duration for kasi)
at least 18  A 60 year old HIV male patient, manifest with
months headache,nuchal rigidity, brudzinky and kernig. No hx of
Individualized previous tb treatment. On lumbar tap, TB culture
based on DST positive.
XDR-TB result and - Category 1a, ExtrapulmonaryTB (Site: CNS or
Extensively drug-resistant TB meninges), Bacteriologic (TB culture).
Regimen history of
previous  Decompensated liver cirrhosis. Which TB drug should
treatment you not give?
- Pyrazinamide because that is the most hepatotoxic.
 What do you think is the culprit, kasi after 1 month the
Category 1: All new cases, all virgin cases. Bagong patient manifest with tingling sensation sa fingers and
diagnosed na TB and nagtreat ka na pero nag stop ka na ng toes.
treatment for less than 30 days - Isoniazid. For isoniazid treatment. You should give
Category 1a: Kapag CNS, kagaya ng meninges, spinal patient with 25 mg/kg of your Vit B complex
cord or meron kang potts disease or meron kang TB sa sa  Anong gamot causes hypersensitivity reaction?
joints and bones. (ExtraPulmonary TB new cases) - Pyrazinamide
Category 2: Retreatment, Relapse. Ibig sabihin ay  Alin dito ang usually, hindi binibigay kapag nag dialysis?
naggamutan na dati. So non-viirgina na siya. “old cases”. Nag Category 1 ang patient, new case
stop ka na ng treatment for more than 30 days. - Ethambutol. Nagca-cause din siya ng kidney
Category 2a: Kapag CNS, joints, spines, and bones (old damage. Ang pinaka harmful sa kidney ay
cases, non virgin cases) Streptomycin but take note that in Category 1 wala
namang Streptomycin so it’s Ethambutol.

Treatment Category I (2HRZE/4HR) MONITORING RESPONSE TO TREATMENT

 Treatment response of PTB patients shall be monitored by
Continuation
Intensive Phase follow-up DSSM according to the standard schedule below:
Phase
2 months of (HRZE) A. Schedule of Follow-up DSSM for Category I Patients
Body Weight (Kg) 4 months* of (HR)
daily
daily
No. of tablets per day
30-37 2 2
38-54 3 3
55-70 4 4
>70 5 5
*10 months for Category Ia

Treatment Category II (2HRZES/HRZE/5HRE)

Continuation
Intensive Phase
Phase
Body
First 2 months Third month 4th to 8th month**
Weight  For new cases on Category I, follow-up DSSM shall be
HRZE HRZE
(Kg)
No. of
S
No. of
HRE done at the end of the intensive phase, at the end of the 5th
(1g/2mL) No. of tablets month, and at the end of treatment.
tablets tablets
30-37 2 2 2 1. If sputum (+) at the end of the intensive phase,
38-54 3 3 3 proceed to the continuation phase but repeat DSSM at
1g***
55-70 4 4 4 the end of the 3rd month.
>70
th th
5 5 5 a. If sputum (+) at the end of 3rd month, refer to a
**4 to 12 month for Category IIa
DOTS facility or an Xpert MTB/RIF site for testing.
*** For patients with BW <50kgs and those >60 yrs old consider 500-700mg or
10mg/kg/day Continue treatment while waiting.
b. If sputum (-) at the end of 3rd month, repeat
Duration for treatment for new cases is 6 months, for old cases, DSSM at the end of the 5th month.
more than 6 months.

TUBERCULOSIS 9 of 14
 2. If smear (+) at the end of 5th month, classify outcome
as treatment failed and refer to DOTS facility or an
Xpert MTB/RIF site for testing.
o If sputum (-) at 5th month, repeat DSSM at the end of
treatment.
3. If smear (+) at the end of treatment, classify outcome
as treatment failed and refer to DOTS facility or an
Xpert MTB/RIF site for testing.
o If sputum (-) at end of treatment, classify outcome as
cured or treatment completed.
B. Schedule of Follow-up DSSM for Category II Patients
 For retreatment cases on Category II, follow-up DSSM
shall be done at the end of intensive phase, at the end of
the 5th month, and at the end of treatment.
1. If smear (+) at the end of intensive phase, refer to
DOTS facility with PMDT services for screening. Start
continuation phase while waiting for recommendation.
o If sputum (-) at the end of the intensive phase,
repeat DSSM at the end of the 5th month.
2. If smear (+) at the end of 5th month, classify outcome
as treatment failed and refer to DOTS facility or an
Xpert MTB/RIF site for testing.
o If smear (-) at the end of 5th month, repeat DSSM at
the end of treatment.
3. If smear (+) at the end of treatment, classify outcome
as treatment failed and refer to DOTS facility or an
Xpert MTB/RIF site for testing.
o If sputum (-) at end of treatment, classify outcome as
cured or treatment completed.
Treatment
Outcome
Definition
 Bacteriologically-confirmed TB at the beginning of
treatment
Cured  Smear (-) or culture (-) in the last month of
treatment and on at least 1 previous occasion in
the continuation phase
 Patient who completes treatment.
 Without evidence of failure
 No records to show that smear or culture results
Treatment
in the last month of treatment and on at least 1
Completed
previous occasion were negative (either because
tests were not done or because results are
unavailable).
 Patient whose sputum smear or culture is (+) at 5
months or later during treatment
Treatment  Clinically diagnosed patient for whom sputum
Failed examination cannot be done and who does not
show clinical improvement anytime during
treatment.
Died  Patient who dies for any reason during the course
TUBERCULOSIS
of treatment.
Lost to  Patient whose treatment was interrupted for 2
Follow-up consecutive months or more.
 Patient for whom no treatment outcome is
Not assigned. (Includes cases transferred to another
Evaluated DOTS facility and whose treatment outcome is
unknown.)
Treatment
 The sum of cured and treatment completed.
Success
 PATIENT CARE AND SUPPORT
 Poor adherence to treatment is one of the most important
impediments to cure.
 The tubercle bacilli harbored by patients who do not fully
adhere to prescribed regimen are likely to become resistant
to the drugs to which they are irregularly exposed.
 Patient-related factors:
o Lack of belief that the illness is worth the cost of
adherence.
o Existence of concomitant medical conditions (notably
alcohol or substance abuse).
o Lack of social support
o Fear of the stigma and discrimination.
o Poverty, with attendant joblessness and homelessness.
 Provider-related factors: lack of support, education, and
encouragement of patients and inconvenient clinical
services.
 TREATMENT FAILURE AND RELAPSE
 Suspected when patient’s cultures (or sputum smears,
when cultures are not available) remain (+) after 3 months
of treatment.
 In management, it is imperative that the current isolate be
urgently re-tested for susceptibility to first-line agents and
second-line agents.
 DRUG-RESISTANT TB
 Arise by spontaneous point mutations in the mycobacterial
genome that occur at low but predictable rates (10-7-10-10).
 Mutations in the rpoB gene – resistance to rifampin
 Mutations in the katG gene and inhA gene promoter
region – resistance to isoniazid
 pncA gene – pyrazinamide
 embB gene – ethambutol
 gyrA-gyrB genes – fluoroquinolones
 rrs gene – aminoglycoside
o C-12T mutation in eis promoter region – most
common
 No cross-resistance among commonly used classes of drugs
o The probability that a strain will be resistant to 2 drug
classes is low
 Development of DR TB invariably follows monotherapy.
 Drug resistance is either primary or acquired:
1. Primary drug resistance – patient is infected from the
start by a drug-resistant strain
2. Acquired drug resistance – develops in infecting
strain during treatment.
 Prevented by adherence to the principles of sound
treatment:
o Inclusion of at least 2 quality-assured, bactericidal drugs
to which the organism is susceptible
o Use of fixed-dose combination products
10 of 14
 o Supervision of treatment with patient support Apply warm
4. Pain at the injection
o Verification that patients complete the prescribed Streptomycin compress. Rotate
site
course. sites of injection.
5. Peripheral Pyridoxine (Vit.
 MDR-TB (Multiple Drug Resistant – TB) Isoniazid
neuropathy B6)
o Any patients whose isolates exhibit resistance to 6. Arthralgia due to
rifampin with the addition of isoniazid if susceptibility Pyrazinamide Aspirin or NSAID
hyperuricemia
to this agent is confirmed via rapid testing or is 7. Flu-like symptoms Rifampicin Antipyretics
presumed. MAJOR
 XDR-TB (Extremely Drug Resistant – TB) Any kind
o Resistant to any fluoroquinolones and to any three 2nd 1. Severe skin rash Discontinue and
(especially
line injectable agents (amikacin, kanamycin, and (hypersensitivity) refer.
Streptomycin)
capreomycin) Any kind
Discontinue and
(especially
 For treatment of MDR-TB and all other rifampin-resistant refer. If subside,
2. Jaundice (hepatitis) Isoniazid,
TB cases in which isoniazid resistance is absent or resume and
Rifampicin &
unknown, two approaches are currently recommended by monitor.
Pyrazinamide)
WHO, 3. Visual acuity and
1. Shorter standardized regimen of 9-12 months color vision Discontinue and
duration Ethambutol
impairment (Optic refer.
o 7 drugs Neuritis)
o 4-6 months of kanamycin, moxifloxacin, 4. Ear problem,
clofazimine, prothionamide, pyrazinamide, high- Discontinue and
dizziness due to CN Streptomycin
dose isoniazid (10 mg/kg and up to 15 mg/kg), and refer.
8 problem
ethambutol 5. Oliguria/albuminuria Streptomycin/ Discontinue and
o Followed by 5 months of moxifloxacin, clozamine, (renal disorder) Rifampicin refer.
pyrazinamide, and ethambutol 6. Psychosis and Discontinue and
2. Long regimen of 18-24 months duration consisting of Isoniazid
convulsion refer.
an optimal combination of drugs according to a 7. Thrombocytopenia, Discontinue and
standard design Rifampicin
anemia, shock refer.
o At least 5 effective TB drugs during intensive
phase;
o should include pyrazinamide and 4 2nd line TB
DECIDING WHEN AN ADULT PTB PATIENT IS NO LONGER
agents – one from group A, one from group B, and
at least 2 from group C. INFECTIOUS DURING TREATMENT
 In situation where adult patient needs a certificate to return
 Patients with XDR-TB have fewer treatment options and to work, assess the patient’s infectiousness based on DSSM
much poorer prognosis. results and clinical improvement during treatment.
o As part of a patient-centered approach, palliative and
 For bacteriologically-confirmed adult patients, sputum
end-of-life care should be provided to these patients as
a priority when all treatment options have been microscopy exam can be done 1 month after start of
exhausted; respiratory infection-control measures treatment for purposes of certifying that the patient can
should be observed throughout return to work/school.
o The design of XDR-TB regimens follows the same o Issue a certificate that patient is no longer infectious
principles as in the Longer MDR-TB Regimen. and can safety return only after demonstrating sputum
smear (-).
Reintroduction of Anti-TB Drugs Following Drug Reaction
o No bacteriologically-confirmed case should be allowed
Likelihood Challenge Doses
to return to work without a negative follow-up smear.
Drug of Causing
a Reaction
Day 1 Day 2 Day 3  For clinically-diagnosed adult patients (smear (-) or smear
Isoniazid Least likely 50mg 300mg Full dose not done), it is possible to issue a certificate after 2 weeks of
Rifampicin 75mg 300mg Full dose appropriate and adequate therapy for as long as treatment
Pyrazinamide 250mg 1000mg Full dose compliance is assured and there is clinical improvement.
Ethambutol 100mg 500mg Full dose
Streptomycin Most likely 125mg 500mg Full dose MANAGEMENT OF CASES WHO INTERRUPTED TREATMENT
Do DSSM if How long has
Length of
>1 Month patient been Disposition
MANAGING ADVERSE DRUG REACTIONS DURING TREATMENT interruption
Interruption treated?
*FAMILIARIZE/MEMORIZE* <1 month Continue treatment and prolong to compensate
Drug(s) probably (-) DSSM Continue treatment and prolong to
Adverse Reactions Management compensate
responsible
MINOR >1 month (+) DSSM <5 months Continue
Rifampicin/ Give drugs at treatment and
1. Gastro-intestinal prolong to
Isoniazid/ bedtime or with
intolerance compensate
Pyrazinamide small meals.
2. Mild or localized >5 months Classify as
Any kind of drugs Anti-histamines Treatment
skin reactions
3. Orange/red colored Failed
Rifampicin Reassure patient >2 months Classify as Lost to Follow-up
urine

TUBERCULOSIS 11 of 14
TREATMENT MODIFICATIONS FOR SPECIAL SITUATIONS
Pregnancy
 Most anti-TB drugs are safe except Streptomycin, which is
ototoxic to the fetus.
o Successful treatment of TB with the recommended
standardized treatment regimen (2HRZE/4HR) is
important for a successful outcome of pregnancy.
o Isoniazid should be taken with Pyridoxine (Vit B6) at 25
mg/day.
Breastfeeding
 Should receive a full course of TB treatment
Extrapulmonary Tuberculosis
o Effects of exposure to anti-TB drugs found in breast
milk on infants have not been established.
o Feed infants before taking medications
o Supplemental Pyridoxine (Vit B6) given at 5-10 mg/day
when taking INH.
Oral Contraceptives
 Rifampicin interacts with oral contraceptives medications
with a risk of decreased protective efficacy against
pregnancy
o Take an oral contraceptive pill containing higher dose of
estrogen (50u), following consultation with a clinician;
o Use another form of contraception
Liver disease or History of Liver disease
 Isoniazid, Rifampicin, and Pyrazinamide are associated
with hepatitis. Rifampicin least, Pyrazinamide most
hepatotoxic.
BCG VACCINATION
o Treatment should be interrupted and a modified or
alternative regimen used: ALT elevation >3x upper limit
+ hepatitis symptoms and/or jaundice OR ALT elevated
5x with no symptoms
o Wait for liver function test to revert to normal and clinical
symptoms to resolve
o Once resolved, drugs are reintroduced, starting with
Rifampicin; after 3-7 days, Isoniazid; avoid
Pyrazinamide.
o If symptoms recur, last drug added should be stopped.
Established Chronic Liver Disease
 Should not receive Pyrazinamide
o Alternative: 2SHRE/6HR, 9RHE, or 2SHE/10SE
Acute Hepatitis
 Uncommon; clinical judgment necessary
o Safest option is the combination of 3SE, once hepatitis
resolved, continuation phase of 6HR; if not, 12SE.
Renal Failure
 Should receive Isoniazid with Pyridoxine to prevent
peripheral neuropathy.
o Streptomycin, Ethambutol and metabolites of
Pyrazinamide are excreted by the kidney; doses
should be adjusted.
o If possible, Streptomycin should be avoided.
TB/HIV co-infection
 Priority is to treat TB.
o Can have Anti-Retroviral Therapy (ART) and anti-TB at
the same time; with careful management
o Should also receive Co-Trimoxazole as phrophylaxis for
other infections.
 All HIV-infected TB patients, regardless of CD4+ T
cell count, are candidates of ART, and initiated as soon
TUBERCULOSIS
as possible after the diagnosis of TB and within the
first 8 weeks of anti-TB therapy.
- ART should be started within the first 2 weeks of
TB treatment for profoundly immunosuppressed
patients with CD4+ T cell counts <50/µL.
 Adverse drug reactions may be more pronounced in
HIV-infected patients. Consider relevant:
- Increased frequency of paradoxical reactions
- Interactions between ART and rifamycins
- Development of rifampin monoresistance with
intermittent treatment.
● The exception to the statement is tuberculous meningitis for
which experts recommend treatment duration of 9-12
months [Grade C].
 ADJUNCTIVE THERAPY
o Immunomodulators (not recommended)
o Micronutrient and vitamin supplementation
- Arginine, vitamin A and zinc are beneficial in HIV
negative patients with smear-positive PTB
 Initiation Phase: 2HRZE
 Continuation Phase: 4-7HR
PREVENTION
 Diagnose and isolate infectious cases rapidly
 Administer appropriate treatment until patients are rendered
noninfectious (usually 2-4 weeks after the start of proper
treatment) and the disease is cured
 Additional:
 Derived from an attenuated strain of M. bovis
 First administered to humans in 1921
 Vary in efficacy, from 80% to nil.
 Higher rates of efficacy in the protection of infants and young
children from serous disseminated forms of childhood TB.
 Safe and rarely causes serious complications.
 Local response begins 2-3weeks after vaccination, scar
formation and healing within 3 months.
 Side effects (1-10%):
o Ulceration at the vaccination site
o Regional lymphadenitis
o Osteomyelitis (~1 case/M)
o “BCGitis” and death (1-10 cases per 10M)
 Recommended for routine use at birth in countries or among
populations with high TB prevalence.
 Over the past decade:
 MVA-85A vaccine – modified poxvirus-vectored
vaccine that expresses immune-dominant M.
tuberculosis Ag 85A
- Result was well tolerated and modestly
immunogenic but did not confer
significant protection
 As of late 2017, 12 candidate vaccines in clinical trials.
NOTES
 Patient with Pulmonary TB kelangan ba niya magsuot ng
surgical mask?
- Yes, Patient should wear surgical mask
 Should your patient wear N95?
- No need, N95 would prevent the 95% from being
inhaled
 Healthcare workers should wear N95
 You gave this patient 3 surgical mask to wear. Is it advisable?
- No
 Itong nurse or doc, nka N95 na naka mask pa sa loob. Or
handkerchief?
- Not advisable
 N95 has fit requirement kaya tayo may tinatawag na fit test
because N95 mask comes with sizes of
 How would you know that n95 fits sa face mo?12 14
- There’s what we call blow and suck test.
 LATENT TUBERCULOSIS INFECTION
PRINCIPLES
 An estimate of 1.7B people, more that ¼ of human
population, have been infected with M. tuberculosis
o Small fraction will progress toward active disease in a
lifetime
 No gold-standard diagnostic test that confirm true infection
or predict individuals with LTBI who will develop active TB
 High-risk groups can only be presumed identified by
Tuberculin Skin Test or IGRA.
What is a latent TB?
- Kapag nag positive sa PPD more than 10 mm. it
means that this px has been expose to the past.
This patient is infected but this patient has a very
good cell mediated immunity.
What is the treatment for latent TB?
- It’s your isoniazid. New guidelines: 6 months
(old: 9 months)
Preventive chemotherapy or Chemoprophylaxis
TUBERCULOSIS
 Skin Testing:
o 5 tuberculin units of polysorbate-stabilized PPD
should be injected intradermally into the volar surface of
the forearm (Mantoux method)
o Multipuncture tests not recommended.
o Reactions are read at 49-73 hours as the transverse
diameter (mm) of induration; diameter of erythema not
considered.
Immunocompromised patients,No active TB but never
treated for TB. You want to do prophylaxis, you want to
prevent TB.
- Also give Isoniazid. Give 300 mg 1 tab daily for 6
months (IPT- Isonizid Prophylactic Therapy)
TB CONTROL
● Prompt detection of cases and the provision of short-course
chemotherapy to all TB patients under proper case-
management conditions, including directly observed therapy.
● Screening of high-risk groups
○ immigrants from high-prevalence countries,
migratory workers, prisoners, homeless individuals,
substance abusers, and HIV-seropositive persons
● Measure to prevention of transmission of TB
○ Respiratory isolation of persons with suspected TB
until they are proven to be noninfectious
○ Proper ventilation in rooms of patients with
infectious TB
○ Use of ultraviolet irradiation in areas of increased
risk of TB transmission
○ Periodic screening of personnel who may come
into contact with known or unsuspected cases of
TB.
Latent TB infection: kelan ka lang magtetreat ng latent
TB? Kelan mo lang sila I-screen?
- Kapag sila na ay Exposed, Immunocompromised,
Nakakulong, HIV, Transplant patient, Diabetic
patient, Hepatitis patient na may cirrhosis, you have
high risk group. Give them Isoniazid Prophylaxis
Therapy (IPT)
Ex. mat TB ka ngayon, chest x-ray positive, sputum
positive, kelan kita papabalikin sa work?
- After 2 weeks of continuous treatment. A case of a
bacteriologically confirmed TB pwede ng bumalik sa
work.
Ex. Pano kung wala kang plema na maidahak pero tinira
ka ng TB treatment? Ilang days bago kita pabalikin sa work?
- It’s 5 days. Kapag clinically diagnosed case ka lang
ay 5 days of continuous treatment. You can already
be cleared to go back to work.
Ex. Pano kung na treat ka na before tapos need mo ng
clearance. X-ray may fibrosis. You have to make sure that is
not an active TB.
- Sputum exam pa rin test.
Ano yung isa pang test na pwede mong iorder aside from
chest xray?
- CT scan. Will not show you specific feature of TB,
but will show you tree in a bud appearance. Kung
wala naman na ganitong appearance. Then that’s
the time you clear the patient.
-
13 of 14
DOTS
● DOTS approach consists of
○ Political commitment with increased and sustained
financing
○ Case detection through quality-assured
bacteriology
● Microscopic examination of sputum from patients with
cough of >2–3 weeks' duration, culture, and possibly
drug susceptibility testing
○ Administration of standardized short-course
chemotherapy, with direct supervision and patient
support
○ Effective drug supply and management system
○ Monitoring and evaluation system, with impact
measurement
■ including assessment of treatment
outcomes

NATIONAL LEVEL

APPENDIX

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REFERENCES
1. Harrison’s Internal Medicine 20th ed.
2. DOH- National Tuberculosis Control Program, MOP 5th ed.
3. Recordings
4. Chewie Trans

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