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Tuberculosis
Presenter: Kogilavani Mani ( Kogi )

Epidemiology
In Malaysia, Sabah has recorded the
highest number of TB cases followed by Selangor in the year of
2023
In the year 2023, a total 5,814 cases of tuberculosis were reported in
Sabah, followed by Selangor 5,631 cases and Sarawak with 3,177
cases.
The district with the highest TB cases was Kota Kinabalu with 793
cases followed by Sandakan 485 cases, Tawau 445 cases, Lahad Datu
353 cases, Semporna 334 cases and Keningau 277 cases. The other
district only reported less than 200 cases per year.
Source: Sabah Handbook on Management of TB

Introduction
Etiology
Mycobacterium
tuberculosis
Mode of
transmission
inhalation of infected
aerosolized droplets.
" It mainly affects the lungs,
making pulmonary disease the
most common presentation "
" Tuberculosis can affect every
organ in the body except nail,
hair and teeth "
Tuberculosis

Approach to patient suspected with TB

Presentation
Extrapulmonary symptoms
GIT:Abd. pain, diarrhoea, bloating
CNS: Headache, focal neurology deficit
CVS: chest pain, failure symptoms
Bone/Joint: swellings, fractures, discharging sinus.
Larynx: hoarseness of voice, odynophagia, dysphagia
Constutional symptoms
1.Prolonged Fever
? Low grade fever
2. Night sweats
3. Loss of weight and
loss
of appetite
Risk factors
? Any h/o close contact
with PTB patients
? High risk behaviour:
Subtance Abusers, h/o
multiple partners
? Active smokers
? Overcrowded
conditions: prison,
shelters, immigrants
Respiratory symptoms:
? Prolong cough
? Chest pain
? SOB
? Hemoptysis

Examination
Physical examination findings associated with TB depend on the organs
involved.
General condition:
Cachexic, lethargic looking, tachypneic
Pulmonary TB
Palpation: Reduced chest expansion,
increased vocal fremitus
Percussion: Dull
Auscultation: Bronchial breath,
Increased vocal resonance
Signs of extrapulmonary TB
Differ according to the organs involved

What is a ghon focus?
A Ghon focus is a primary lesion usually subpleural, often in the mid to lower zones, caused by Mycobacterium
bacilli (tuberculosis) developed in the lung of a nonimmune host (usually a child). It is named for Anton Ghon
(1866–1936), an Austrian pathologist.
Approximately three weeks after the initial infection, more specific immune cells (e.g., T cells, B cells,
and Neutrophils) surround the site of TB infection, creating a wall of immune cells known as a granuloma, which
isolates the bacteria and prevents it from spreading. The tissue inside the granuloma then dies during a process
referred to as caseous necrosis, or cheese-like necrosis. This necrotic area is known as a Ghon focus.
TB infection can also spread to nearby hilar lymph nodes, either carried through the lymph or by
direct extension of the Ghon focus. Together, the caseating tissue and associated lymph node involvement make
up the characteristic “Ghon complex.”

Sometimes, the Ghon complex can present similarly to the “Ranke
complex,” which is a later manifestation of the Ghon complex that forms
when the granuloma undergoes fibrosis, and often calcification. On
chest X-ray, the Ranke complex is characterized by the presence of a
calcified Ghon lesion along with same side calcified mediastinal lymph
nodes.

The usual location for Ghon focus is the
apical segment of right lower lobe.
?Ghon complex comprising Ghon focus
and right hilar lymphadenopathy plus
pleural effusion.

The combination of late fibrocalcific lesions of
the lung and lymph node which evolved from
the Ghon complex is referred to as the “Ranke
complex”
Ranke Complex. There is a combination of a
calcified peripheral granuloma (black arrow)
and a calcified hilar lymph node (white
arrow) on the same side. Several other, small
calcified granulomas are seen in the right
mid-lung field.

? Parenchymal opacities –
heterogeneous opacities most
commonly in apical and posterior
segmental upper lobes and the
superior segment of the lower lobes.
? Cavitation and Air-fluid levels
? Bronchogenic spread
Chest X-ray of our patient at the time of
admission

TypIcal features Of prImary PTB
consolidation of the upper zone
with ipsilateral hilar enlargement
due to lymphadenopathy

GRADING OFPULMONARY TUBERCULOSIS SEVERITY BASED ON
CHEST RADIOGRAPH IN ADULTS (1/3)
Minimal
● Minimal lesions
confined to a small part
of one of both lungs
● total extent of the lesions
should not exceed the
volume of the lung on
one side.

GRADING OFPULMONARY TUBERCULOSIS SEVERITY BASED
ON CHEST RADIOGRAPH IN ADULTS (2/3)
Moderately Advanced
● One of both lungs may be involved but the total extent of the
lesions should not exceed the following limits:
○ Disseminated lesions of minimal to moderate density not
exceeding the total volume of one lung of the equivalent in
both lungs
○ dense and confluence lesions not exceeding one third of
the volume of one lung
○ Total diameter of cavitations, if present, must be <4
cm.

GRADING OF PULMONARY TUBERCULOSIS SEVERITY BASED
ON CHEST RADIOGRAPH IN ADULTS (3/3)
Far Advanced
Lesions are more
extensive than
moderately
advanced

CXR
Example of patient’s CXR

Sputum AFB
Example of lab result
Microscopic evaluation of sputum for acid-
fast bacilli begins with making a smear

What if the AFB is Negative?
Always ensure satisfactory specimen

MTB GeneXpert
? Able to simultaneously detect MTBC
and Rifampicin resistance
? Sputum should be sent for MTB
GeneXpert if smear negative PTB is
suspected.
? In 2020, WHO recommended that
this test be used as the first line TB
screening test, however this is not
feasible as yet in Sabah due to steep
testing costs.

Investigations
PTB Specific Investigations Other investigations Investigations for Extra-PTB
1. Sputum AFB
- x1, x2, x3
2. Mycobacterial culture and
sensitivity
* Taken at initiation of TB treatment
* To confirm presence of
Mycobacterium Tuberculosis
* To test for drug sensitivity
LTAT for culture is 14 days while LTAT
sensitivity is 42 days to 68 days
3. MTB GeneXpert
4. Sputum LPA ( Line Probe
Assay )
- is another molecular method and
relatively fast in determining Isoniazid and
Rifampicin resistant
- Indication:
a. Persistant smear positive despite after
2month of effective regime
b. Prior to MDR regime initiation (to
determine mutation )
c. Newly diagnose PTB smear positive
patient with positive contact with Isoniazid
resistant index.
5. Imaging
– CXR
1.Blood
Baseline
? FBC, RP, LFT,CRP,ESR
TRO
immunocompromised
state
? Infective screening
? FBS
2. Urine
- UPT ( all female
childbearing ages )
1. CNS
* Contrasted CT brain
* Lumbar puncture
- MTB GeneXpert
- AFB
- MTB C&S
2. Spine
* CT/MRI Spine
* Tissue for HPE MTB C+S
* Pus
- AFB
- MTB C+S
- MTB GeneXpert
3. Pericardium
* Echocardiography
* Pericardial tapping
- AFB
- MTB C+S
- MTB GeneXpert
4. Abdomen ( Liver, Gut,
Peritoneum )
* Ultrasound Abdomen
* CECT Abdomen if needed
* Colonoscopy
* Tissues for HPE & MTB C+S
5. Lymph node
* Lymph node FNAC and/or
biopsy
- HPE & MTB C+S
6. Pleural
* Pleural fluid ADA
* MTB C+S
* AFB

Treatment for new case
Six-month regimen consisting of two months of daily EHRZ* (2EHRZ) followed by four
months of daily HR* (4HR) is recommended for newly-diagnosed PTB
Pyridoxine 10 mg OD is also prescribed
to prevent peripheral neuropathy
caused by Isoniazid

Treatment for new case
After measuring latest body weight, attending clinician should round ATT dosage
to nearest available preparation (highest range is preferred for H & R)

Refer to Opthal Clinic for Eye Assessment
Ethambutol
ADR: Optic neuritis
- decrease in visual acuity, red- green colour blindness, blurring and central scotoma.
Snellen’s Chart Ishihara

Duration of ATT
will depend on severity or site of infection.
All EPTB cases in Sabah
should be referred to
Infectious Disease (ID) team
for optimum regime &
duration of treatment.

Steroid
? is required for TB meningitis and TB pericarditis.
? It can improve symptom and survival

So until when do we keep the patient?
By right, we can allow discharge and continue follow up in JPL, if:
1.
- Patient is clinically well
- Sputum smear conversion
* Sputum AFB is repeated @ 2 weeks after ATT initiation
* Indicating response to ATT
* Reduces risk of transmission
2.
* If patient has an isolated room in his/her house
* Clinically well

Directly observe therapy (DOT)
Every clinician managing TB should ensure all TB
patient that on ATT treatment need to undergo DOT
to optimised management of TB.

Problems During
Follow Up
Common problems encountered in managing TB are:
? Adverse drug reaction:
-Drug-induced liver injury(DILI)
- Drug-induced rash(DIR)
- Other common adverse drug reactions(ADR)
? Delay conversion
? Treatment interruption

Drug Induced Liver Injury ( DILI )
The most important aspect of DILI management is that the clinician should know when to
stop and how to rechallenge.
The most common drug causing transaminitis are as below:
? Pyrazinamide
? Isoniazid
? Rifampicin
Cases should be divided into symptom and/or severity of transaminitis. Healthcare providers
should be aware that the initial presentation of DILI could be as mild as:
?Abdominal pain
?Nausea
?Vomiting
?Lethargy
?Jaundice will usually increases later as severity increase.

Resources
? Adigun R, Singh R. Tuberculosis. [Updated 2023 May 14]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK441916/
? Das S, Das D, Bhuyan UT, Saikia N. Head and Neck Tuberculosis:
Scenario in a Tertiary Care Hospital of North Eastern India. J Clin Diagn
Res. 2016 Jan;10(1):MC04-7. doi: 10.7860/JCDR/2016/17171.7076. Epub
2016 Jan 1. PMID: 26894099; PMCID: PMC4740627.
? Sabah Handbook on Management of Tuberculosis, 2021
? CPG Management of Tuberculosis, 4th Edition

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