Pulmonary T.B
Organism
1- Mycobacterium tuberculosis (human type) it causes most of infection.
2- Mycobacterium bovis
is endemic in chattle & rarely affect man
3- Atypical mycobacteriuim (cause +ve tuberculin)
It is lead to +ve tuberculin
Affect cervical L.N. Common in immunopomromised patients.
ex. * M. Marinum
* M. Kansasii
* M. Avium
Pathology
1- Those at risk of acquiring T.B.
* Children * Contact
* Immunocompromised * Living in overcrowding
2- Entry of the organism through alimentary or respiratory tract. So, the appearance of C/P depend on

Natural resistance Standard of living The presence of previous disease as D.M. or uremia or liver cirrhosis Predispose to pulmonary. T.B.
3- The reaction of the body towards tubercle bacilli depends on whether those bacilli first seen by the body or it is the 2nd exposure so if:

1st exposure or 2nd exposure (post primary)

1ry complex the body develop resistance & hypersensitivity
* Gohns focus which is small area of consolidation in the upper part of lower lobe or lower part of upper lobe.
* lymphangitis
* lymphadenitis (hilar L.N.)

Fate of primary
T.B. complex

I- Healing
Complete resolution by fibrosis and calcification.
Partial healing for months or years then hematogenous spread to other organs.
e.g. during low resistance
Exacerbation
II- Hypersensitivity: Erythema nodosum.
Phylectinular conjunctivitis
Pleural effusion
III- Progress:
Progress of glands Gohns focus

Progressive pulmonary T.B.
e.g. T.B. pneumonia
Enlargement Rupture

Middle lobe $ Pericardium T.B. Pericarditis
Mediastinal $ Pleura
pleurisy
Pulmonary collapse Pulmonary vein
military T.B.

The term post primary TB. May be reactivation or re-infection
Ex.

Reactivation of hematogenous Re-infection
an incompletely spread from
healed unhealed L.N.
1ry focus
So, presentation of post 1ry T.B. according to resistance & organism

T.B. bronchopneumonia Fibrocaseous T.B. Miliary T.B.




C/P of TB
1st common symptoms with pulmonary T.B. (2N-2L)

­ Night fever ­ Night sweating ­ Loss of Wt ­Loss of
appetite
I-C/P of lry complex
In most cases the 1ry infection produce no symptoms or signs & the condition usually passed unnoticed unless the following investigations done.

X-ray Sputum Tuberculin test shows
conversion from -ve
+ve
Fever, dry cough may occur for 1-2 weeks !?
II-As a result of hypersensitivity:
a- Erythema nodosum * Bluish red
* Raised
* Tender
* Cutaneous on the skin of tibia
* Tuberculin test is strongly + ve
b- Pleural effusion
exudative reaction
c- Phylectinular conjunctivitis.
III- progression of primary pulmonary tuberculosis
G. features of T.B. Apical lesion Sputum +ve Haemoptysis

­
Cavity
­ Pneumonia
Post primary (adulthood TB)
A patient with 1 ry T.B. with 2nd exposure or reactivation as mentioned, may presented by the following:
C/P * G. features of T.B. 2N&2L
* Cough, expectorant
* Haemoptysis may result form

1- bleeding from vascular 2- erosion of big vessel traversing
tissue granulation tuberculous cavity
Manifestation of pneumonia or cavity
Dyspnea .. why?
Pleural effusion
L.N. ++
pr. on bronchus.
Bronchostenosis or pulmonaiy fibrosis are late complication
Investigation (T.B. is a bacteriological diagnosis)
1- Bacterial examination: -ve for 3times = -ve
Isolation of organism from


Sputum Child Bronchial lavage Tracheal aspiration

Gastric lavage
2-Radiological picture:(apical lesion)
* Cavity * Fibrosis
* Consolidation * Effusion
* Collapse * Military shadow
3-Tuberculin test: (It is an intradermal test)
We use PPD (protein purified derivative) of bacilli, +ve if give red, indurated about 1 cm.
It is Good -ve
i.e. A patient with chest trouble & -ve tuberculin test repeatedly
He is mostly not tuberculous
Values of tuberculin test:
1. +ve in child = tuberculous infection.
2. Repeatedly - ve in chest troubles usually rules out T.B.
3. For contact with a case

If contact -ve If +ve

Repeat after 6 m if- ve Follow up (sputum, X-ray) if
give BCG -ve give INH for one year, +ve
cases treated by antituberculous
as usual
Cause of -ve tuberculin:
1- Before 6 wks 4- lmmunocompromised
Steroids
2- Bad technique (anergy)
Cytotoxic
AIDS
3- Miliary T.B 5- viral infection.
False +ve T.B.
Atypical mycobacterium
4- E.S.R: ESR ­­ in active .T.B. (usually> 100)
is used in follow up
Can rule out T.B if normal
5- Blood picture:
Leucopenia with
­­ lymphocytes
Hb.

6- PCR: recently is an accurate technique
7- pleural biopsy:
DD. of T.B
1- Cases of pl. effusion
2- Cases with bronchopneumonia
3- Mediastinal $
4- Coin shadow T.B.
Bronchial carcinoma, Bronchial adenoma
Aspiregelloma
5- Miliary shadow
6- Fever of unknown etiology & loss of Wt.
# BCG (Bacilli calmette - Guerin)
0.1 ml l.D at the junction of the upper and middle 1/3 of the upper arm protection for 7 years.
Medical Treatment:
1- Bed rest and isolation for pts who are excreting organism
2- Good nourishment
3- Drugs
Rules 1- Long course to avoid relapse
2- Combinations to avoid resistance
3- Rifampicin
shorten course to 9m
4- 1 N H must be used
5- Side effects of drugs must be known.
Drugs
I.N.H:
the most effective constant drugs
Dose: 5-10 mg/kg
Side effects: hepatotoxic, neuritis
Streptomycin:
Dose: 1gm I.M daily
Main side effects: ototoxicity
irreversible
PAS:
dose 12- 20 gm/d
Side effects: GIT upset
Rifampicin
450-600 mg/d (10-20 kg) it is hepatotoxic
Ethambutol
25 mg/kg, it lead to optic neuritis
Pyrazinamid
20- 35 mg/kg, (Hepatitis - gout)
Surgical ttt
Lobectomy with resistant cases or recurrent Haemoptysis
Q Role of corticosteroids.
Indication = 1- Miliary T.B
2- Serious membrane affection to prevenr fibrosis.
3- Replacement therapy for Addison.
● Chemo prophylaxis of T.B.
INH 5 mg/kg/d for 1 yr can be given in non vaccinated contact who have recently tuberculin +ve, immunosuppressed pts and infants of highly infectious mothers. (the latter can treated for 6wks)

Recent antituberculous can be used in resistant cases

Capreomcycin
Clarithromycine
Ciprofloxacine
Cyclosporine
Azithcomycine
Ofloxacine



Source: Internal Medicine Book of Dr.Osama Mahmoud (Ain Shams University)