Childhood Tuberculosis Flashcards
Nigeria ranks _____th among the ______ high burden countries that account for 80% of the Global TB burden.
Under-diagnosis!! WHO-___ per cent of the three million people undiagnosed for TB around the world are in Nigeria, (slum areas)
11
22
15
Predisposing factors to tuberculosis
__________ system defects
__________
__________
measles
__________
Drugs steroids, chemotherapy
Immune system defects
overcrowding
age
measles
Malnutrition
Drugs steroids, chemotherapy
Mycobacterium tuberculosis
_______ shaped, (aerobic or anaerobic?), (spore or non-spore?) forming, ______cellular organism
_____________ present in cell wall makes it acid fast- meaning it ______________by acid and alcohol when stained.
Rod ; aerobic ; non-spore
intracellular ; Mycolic acid
resists decolorization
Mycobacterium tuberculosis
(Thin or Thick?) cell wall that prevent _________. Multiplies (slowly or rapidly?), can remain dormant for decades.
Thick cell
phagocytosis
slowly.
Mode of transmission of TB
Person to person through _______________________.
Ingestion of M. _______ in _____________________ .
___________ (skin tb)
___________ (rare)
inhalation of mucous droplet nuclei.
M. Bovis ; unpasteurized milk.
Inoculation ; Transplacental
Pathogenesis of Tb
Inhalation- nuclei settle in _____________________
________________ infiltration-__________ , __________, __________ cells, __________ cells.
Tissue __________
Terminated by a __________ (CMI) response 2-3 weeks after initial infection.
sub-pleural pulmonary alveoli
Mononuclear ; macrophages
monocytes ; plasma cells
mast cells ; destruction
Cell-mediated immune (CMI)
The role of cellular immunity in TB
Helper T cells
Activate __________ to kill _____________ with resultant ______________ formation
Cytotoxic T cells
Lyse the ___________ infected with the mycobacteria, resulting in the formation of ______________
macrophages ; intracellular
bacteria
epitheloid granuloma ; macrophages
caseating granulomas
M. Tb can’t thrive in _______ extracellular environment-walled off in immunocompetent
acidic
Classification of tuberculosis
_________ Tb
_________ Tb
_________ Tb
_________ Tb
Primary Tb
Primary progressive Tb
Reactivation Tb
Latent Tb
Primary TB
Develops in a previously (exposed or unexposed?) individual
Inhaled bacilli implant in the (proximal or distal?) airspaces of (upper or lower?) part of the upper lobe or (upper or lower?) part of lower lobe.
__________ inflammation with __________ develops known as _________.
unexposed ; distal
lower ; upper
Grey white ; consolidation
Ghon focus.
Ghon complex =??
Ghon focus + surrounding lymph nodes
Primary infection :
__________ + __________ + __________
=
Primary complex or Ghon complex
Primary focus + Draining lymph nodes + surrounding lymph nodes
Primary infection
Mostly < _____ years in unvaccinated children
Lasts __________
Usually asymptomatic, _____ grade pyrexia, _______ may be present.
Bacteremia with development of ______ immunity- +ve ___________ test
5 years ; 2-12 weeks
low ;malaise may be present.
cellular immunity
tuberculin test
Primary infection
Allergic manifestations to the tubercle protein- phylectenular __________ (rred eye associated with white speck(s) at
the border of the cornea) and _______________, erythematous rash at the distal lower extremities over the shins)
Bacteria killed, focus heals by fibrosis in immunocompetent children.g
conjunctivitis
Erythema Nodosum (EN)
Primary Progressive TB
Predisposing factors
__________ of bacilli inhaled
__________ of organisms
__________
__________
Intense contact Measles
__________ drugs: Prednisolone, Ca chemotherapy
Malignancies
Defects of the immune system
Number ; Virulence
Young age; Malnutrition
Immunosuppresive drugs
Primary Progressive TB
Contiguous spread - Tuberculous __________, pleurisy
Merging of _________ and _________- consolidation
Extensive _________ and _________
Compression of _________ by lymph nodes- atelectasis or collapse
Blood vessel erosion- haematogenous spread- _________/_________ tuberculosis.
pneumonia,
focus and nodes
caseation and liquefaction
bronchus
disseminated/miliary tuberculosis.
Clinical features of tuberculosis
General
Non-specific!–high index of suspicion
______ grade fever ± chills
Malaise , Weight ______, _________ , loss of milestones
_________
History of contact with _________
Low ; Weight loss
failure to thrive; Night sweats
adult with chronic cough.
Clinical features of tuberculosis
Depends on site (Disseminated if >1 site is involved.)
Pulmonary (_________)- _________ cough, _________, wheezing, _________, _________ breath sounds, _________ (pleuritic chest pain), normal findings.
Koch’s ; Chronic cough
dyspnea ; hemoptysis
bronchial ;pleural effusion
Clinical features of tuberculosis
Abdominal- lymph nodes, Peritoneum, gastrointestinal tract
chronic ____________ , ____________, abdominal ________, ____________, intestinal ____________
jejunum and ileum commonest –____________ ____________
diarrhoea ; malabsorption
abdominal pain ; ascites
intestinal obstruction
shallow ulcers
Clinical features of tuberculosis
Spine (Pott’s)-
affects _________ , spares _________
Mid and lower _________ followed by _________ and _________.
(Painless or Painful?), (tender or Non-tender?) spine, spasms with rigidity, _________, _________, gibbus
Spinal cord _________-_________ tonia, _________, ankle _________, paraplegia, incontinence
body ; spinous processes
thoracic ; lumbar ; cervical.
Painful ; tender ;kyphosis
scoliosis ; compression
hypertonia ; hyper reflexia
clonus
Clinical features of tuberculosis
CNS- _____________ or tuberculoma
_____ stages: _____ weeks each.
i:Non –specific e.g _______ , irritability, ____________, headache
ii. Signs of _____________: _____________, _____________, _____________, focal neurologic signs, cranial nerve palsies.
iii. ____________, hemiplegia, _____________ rigidity, _____________
Tuberculoma. Mostly infratentorial, space occupying lesion.
meningitis , 3 stages
2 ; fever ; weight loss
meningeal irritation ; neck stiffness
+ve Kernig’s Brudzinski’s
seizures ; Coma
decerebrate rigidity ; opisthotonus
Tuberculoma. Mostly infratentorial, space occupying lesion.
Clinical features of tuberculosis
Miliary TB-Most severe form of __________ , _______________ spread, generalized lymphadenopathy, hepato-splenomegaly.
disseminated
haematogenous
Diagnosis
Gold standard: __________
- Tuberculin skin test
Based on previous exposure to the organism
___________ injection of _____mls of ___________ , Read induration ________ after
Interpretation:
______mm=negative
________mm=doubtful positive/borderline
________=positive
Culture
Intradermal ; 0.1mls
purified protein derivative (PPD)
48-72hrs ; <5mm
5-9mm
> 10
Interpreting a Mantoux test
> 5 +ve if :
_______ with known TB case, on ___________ drugs or __________, Abnormal CXR etc.
False negatives- _____ technique, severe ________, ___________ etc
False +ves= ___________ with other mycobacteria
contact; immunosuppressive
immunosuppressed
poor
malnutrition; immunosuppression
cross sensitization
Diagnosis
Advances in molecular biology – alternatives to the TST
_________________- (IGRA’s) –
In-vitro measurement of _______ (IFN) released by sensitized _________ after stimulation by M. tuberculosis.
E.g’s
- ___________-TB Gold
- _________________ (ELISPOT)- T-SPOT
Interferon Release Gamma Assays
nterferon (IFN) ; lymphocytes
- QuantiFERON
- Enzyme-linked immunospot (ELISPOT)
Diagnosis
PROS
_________ than the TST.
Better correlation with recent exposure to M. tuberculosis in ___________ settings.
Less _____________ than the TST because of previous BCG vaccination.
Need for only ______________
Higher specificity
low incidence
cross-reactivity
one patient encounter
Diagnosis
CONS-
No differentiation between __________ and __________.(__________ vs __________)
________ volumes of blood.
TST preferable in <____’s
______________ in children
infection and disease
latent vs active
High ; <5’s
Limited studies
Diagnosis
Bacteriology- sputum, gastric aspirate, CSF, , blood, pleural, pericardial FNAB (high yield)
AFB staining- ___________ stain, Others- Kinyoun stain, Fluorochrome stains, such as auramine and rhodamine (faster but require ZN confirmation)
Ziehl-Neelsen
Diagnosis
Gene Xpert –
New test for tuberculosis.
Detects infection and resistance to _______________________________
Detects and amplifies DNA specific to the TB bacterium. (PCR)
Also looks at the _________ of the _______ - important to detect _______________.
PROS
- Very sensitive (up to _____%), similar with __________ .
-Very useful in the __________ e.g AIDS who falsely test negative for TB
Cons- __________, requires constant __________, connection to __________.
one of the common TB drugs, rifampicin.
structure ; genes ; resistance to drugs.
98%; culture.
immune-compromised
Expensive ; electricity; computer.
WHO(2010)- ____________ should in many settings, be the first test conducted to find out if a person has TB.
Gene Xpert
Diagnosis of tuberculosis
Full blood count- ___________ with >__________, raised ______.
CSF pleocytosis- ___________ protein, ______ coloured. CSF ____________
Other imaging -CNS-tuberculoma
-Spine- __________ of the spine.
leukocytosis ; >lymphocytes
ESR ; markedly raised
straw ; lymphocytosis
Angulation
Treatment of tuberculosis
Major principle: Combination therapy Phases :
1. ________
2. ___________
Drugs: 1. ___________ 2.__________
Intensive
Continuation
Bacteriostatic
Bacteriocidal
Ist line: ???
2nd line: ????
Rifampicin (R), Isoniazid (H), Pyrazinamide (Z), Streptomycin(S)
Ethambutol €,
capreomycin, ciprofloxacin, cycloserine, ethionamide, kanamycin, ofloxacin, levofloxacin, and para-aminosalicylic acid
Treatment of tuberculosis
Six Months Regimen(2RHZ+E/4RH):
– A 6 months Short Course Chemotherapy under supervision for a child with:
-__________ TB
- any form of extra – pulmonary TB other than TB _________ and TB of the_________ (___________ TB)
pulmonary
meningitis
bones
osteo-articular
Treatment of tuberculosis
Twelve Months Regimen (2RHZ+E/10RH):
– A 12 months Short Course Chemotherapy for a child diagnosed with:
- TB ____________
- TB of the ________(_______)
meningitis
bones (osteo-articular TB)
Treatment of tuberculosis
Supportive Others:
__________- Tb meningitis, pleural effusion. Surgery- drainage of paraspinal abscess
___________ rehabilitation
Steroids
Nutritional
Treatment of Tuberculosis
Resistance to anti-tuberculous medications
•Natural resistance: Resistance of mycobact to _____________________________________ .
Primary resistance: Resistance to anti-TB treatment in an individual who _______________________ . (Acquired a ______________ strain)
•Secondary resistance:_________ of resistance during the ________________________ (initially ________)
Multi-drug resistant TB: Resistance to a number of anti-tb drugs including _________ and ____________.
a drug it has never encountered
has no history of previous treatment; drug resistant
Emergence; course of ineffectual anti-TB therapy.; sensitive
Isoniazid; Rifampicin
DOTS PRINCIPLE: ??
Directly observed treatment short course.
Prevention of TB
Newborn infant of mother with TB
separate
