Professional Documents
Culture Documents
Tuberculosis
The reaction of the tissues of the
human host to the presence and
multiplication of Mycobacterium
tuberculosis or Mycobacterium
bovis
treatment
Treatment
Adherence / compliance
Drug discontinuation treatment failure
Multi drug resistance (MDR)
12/22/2014
symptomatology
pathophysiology
pathology
pathogenesis
immunology
etiology
simtomatologi
patofisiologi
patologi
patogenesis
imunologi
etiologi
Penunjang
diagnosis
simtomatologi
patofisiologi
patologi
patogenesis
imunologi
etiologi
Penunjang
diagnosis
simtomatologi
patofisiologi
patologi
patogenesis
imunologi
etiologi
Baku emas
diagnosis
simtomatologi
patofisiologi
patologi
patogenesis
imunologi
etiologi
Etiology
Mycobacterium tuberculosis
Mycobacterium bovis
Characteristics :
1. live in weeks in dry condition
2. no endotoxins, no exotoxins
3. hematogenic spread
4. grows slowly (24-32 hr)
5. non specific clinical manifestation
6. aerob, organ predilection - lung
7. wide spectrum of replication: dormant
Transmission
adult patient, active lung TB
cough, sneeze, speak, sing
droplet nuclei: 1-5
airborne for long periodes
inhalation, reach alveoli
middle and lower lobes
Lung
Intestine
Skin
Nose
Tonsil
Middle ear (Eustachian tube)
Parotid
Conjunctiva
Undetermined
95.93
1.14
0.14
0.09
0.09
0.09
0.05
0.05
2.41
TB pathogenesis
lymphadenitis
lymphangitis
primary focus
TB pathogenesis
droplet nuclei
inhalation
alveoli
ingestion by PAMS
intracellular replication
of bacilli
destruction of PAMS
destruction
of bacilli
Tubercle formation
Lymphogenic spread
primary focus
lymphangitis
lymphadenitis
hematogenic spread
acute hematogenic
spread
disseminated primary TB
occult hematogenic
spread
multiple organs
remote foci
primary
complex
CMI
TST
M. tuberculosis inhalation
phagocytosis by PAM
TB pathogenesis
live bacilli
multiplies
bacilli dead
incubation period
(2-12 weeks)
TST (+)
P
r
i
m
a
r
y
TB disease
TB infection
T
B
Optimal immunity
3)
Dead
immunity
reactivation/reinfection
Cured
TB disease4)
Incubation period
first implantation primary focus
4-6 weeks (2-12 weeks) incubation period
3
4
first weeks: logaritmic growth, : 10 -10
elicit cellular response
end of incubation period:
primary complex formation
cell mediated immunity
tuberculin sensitivity
PrimaryTB infection has established
Hematogenous spread
during incubation period, before TB
infection establishment:
lymphogenic spread
hematogenic spread
hematogenic spread (HS):
occult HS
acute generalized HS
protracted HS
Occult HS
most common
sporadic, small number
no immediate clinical manifestation
remote foci in almost every organ
rich vascularization: brain, liver, bones
& joints, kidney
including: lung apex region
CMI (+): silent foci - dormant,
potential for reactivation
Acute HS
less common
large number
immediate clinical manifestation:
disseminated TB
milliary TB, meningitis TB
tubercle in same size, special
appearance in CXR
Primary complex
end of incubation period
TB infection establishment
cell mediated immunity (CMI)
tuberculin sensitivity (DTH)
end of hematogenic spread
end of TB bacilli proliferation
small amount, live dormant in granuloma
new exogenous TB bacilli: destroyed / localized
TB infection
TB
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CMI
24
TB disease
CMI
TB
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25
Hypersensitivity type IV
delayed type hypersensitivity (DTH)
cannot transferred by serum, can be by T-cells
cellular mediated
reflects the presence of Ag-specific CD4 T-cells
associated with protective immunity, but not a
complete correlation
three variants of DTH:
1. contact hypersensitivity
2. tuberculin type hypersensitivity
3. granulomas
Tuberculin hypersensitivity
originally described by Koch Koch
phenomenon
TB patients tuberculin filtrate fever &
generalized sickness
at the injection site, developed area of
swelling & hardening
TST is an example of the recall response to
soluble antigen previously encountered
during infection
Ag-spec Tcells
IFN
macrophages
Leucocytes-receptors
endothelial cells
ICAM-1 & VCAM-1
induces, activates
produces
Tuberculin negative
1.No TB infection!
2. Anergy?
3. Incubation period??
Mantoux TST
Mantoux : intracutan injection 0.1 ml PPD
location
: volar lower arm
reading time
: 48-72 h post injection
measurement
: palpation, marked, measure
report
: in millimeter, even 0 mm
Induration diameter :
0 - 5 mm : negative
5 - 9 mm : doubt
> 10 mm : positive
Mantoux
tuberculin
skin test
Tuberculin positive
1. TB infection :
infection without disease / latent TB infection
infection AND disease
disease, post therapy
2. BCG immunization
3. Infection of Mycobacterium atypic
Anergy
Patient with primary complex do not give reaction
to TST due to supression of CMI :
Severe TB: miliary TB, TB meningitis
Severe malnutrition
Steroid, long term use
Certain viral infection: morbili, varicella
Severe bacterial infection: typhus abdominalis,
diphteria, pertussis
Viral vaccination: morbili, polio
Malignancy: Hodgkin, leukemia, ...
Diagnosis
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36
Diagnostic tools
gold standard
capture the trouble maker
microbiologic examination
adult TB
pediatric TB
sputum
scarce specimen
LJ - TB culture
direct - AFB
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Mantoux
TST
37
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38
39
100
Overdiagnosis
80
60
40
32
20
0
Diagnosed by Xray alone
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Actual cases
40
Diagnostic tools
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Clinical manifestation
Tuberculin skin test
Chest X ray
Microbiology
Pathology
Hematology
Others : serologic, lung function,
bronchoscopy
41
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42
Mantoux
test
proveTB
infection
positive
negative
Diagnosis TB
completed:
Ro, lab
not TB
treatment
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Seek other
etiologies
43
Manage
ment
proph I
proph II?
therapy
Resume diagnosis
Aspek
Simtomatologi
Patologi Anatomik
Patologi pencitraan
Imunologi tuberkulin
Etiologi mikrobiologi
Spesifik
--+++
-++
++++
Sensitif Kemudahan
++
++
+
++
++
+
-+
+
---
Pajanan
Tidak
jelas
dilaporkan,
BTA(-)
BTA(+)
Mantoux
positif
BB(KMS)
BGM
BB
Malnutrisi
berat
Demam
Tidak jelas
sebabnya
Batuk
<3weeks
>3 mgg
P> KGB
>1 KGB,
>1cm,
tdk nyeri
Tulang sendi
Bengkak
Rontgen
Normal
Sugestif
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46
Skor
47
Thank you
Presented
Lecture material
FMUI student
CAH module
26 Aug 2009
BCG vaccination
BCG vaccination
BCG
injection
deltoid
ingestion by Mcrp
intracellular replication
of bacilli
destruction of PAMS
tubercle formation
lymphogenic spread
primary focus
lymphangitis
destruction
of bacilli
hematogenic spread
acute hematogenic
spread
occult hematogenic
spread
disseminated primary TB
multiple organs
remote foci
primary
complex
CMI
TST