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LESSON 101

MYCOBACTERIUM

TUBERCULOSIS

PPP MOHAMAD NOOR FAHMI BIN MOHD FAUZI

PENGELOLA RAWATAN TB JKWPKL&P

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10.0 million people

contracted tuberculosis (TB) and 1.4 million people died of it in 2019 World Wide and 2,320 deaths in Malaysia 2020.

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EPIDEMIOLOGY

De Castro N, Marcy O, Chazallon C, et al.

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Ancient Origins:

    • Evidence found in Egyptian mummies (2400 BCE).
    • Described by Hippocrates as "phthisis" (consumption).

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20th Century Developments:

    • 1921: BCG Vaccine developed (Calmette & Guérin).
    • 1944: Streptomycin discovered, the first effective TB treatment

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1882 - Discovery:

Robert Koch identified M. tuberculosis as the cause of TB.

    • MDR-TB and XDR-TB (Drug-resistant strains).
    • Ongoing global efforts by WHO to eliminate TB.

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Modern Era Challenges:

TIMELINE OF TUBERCULOSIS

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CHARACTERISTICS

MycoBacterium TuberculOsis

Mycolic Acid

Acid fast

Anatomically

Gram Positive Rod

Granule

Condition In Medical Term

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CHARACTERISTICS

Mycobacterium TuberculOsis

zn stain

fluorescent stain

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SIGN AND SYMPTOM

FEVER

NIGHT SWEAT

COUGH

LOST APPETITE

LOST WEIGHT

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CHAIN OF INFECTION

Causative Agent

Reservoir

Portal Of Exit

Mode of Transmission

Portal of Entry

Susceptible Host

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TYPE OF TB

LATENT TB INFECTION (LTBI)

ACTIVE TB DISEASE

DRUG-RESISTANT TB (DR-TB)

    • Bacteria are present in dormant state
    • Pulmonary TB
      • Positive
      • Negative
    • Extrapulmonary TB
      • Lymph nodes
      • Bones and joints
      • TB meningitis
      • Kidneys
    • Monodrug-Resistant TB
    • Multidrug-Resistant TB
    • Extensively Drug-Resistant TB (XDR-TB)

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TYPE OF TB

COLOUR CODING

LATENT TB INFECTION (LTBI)�(BIRU)

TB DISEASE

(PEACH / PUTIH)

DRUG-RESISTANT TB (DR-TB)�(MERAH)

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DIAGNOSING TUBERCULOSIS

CLINICAL EVALUATION

IMAGING

LABORATORY TEST

Empirically Treat

    • Symptom
    • Risk Factor
    • Delayed / Inconclusive Lab IX
    • Chest X-ray (CXR)
    • Computed Tomography (CT) Scan
    • Magnetic Resonance Imaging (MRI)
    • Ultrasound
    • Positron Emission Tomography (PET) Scan
    • Sputum smear microscopy
    • Sputum culture
    • Molecular tests (GeneXpert)
    • IGRAs and TST
    • Drug susceptibility testing
    • Urine Lipoarabinomannan (LAM)

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DIAGNOSING TUBERCULOSIS

AFB TEST

SPUTUM AFB CUP

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DIAGNOSING TUBERCULOSIS

GOLD STANDARD

MTB CULTURE AND SENSITIVITY

  • Highest sensitivity and specificity compared to smear microscopy or molecular tests.
  • Allows confirmation of TB diagnosis by actual growth of the organism.
  • Enables drug susceptibility testing (DST) to guide treatment, especially important for MDR-TB/XDR-TB.
  • Can differentiate Mycobacterium tuberculosis complex (MTBC)

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DIAGNOSING TUBERCULOSIS

MOLECULAR TESTING

GENE XPERT

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M10

  • PCR-based
  • Results in 2 hours.
  • Sensitivity: Higher than smear microscopy, especially in smear-negative cases
  • Detect HR resistance

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DIAGNOSING TB INFECTION

TUBERCULIN SKIN TEST

Purified Protein Derivative (PPD) tuberculin

26–27 gauge

fleksor lengan (forearm)

lengan tangan yang tidak dominan

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DIAGNOSING TB INFECTION

TUBERCULIN SKIN TEST

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DIAGNOSING TB INFECTION

IGRA TEST

T-cells release interferon-gamma (IFN-γ) in response

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TREATING TB

FIX DOSE COMBINATION

    • Drug-sensitive TB: 6-9 months, combination of four first-line drugs (EHRZ).
    • Latent TB: 3-9 months, depending on the regimen.
    • MDR-TB: 18-24 months with second-line drugs, longer and more toxic regimen.
    • XDR-TB: Specialized and prolonged treatment with third-line drugs.
    • Extrapulmonary TB: Same drugs as pulmonary TB, with possible extended treatment for certain forms.

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TREATING TB

MODE OF ACTION

Isoniazid (INH)

Rifampicin (RIF)

Pyrazinamide (PZA)

Ethambutol (EMB)

Inhibits mycolic acid synthesis, weakening the bacterial cell wall.

Inhibits RNA synthesis by blocking RNA polymerase

Disrupts energy production, effective in acidic environments.

Inhibits arabinogalactan synthesis, disrupting cell wall integrity.

Inhibit protein synthesis by binding to ribosomes

Streptomycin

TB CELL

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DOT

DOT atau directly observed treatment adalah penyeliaan atau pemerhatian langsung terhadap pesakit tibi setiap kali pesakit mengambil ubat Tibi

Garispanduan Penyeliaan DOT 2016

Apa jua kaedah pemberian rawatan tibi kepada pesakit, ia perlu menitikberatkan aspek hak asasi individu dan juga hak masyarakat untuk hidup bebas tanpa dijangkiti.

Penyelia Dots

  • Anggota kesihatan
  • Ahli keluarga
  • Sukarelawan Masyarakat
  • Non Government Organization

Lokasi Dots

  • Fasiliti kesihatan kerajaan
  • Pusat komuniti
  • Tempat kerja
  • Sekolah
  • Di rumah

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DOT

Kesan sampingan berikut tidak merbahaya (Berikan keyakinan kepada pesakit)

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  • Air liur /air mata /air kencing bertukar kepada warna jingga
  • Kulit pedih apabila terdedah kepada matahari
  • Hilang selera makan yang ketara
  • Loya atau muntah-muntah
  • Warna kulit atau mata bertukar menjadi kuning
  • Demam melebihi 3 hari
  • Sakit perut
  • Kebas pada jari, tangan, kaki atau sekeliling mulut
  • Ruam kulit
  • Mudah berdarah (membran mukosa)
  • Mudah lebam pada kulit
  • Sakit-sakit sendi dan Pening
  • Kabur penglihatan
  • Batuk berdarah

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PREVENTION

1. Vaccination: BCG Vaccine

2. Screening and Testing: Identify and Treat Latent TB

3. Infection Control in Healthcare Settings : Administrative measure

4. Public Health Education : Awareness Campaigns

5. Prompt Diagnosis and Treatment : Early Detection and Complete Treatment

6. Protective Measures : Face Masks and cough etiquette

7. Reducing Risk Factors : Addressing Comorbidities

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Thank you!

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