NOTES

NOTES
TUBERCULOSIS

MICROBE OVERVIEW
▪ Tuberculosis (AKA Mycobacterium ▫ Staining: acid-fast stains like Ziehl–
tuberculosis) mycobacterium that primarily Neelsen, fluorescent stains like
infects lungs but may infect any bodily auramine/rhodamine
organ/tissue ▪ Clumped colonies
▪ Important properties ▪ Distinctly slow growing (up to 6 weeks for
▫ Curved rod shaped bacteria often visible growth)
wrapped together in cord-like ▪ Grown on Lowenstein–Jensen media
formations ▪ Resistant to weak disinfectants, can survive
▫ Obligate aerobe on dry surfaces for months
▫ Impervious to Gram staining due to ▪ Can avoid mucus traps, getting into deep
waxy cell wall composed of fatty acids airways (alveoli)
(e.g., mycolic acid)

MYCOBACTERIUM TUBERCULOSIS
osms.it/mycobacterium-tuberculosis
fusion → bacteria survives, proliferates,
PATHOLOGY & CAUSES creates localized infection → primary
tuberculosis development
TYPES ▫ TB infiltrated macrophage fusion →
Primary tuberculosis Langhans giant cells
▫ Cell-mediated immunity activation →
Reactivation tuberculosis granuloma forms within infected area →
▪ In about 5–10% cases of primary TB caseous necrosis inside granuloma →
Ghon focus
Extrapulmonary tuberculosis ▫ Lymphatic dissemination of TB → lymph
▪ May involve any organ (most commonly node caseation
kidneys, meninges, lymph nodes, etc.) ▫ Ghon focus + involved lymph node →
▪ Systemic miliary tuberculosis Ghon complex
▫ Ghon complex fibrosis, calcification →
STAGING Ranke complex
▪ Transmitted by inhaling infectious aerosol ▪ Primary infection resolution
droplets from individual with active TB (e.g. ▫ Mycobacteria killed by immune system
coughing, sneezing, speaking, etc.) ▫ Bacteria walled off in granuloma
▪ TB enters lungs, gets phagocytized by remains dormant but viable →
macrophages → TB produces enzymes that latent tuberculosis with no further
inhibit lysosome and phagocytic vacuole complications in immunocompetent

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 individuals
▪ Compromised immune system → more
caseous necrosis areas → cavity formation
→ reactivation tuberculosis

RISK FACTORS
▪ Immunocompromised states
▫ HIV
▫ Diabetes mellitus
▫ Hematologic malignancy
▫ Chronic lung disease (especially
silicosis)
▫ Malnutrition
▫ Aging
▪ Substance abuse
▫ Alcoholism Figure 105.1 The gross pathological
▫ Injection drug users appearance of a Ghon focus.
▪ Close contact with individuals with active
TB infection
▫ Healthcare providers
SIGNS & SYMPTOMS
▫ Incarceration
▪ Lower-income, medically underprivileged ▪ Primary tuberculosis
countries
▫ Usually asymptomatic (90-95% of
▫ Recent immigrants from high- cases)
prevalence countries
▫ Mild flu-like illness
▫ Rarely pleural effusion
COMPLICATIONS ▪ Reactivation tuberculosis
▪ Bronchopneumonia ▫ Constitutional symptoms (fever, chills,
▪ Pneumothorax night sweats, fatigue, appetite loss,
▪ Extrapulmonary tuberculosis weight loss, pleuritic chest pain)
▫ Kidney → dysuria, pyelonephritis with ▫ Cough (dry cough, prolonged
sterile pyuria cough producing purulent sputum,
▫ Meninge → meningitis hemoptysis—suggesting advanced TB)
▫ Lumbar vertebrae → Pott disease ▫ Crepitations during lung auscultation
▫ Liver and gallbladder → hepatitis, ▪ Extrapulmonary tuberculosis
obstructive jaundice ▫ Depending on affected organ/tissue
▫ Lymph nodes → cervical tuberculous ▪ Miliary (disseminated) tuberculosis
lymphadenitis (scrofula) ▫ Can affect any organ (e.g. choroidal
▫ Peritonitis tubercles in eye, granulomas within
▫ Pericarditis organs)
▪ Systemic infection ▫ Weight loss
▫ Fever, chills
▫ Dyspnea

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 Chapter 105 Tuberculosis

Antibiotic resistance
DIAGNOSIS ▪ Multiple-drug-resistant TB
▫ Resistant to isoniazid and rifampin
DIAGNOSTIC IMAGING ▪ Extensively drug-resistant TB
▫ Resistant to both isoniazid and rifampin,
Chest X-ray
any fluoroquinolone, at least one
▪ Used in PPD/IGRAs positive second-line drug
▪ Ranke complex → sign of healed primary
TB
▪ Cavities → active TB sign

LAB RESULTS
PPD intradermal skin test (tuberculin test)
▪ Screening test for people at high risk for TB
▫ Tuberculin injection between dermal
layers, induration area measurement
within 48–72 hours
▪ Induration area ≥ 5mm: positive in
immunocompromised individuals, persons
with primary TB radiographic evidence/
close contact with those with active TB
▪ Induration area ≥ 10mm: positive in
residents/immigrants from high-prevalence
countries, children > four years of age, high Figure 105.2 An X-ray image of the chest
risk populations (e.g., medical employees) demonstrating diffuse interstitial granular
▪ Induration area ≥ 15mm: considered densities in an individual with milliary
positive in individuals with no known risk tuberculosis.
factors
▪ Cannot be used for differentiation between
active and latent TB
▪ PPD result interpretation
▫ Positive → exposure evidence
▫ False-positive → previously immunized
with BCG vaccine
▫ Negative → no exposure evidence
▫ False-negative → sometimes seen
in individuals with sarcoidosis,
malnutrition, Hodgkin’s lymphoma

Sputum testing
▪ Used for definitive diagnosis
▪ Staining, culture, PCR

OTHER DIAGNOSTICS
Figure 105.3 Multifocal patchy opacities
Interferon gamma release assays (IGRAs)
in the right upper lobe of an individual who
▪ Alternative for PPD presented with night sweats, weight loss and
▪ Unlike PPD, doesn’t show false-positive persistent cough. The presenting symptoms
results in BCG vaccinated and radiological appearance are consistent
with pulmonary tuberculosis.

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 TREATMENT
MEDICATIONS
▪ Prophylactics
▫ BCG vaccine (some countries)
▪ Latent TB
▫ Isoniazid for 9 months
▪ Active TB
▫ First line anti-TB drugs: isoniazid,
rifampin, pyrazinamide, ethambutol/
streptomycin
▪ Antibiotic resistance
Figure 105.4 The histological appearance
▫ For multiple-drug-resistant TB, of a tuberculosis granuloma. The granuloma
treatment requires second-line drugs is formed of epithelioid macrophages and
(amikacin, kanamycin, capreomycin) giant cells with a focus of caseating necrosis
at the centre and a rim of lymphocytes at the
OTHER INTERVENTIONS periphery.
▪ Active TB
▫ Compulsory isolation (until sputum
negative for TB)

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