YL7

PULMONARY MODULE [CLINICAL MEDICINE]

OUTLINE
I. Introduction
A. Millennium Development Goals
B. Global Situation
C. Philippine Situation
II. Mycobacterium tuberculosis
III. Transmission
IV. Factors Affecting Tuberculosis
V. Symptoms of TB
VI. Differential Diagnoses
VII. Diagnosis of TB Diseases
VIII. Treatment
IX. DOTS Program
X. WHO Strategy
XI. QUIZ!!!

I.

I N T R O D U C T I O N
A.

B.

Millennium Development Goals

1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower women
4. Reduce child mortality
5. Improve maternal health

6.

Combat HIV/AIDS, malaria, and other diseases

7.
8.

Ensure environmental sustainability

Develop a global partnership for development

Global Situation

1
2
3
4
5
6
C.

18 July 2011

Pulmonary Tuberculosis

1% increase in global TB incidence annually

1 in 10 people infected with TB bacilli will progress to
active disease (Risk is higher if immunoccompromised)
2 million deaths annually due to TB
2 billion people infected with TB bacilli
3 leading causes of 6 million deaths annually (HIV/AIDS,
malaria, TB)
4 of 10 (40%) TB cases not properly detected and treated
(Do doctors follow guidelines and protocols? Are the
patients being advised/educated well?)
5% of all TB cases have MDR-TB
(Current statistics: almost 15%)
th
6 leading cause of mortality in the Philippines
6 countries that contributed to half of all new cases
(Bangladesh, China, India, Indonesia, Pakistan,
Philippines)

Philippine Situation
Table 1. TB in the Philippines (2007)
Population in thousands
87,960
Incidence of all TB*
255
New sputum smear*
115
Prevalence of all TB*
36
MDR-TB

Among new cases (%)
4
Among previously treated cases (%)
21
DOTS Coverage (%)
100
Treatment Success (%)
88

Evelyn Victoria E. Reside

Table 2. Philippine Situation: Causes of Mortality, All Ages (2010)

Ilocos
Cagayan Valley
Central Luzon
1. Cardiovascular 1. Cardiovascular
1. Cardiovascular
diseases
diseases
diseases
2. Pneumonia
2. Pneumonia
2. Cancer
3. Cancer
3. Cancer
3. Pneumonia
4. Accidents
4. Assaults/injuries 4. Pulmonary TB
5. DM
5. Cerebrovascular 5. Cerebrovascular
disease
6. Pulmonary TB
diseases
7. Cerebrovascular 6. COPD
6. COPD
7. Kidney disease
disease
7. DM
8. TB, all forms
8. COPD
8. Kidney disease
9. Bronchial
9. Bleeding peptic
9. Hypertension
asthma
ulcer
10. Accidents
10. Kidney disease
10. Bronchial
asthma
NOTE:
Prevalence is high because old cases are still being
handled in addition to the new cases (addictive effect)
Rising incidence of MDR-TB
100% DOTS Coverage does not mean that all Filipinos
with TB are under the DOTS Program; rather, it means
that all the local health units have a DOTS program
available

II.

M y c o b a c t e r i u m t u b e r c u l o s i s

Most significant Mycobacterium to humans

Rod-shaped, non-spore-forming, thin aerobic bacterium
0.5 um x 3um in size
Acid-fastness due to high mycolic and fatty acid content
in the cell wall

Question 1: Which among the following confer the

highest risk for TB transmission?
A. Kissing
B. Talking
C. Singing
D. Coughing increased force of expiration increases
risk of spreading infected air droplets

*thousands of deaths per year

NOTE: Additional burden on environment because of population

- Tendency of the government is to prioritize programs,
which leaves them not as unified as they should be
Group 6

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PULMONARY TUBERCULOSIS
I I I . T R A N S M I S S I O N

IV.
A.

B.

C.

D.

Human to human via aerosolized droplet nuclei

Coughing, sneezing, speaking
Most infectious: cavitary, laryngeal, or sputum smear (+)
disease
o Near the oral cavity; can easily occupy mucus secretions
and is coughed out
Burden of bacteria in lungs would also impact number of
bacteria expelled in sputum exam
o E.g., Low bacterial burden means bacteria would be
coughed out in the morning. Sputum samples taken in
the afternoon will yield negative.

CLINMED
VI.

Triad of chronic cough (GERD, post-nasal drip or upper

airway cough syndrome, allergic rhinitis)
Bronchitis
Pneumonia
Malignancy

V I I . D I A G N O S I S O F T B D I S E A S E

F A C T O R S A F F E C T I N G T U B E R C U L O S I S
Health-care Provider Factors
Failure to detect TB
Apprehensiveness to accommodate TB patients due to
fear of acquiring the disease
Global Factors
Massive migrations and convenience of travel
Global Fund or NGOs that donate to TB programs, but
theyre mostly focused on HIV/AIDS
Patient Factors
Health-seeking behavior refusal to or delay of consult
Non-compliance to treatment
Internal or perceived stigma patients are usually
embarrassed to be treated for TB
Societal Factors
National Tuberculosis Program local initiative
Lack of funds or of information
Overpopulation
Social stigma
Poor nutrition
Availability of doctors/healthcare providers

D I F F E R E N T I A L D I A G N O S E S

Wide range of signs and symptoms

Sputum smear (+) priority test for NTP
AFB culture (+) definitive diagnosis
Histopathologic evidence for extrapulmonary TB
Suggestive chest radiograph
TB PCR (+) used for non-sputum specimens sputum (e.g.,
pleural fluid)
PPD Skin Test no longer conducted
TB Diagnostic Committee (TBDC) decision

Figure 2. Chest X-ray of a TB infection

NOTE: Upper lobe involvement is most common

V.

S Y M P T O M S O F T B

Question 2: Which among the following suggests active TB?

A. Thin cachectic person
B. Chronic cough
C. Afternoon fever
D. Coughing out of blood

A.

Approach to smear (-) TB suspects

Sputum Smear Negative
Symptomatic Treatment

Chest X-ray

TB Diagnostic Committee

TB Diagnostic Committee (TBDC)

o Composed of: pulmonologist, TB nurse, radiologist

o Mandated to meet at least twice a month to discuss
cases that are in the grey area (e.g., smear-negative
with few symptoms but with suggestive CXR findings)

Figure 1. Symptoms of TB
Group 6

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PULMONARY TUBERCULOSIS
B.

CLINMED

Terminology of TB
Table 3. New and Old Terminologies for TB
American Thoracic Society
(Old)
0 No TB exposure
1 TB exposure, no evidence
of infection
2 TB infection, no evidence
of disease
3 TB, clinical active

4 TB, not clinically active

5 TB suspect (pending
diagnosis)

Question 3: In his National Agenda, President

Aquino should prioritize?
A. Food security and nutrition
B. TB control
C. Health insurance for all
D. Population control and RH Bill
All are important and should be prioritized.

World Health Organization

(New)

B.

Latent TB dormant cases

Active TB Case
Pulmonary or

Extrapulmonary (TB
meningitis, adenitis, GI)
Smear (+) or (-)

Complete diagnosis (based on WHO standard):

Active Pulmonary Smear-positive Pulmonary Tuberculosis
For extrapulmonary TB:
Active Extrapulmonary-positive, Smear-positive Tuberculosis or
Pulmonary TB with an Extrapulmonary Source
In cases wherein both pulmonary and extrapulmonary TB exist,
the pulmonary component supersedes the extrapulmonary
component since these are patients that transmit the bacteria
and are priorities for treatment

Other Terminologies:
Drug-Resistant TB (DR-TB) resistant to one or more anti-
TB drugs based on susceptibility testing
Multi-drug-resistant TB (MDR-TB) resistance to isoniazid
(INH) and rifampicin (RIF)
Extreme Drug Resistant (XDR-TB) resistance to INH, RIF,
quinolones, and any of the second-line anti-TB drugs
NOTE: There are only 2 facilities equipped to handle
MDR- and XDR-TB:
-
Tropical Disease Foundation (Makati Med)
-
Philippine Lung Center
Latent TB Infection
o 5 mm induration
HIV (+) cases, recent contacts of smear (+) TB cases,
fibrotic findings on CXR, patients with organ
transplants or the immunosuppressed
(e.g. on steroids)
o 10 mm induration
Recent immigrants from high prevalence countries,
IV drug users, high-risk groups (e.g., diabetics, age <
4 years, cancer patients)
o 15 mm induration no risk factors for TB

Active Disease (Classification)

Legend:
R/RIF Rifampicin
H/INH Isoniazid E Ethambutol
Z Pyrazinamide S Streptomycin
NOTE: In TB, 1 month is equal to 28 days.
New
o No previous anti-TB treatment
o TB treatment for <4 weeks
o 2 HZRE + 4 HR
(2 months of isoniazid, pyrazinamide, rifampicin,
ethambutol + 4 months of isoniazid and rifampicin)
Relapse
o Cured TB in the past
o Currently sputum (+)
o 2 HRZES + 1 HRZE + 5 HRE
Failure
th
o Patient sputum (+) on 5 month
nd
o Sputum (-) to (+) on 2 month
o 2 HRZES + 1 HRZE + 5 HRE
Chronic
o Remain sputum (+) even after second treatment
o Remain sputum (+) on re-treatment
o 2 HRZES + 1 HRZE + 5 HRE

C.

DOTS Treatment for New Cases

Intensive Phase
o 4-drug fixed dose combination = H + R + Z + E
o 2 months (56 days)
Maintenance Phase
o 2-drug fixed dose combination = H + R
o 4 months (112 days)

IX.

D O T S P R O G R A M

V I I I . T R E A T M E N T
A.

Group 6

Latent Tuberculosis Infection use PPD Skin Testing

6 or 9 months of INH gold standard
4 months of RIF if intolerant of INH or with known
INH resistance
3 months of INH + RIF

Figure 4. Components of TB-DOTS Program

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PULMONARY TUBERCULOSIS
X.

W H O S T O P T B S T R A T E G Y

Vision: A world free of TB

Goal: To dramatically reduce the global burden of TB
by 2015 in line with the Millennium Development
Goals and the Stop TB Partnership Targets
Targets
o MDG 6, Target 8
o Targets linked to the MDGs and endorsed by Stop TB
partnership
By 2005: Detect at least 70% of new sputum
smear (+) TB cases and treat at least 85% of these
By 2015: Reduce the prevalence of and deaths
due to TB by 50% relative to 1990
By 2050: Eliminate TB as a public health problem
(<1 million cases per million population)

XI.

1.

2.

3.

4.

5.

Q U I Z ! ! !
Which of the following is false?
A. Humans are the only known reservoir of M. tuberculosis
B. Mycobacterium tuberculosis is a rod-shape, non-spore
forming, thick aerobic bacteria
C. 0.5 um x 3 um in size
D. Acid-fast due to high mycolic acid and fatty acid content
Which of the following is not a known mode of TB
transmission?
A. CPR, mouth-to-mouth
B. Shouting
C. Not washing hands before cooking
D. Karaoke
Which of the following is true?
A. The most common symptom of active TB is fever.
B. Chronic cough of at least 3 weeks warrants sputum AFB
smear, according to the DOTS algorithm.
C. A differential diagnosis for TB is malaria, due to night
sweats.
D. The triad of chronic cough includes GERD, post-nasal drip,
and bronchitis.
Which of the following is false?
A. Laryngeal TB infection is one of the most infectious
states.
B. A CXR with positive findings for TB does not carry the
same diagnostic value as an AFB smear.
C. Gastric aspirate may be collected for workup if there is
no sputum production.
D. Sputum smear collection should be done on 3 alternating
days.
Which of the following is true?
A. The gold standard for treatment of latent TB is 2HRZE +
4HR.
B. Tiny calcific foci deposited in the lung apices are called
Simon foci.
C. Diagnosed latent cases should be handed over to a DOTS
program.
D. A Mantoux test can be used to diagnose active TB
infections.

CLINMED
Properly interpret the tuberculin test in questions 6-10; answer
with the following choices:
A. Patient has TB.
B. Patient does not have TB.

6. An HIV-positive soldier with an induration of 5mm and
erythematous base of 10mm.
7. A hospital microbiology lab technician with an induration of
5mm and erythematous base of 10mm.
8. A kidney transplant recipient with an induration of 5mm and
erythematous base of 10mm.
9. A construction worker with an induration of 15mm and
erythematous base of 20mm.
10. An infant with an induration of 5mm and erythematous base
of 10mm.









































1B, 2C, 3D, 4D, 5B, 6A, 7B, 8A, 9A, 10B

Group 6

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