TUBERCULOSIS
17.2.2023
INTRODUCTION
Tuberculosis (TB) is caused by bacteria called
Mycobacterium tuberculosis.
Most of the people who fall ill with TB live in low-
and middle-income countries, but TB is present all
over the world. About half of all people with TB
can be found in 8 countries: Bangladesh, China,
India, Indonesia, Nigeria, Pakistan, Philippines and
South Africa.
HIV positivity is another well recognized risk
factor.
Two TB-related conditions : latent TB infection
(LTBI) & TB disease.
Estimated that upto13 million people in US have
LTBI.
People with LTBI do not have signs & symptoms of
TB disease and they cannot spread M. tuberculosis to
others.
If not treated for LTBI, about 5-10 % of infected
people will develop TB disease over their lifetimes.
HOW TB SPREADS
Spreads through the air from one person to
another.
TB is not spreads by
- shaking hands
- sharing food or drinks
- touching bed linens or toilet seats
- sharing toothbrushes
- kissing
LATENT TB INFECTION
Have no symptoms
Don’t feel sick
Can’t spread TB bacteria to others
Usually have a positive TB skin test reaction or
positive TB blood test
Usually have normal chest x-ray
May develop TB disease if they do not receive
treatment for latent TB infection
TB DISEASE
Has symptoms that may include
a bad cough that lasts 3 weeks or longer
pain in the chest
coughing up blood or sputum
weakness or fatigue
weight loss
no appetite
chills
fever
sweating at night
May spread TB bacteria to others
Usually has a skin test or blood test result indicating
TB infection
May have an abnormal chest x-ray, or positive sputum
smear or culture
Needs treatment to treat TB disease
THE RELATIONSHIP BETWEEN
PREGNANCY AND TB
Pregnancy has no impact on the course of TB.
If TB is diagnosed and treated properly, it has no
significant impact on pregnancy.
Delayed or inadequate therapy would be affected to
maternal and fetal outcomes such as increasing the
risks of prematurity and intrauterine growth
restriction.
Presentation and diagnosis are unaffected by
pregnancy, although misguided reluctance in
performance may lead to further diagnostic delay.
Vertical transmission (congenital TB) is extremely
rare and usually occurs only where maternal disease
has been untreated.
Lateral transmission from the mother or other close
contacts, occurring after delivery is a much more
likely cause of infant infection.
One of the following criteria is necessary for the Dx
of congenital TB :
lesions in the first week of life;
a primary hepatic complex or caseating granuloma;
histological evidence of placental or endometrial
involvement;
absence of TB in other careers of the child.
Congenital TB usually presents with fever,
lymphadenopathy, hepatosplenomegaly and
respiratory distress.
It is fatal in one in five cases.
In only half of all cases has the diagnosis of maternal
TB already been made.
CLINICAL FEATURES
Symptoms
The onset is usually insidious and symptoms
include:
Cough
Haemoptysis
Weight loss (or failure to gain weight)
Night sweats
Signs
Can cause any chest signs.
It most typically affects the upper lobes, with coarse
crackles, dullness on percussion or in advanced case
or old cases, signs of fibrosis with deviation of the
trachea towards the side of infection.
Extra-pulmonary sites include:
- lymph nodes
- bone
- liver and spleen
- bone marrow
- caecaum
- central nervous system (CNS)
- eye (choroidal tubercles)
DIAGNOSIS
This can be challenging.
It is suggested by typical appearances on a CXR.
Diagnosis may be confirmed by sputum examination
for acid-fast bacilli (Ziehl-Neelsen stain).
Culture of the organism takes about 6 weeks.
If there is no sputum, washings from bronchoscopy
must be obtained.
The Mantoux test (0.1ml of 10 tuberculin units of
purified protein derivatives of M. tuberculosis) is not
affected by pregnancy.
For non-pulmonary TB, diagnosis relies on
polymerase chain reaction or culture from biopsy
tissue.
Diagnostic blood tests include interferon-gamma
release assays such as the enzyme-linked immunospot
assays and Quantiferon-TB.
These blood tests distinguish from Bacille Calmette-
Gurein (BCG).
They have greater specificity for diagnosing latent
rather than active TB.
MANAGEMENT
The principles of management are similar in
pregnant and non-pregnant women.
Untreated TB represents a greater hazard to
pregnant women and their fetuses than the
treatment itself.
The specialist advice of a respiratory consultant
is essential.
Pregnant mothers with TB should be treated
without delay.
TREATMENT FOR LATENT TB
INFECTION AND PREGNANCY
For most pregnant women, treatment for LTB
infection can be delayed until 2-3 months post-
partum to avoid unnecessary medication during
pregnancy.
For women who are at high risks from LTBI to
TB disease, treatment for LTBI should not be
delayed on the basis of pregnancy alone, even
during the first trimester.
TB TREATMENT REGIMENS FOR PREGNANT
WOMEN
Diagnosis Treatment
Latent TB • 4-month daily regimen of rifampin (RIF)
infection • 3-month daily regimen of isoniazid (INH) and
RIF
• 6 or 9-month daily regimen of INH, with
pyridoxine (Vit B6) supplementation
• The 3-month weekly INH and rifapentine
regimen is not recommended for pregnant
women or women expecting to become pregnant
during the treatment period because its safety
during pregnancy has not been studied
TB Disease • The preferred initial treatment regimen is INH,
RIF and ethambutol (EMB) daily for 2 months,
followed by INH and RIF daily, or twice weekly
for 7 months (for a total of 9 months of
treatment)
• Streptomycin should not be used because it has
been shown to have harmful effect on the fetus
(fetal ototoxicity).
• Pyrazinamide (PZA) is not recommended to be
used because its effect on the fetus is unknown.
HIV-Related • Treatment of TB disease for pregnant women
TB Disease co-infected with HIV should be the same as non-
pregnant women, but with attention given to
additional considerations.
Liver function should be monitored monthly because
of the risk of isoniazid and rifampicin-related
hepatotoxicity.
In the event of the transaminases more than double,
all anti-tuberculous treatment should be temporarily
withdrawn and then individual agents introduced in a
stepwise fashion while liver function tests are
monitored closely.
POTENTIAL RISKS TO THE FETUS OF
ANTI-TUBERCULOUS TREATMENT
Rifampin, isoniazid and ethambutol are safe to use in
pregnancy.
All the patients taking isoniazid should also be
prescribed pyridoxine (Vitamin B6) 50mg/day to
reduce the risks of peripheral neuritis.
Streptomycin has been associated with a high
incidence of 8th nerve damage (>10%) and should
therefore be avoided throughout the pregnancy.
POST NATAL CARE
The mother usually becomes non-infectious within 2
weeks of beginning treatment.
In the rare circumstances of active and infectious
(sputum-positive) TB in late gestation or at the time of
delivery, the neonate must be unfortunately separated
from the mother until she is no longer infectious.
In this circumstances, the neonate should also be
given INH to prevent acquiring neonatal infection.
Breastfeeding should not be discouraged for women
being treated with INH, ethambutol and/or rifampin.
These agents are only found in small concentrations in
breast milk and are not known to produce toxicity in
the newborn.
These concentrations are also not significant enough
to provide any protection to the infant from infection
with TB.
DRUG-RESISTANT TB
Pregnant women who are being treated for drug-
resistant TB should counseling concerning the
risk to the fetus because of the known and
unknown risks of second-line anti-tuberculous
drugs.
