Tuberculosis : Overview

& Recent Updates

Dr. Abed Hussain Khan
Assistant Professor
Department of Internal Medicine
BSMMU
 Case Definition
• Bacteriologically confirmed TB case: One from whom a
biological specimen is positive by smear microscopy e.g.
LED-FM (Light-emitting diode fluorescence microscopy),
Z-N stain or culture (both Liquid & Solid), WHO
recommended rapid diagnostic such as Xpert MTB/RIF,
Xpert ULTRA & TrueNat etc.
• Clinically diagnosed TB case : One who does not fulfill
criteria for bacteriological confirmation but has been
diagnosed with active TB by a registered physician based on
strong clinical evidence followed by a decision to give the
patient a full course of TB treatment. This include cases
diagnosed by clinicians on the basis of X-ray abnormalities
or suggestive histology and extra-pulmonary cases without
bacteriological confirmation.
 Case Definition (contd.)
• TB infection : Latent tuberculosis infection (LTBI) is the
presence of MTB in the body without signs and symptoms,
or radiographic or bacteriologic evidence of tuberculosis
(TB) disease. The life time risk of breaking down to disease
among those infected with TB is 5–15%.
• TB disease: This takes place when the immune system of a
person is not able to prevent the bacteria present in the lungs
and/or other organs from multiplying. This active
multiplication is accompanied by various signs and
symptoms like cough, weight loss, fever, night sweats, chest
pain, haemoptysis, fatigue, and decreased appetite. This is
known as TB disease.
 Risk factors for developing active TB
Risk depends on number of factors that lead to weakened immune
system, damaged lungs, or the intensity and duration of exposure :

• HIV infection
• Diabetes mellitus
• Malnutrition
• Prolonged therapy with corticosteroids and other immunosuppressives
• Malignancies (eg. leukemia, lymphoma or cancer of the head & neck)
• Severe kidney disease
• Alcoholism
• Substance abuse
• Age : Children <5 years have twice the risk. Higher risk in <6 months.
• Pregnancy
Tools for diagnosis of TB available in BD
• Sputum Smear examination
• Radiological examination of lung
• Tuberculin skin Test (Mantoux test)
• Culture
• Drug susceptibility Testing
• Molecular diagnostic test – 1.Xpert MTB/RIF
• 2. Line probe assay (LPA)
• FNAC, Biopsy and histopathology for EP-TB
 Lab Turnaround Time
Tools Turn around Time
Smear ZN 48-72 Hours
microscopy
Auramine
Xpert MTB/Rif 24 hours

Line probe essay for Within 5 days from direct sample.

MDR/XDR TB detection
Culture Solid 2-8 weeks in case of smear (+ve) and 4-8 weeeks for
smear (-ve) samples

Liquid 8- 10 days for smear (+ve) & 2-6 weeks for smear (-ve)
samples.

DST Solid 4—6 weeks

Liquid After inoculation, 2 weeks
 Tools for diagnosis of TB
• Sputum smear examination : 2 sputum samples are to
be collected for microscopy & tested as follows –
➢“On-the-spot” specimen – 1st specimen collected on the
spot when patient identified as presumptive PTB case
(Spot specimen)
➢Early morning specimen – 2nd specimen collected at
home next morning

❖ NTP will replace smear microscopy with WHO recommended

molecular diagnostics as the initial diagnostic test for all presumptive
TB cases in a phased manner. Until the full replacement, the
microscopy (preferably LED) will continue to be used for diagnosis.
 Tools for diagnosis of TB (contd.)
• Radiological (X-ray) examination of the lungs :
➢ In absence of microbiological confirmation, X-ray can
be used as supportive evidence of TB
➢Careful clinical assessment & supportive X-ray findings
can be used to diagnose & such cases considered as
clinically diagnosed TB
➢Apart from X-ray, HRCT is highly sensitive for detecting
TB lesions. Miliary mottling of miliary TB appears
earlier in HRCT.
Common Radiological
Presentations of TB
1.Primary Pulmonary TB
2. Ghon Focus
3. Ghon Complex
4. Ranke Complex
5. TB Consolidation
6. Tubercular Pleural Effusion
7. Atelectasis
8. Post-primary TB
9. Cavitation
10. Healed TB
11. Tuberculoma
12. Pneumothorax
13. Broncho-pleural Fistula
14. Tubercular Empyema
15. Pleural Empyema
16. Post-TB Fibrosis
17. Miliary TB
18. Tubercular Pericarditis
 Tools for diagnosis of TB (contd.)
• Tuberculin skin test (Mantoux Test)
➢Used for diagnosis of Latent TB
➢Only expresses presence of infection, does not confirm
TB disease
➢Adjunct tool in those unable to produce sputum/sample
➢Previous exposure to NTM (non-TB Mycobacteria) gives
false +ve result
➢False –ve in immunocompromised eg. HIV co-infection,
immunosuppressive therapy), severe malnutrition &
miliary TB
 Tools for diagnosis of TB (contd.)
• Culture of TB bacilli :
➢Considered as gold standard
➢Used for follow up of drug resistant TB treatment to
detect early recurrence
➢Can detect low numbers of TB bacilli
➢Culture can be in solid media (eg. Lowenstein-Jensen
media, Middlebrook 7H 10 or 7H 11, Ogawa) or liquid
media (eg. BACTEC & MGIT)
➢Liquid culture system detects growth of MTB faster than
solid culture
 Tools for diagnosis of TB (contd.)
• Rapid Molecular Diagnostic Tests (RMDT)
➢Xpert MTB/RIF (GeneXpert) :
✓GeneXpert is a CB-NAAT test that detects DNA
sequences, specific for MTB complex and Rifampicin
resistance by PCR
✓Samples that can be tested are pleural fluid,
pericardial fluid, ascitic fluid, cerebrospinal fluid,
synovial fluid, aspirate (FNAC), tissue, lymph node
aspirate, lymph node biopsy and pus.
✓Testing of blood, urine and stool samples are not
recommended
✓ Early morning sample preferable.
 Tools for diagnosis of TB (contd.)
• Line Probe Assay (LPA)
– PCR based technologies using various modifications
– used for detecting the presence of putative resistance
genes for Rifampicin, Isoniazid and Fluoroquinolones,
and also for second line injectables etc.
– First line LPA (FL-LPA) detect resistance to Rifampicin
and Isoniazid
– Second line LPA (SL-LPA) detect resistance to
Fluroquinolones and second line injectable drugs (FQs
and the SLIDs)
 Tools for diagnosis of TB (contd.)

• FNAC, Biopsy and Histopathology for EP TB : These are

special tests for confirmation of extra-pulmonary TB and
should be performed by the concerned specialists. Detection
of granulomatous inflammation consisting of non-
necrotizing, caseating granulomas along with giant cells,
epitheloid cells, lymphocytes & histiocytes on
histopathological examination of the biopsy material
obtained from body tissues such as lymph node, peritoneum
(laparoscopic), synovium, spine, bone, liver, spleen, genital
tract, etc. are strongly suggestive of tuberculosis
 Dx Tools of EPTB
TB Lymphadenitis
• Specimen: cervical, submandibular, supraclavicular,
inguinal, axillary LN
• FNAC or Biopsy followed by histopathology

Miliary TB
• CBC : Anemia, leucopenia, neutrophilic leucocytosis &
leukamoid reaction
• Bacteriological confirmation sometimes possible from
sputum, CSF, bone marrow, BAL is more sensitive
• Radiology : HRCT chest >>> X-ray chest
 Dx Tools of EPTB (contd.)
Tubercular pleural effusion
• Pleural fluid analysis : rarely shows AFB, C/S is also no
immediate help. WBC is variable and lymphocyte and
monocyte predominant. ADA is usually high.
• Aspirate is exudative (protein is >3 g/l)
• Presence of pus indicate empyema
• Definitive dx is pleural biopsy & histopathology
– Closed pleural biopsy : 75% Dx yield in single, but increase on
multiple biopsies
– Open pleural biopsy : Increase yield further
 Dx Tools of EPTB (contd.)

• False (+) ve ADA may be found in

– Lymphoma/Hematological malignancy
– RA
– SLE
– Adenocarcinoma of lung
– Mesothelioma
– Para-pneumonic effusion
– Empyema (due to other bacteria)
 Dx Tools of EPTB (contd.)
• False (–) ve ADA may be found in
– Early phase of TB
– Elderly patients
– Current smokers

❖ADA is of two types : ADA-1 & ADA-2

ADA-2 is increased in TB, whereas ADA-1 maybe raised in
empyema & other conditions
In cases of suspected false negative or positive ADA levels, the
ADA-1/ADA(total) ratio is a good parameter
Rise in ADA-2 is expressed by low level of ADA-1/ADA(total) in
tubercular pleural effusion
 Dx Tools of EPTB (contd.)
Pericardial effusion
• ECG, X-ray of chest
• Echocardiography

TB Ascites
• Ascitic fluid analysis : Exudative in nature, ADA maybe
high, yield of microscopy Xpert and culture is very low
• USG shows enlarged mesenteric and retroperitoneal LN
• Definitive dx is peritoneal biopsy & histopathology
• Laparoscopy is also done which shows tubercle
• Laparotomy will confirm near all case but it is too invasive
 Dx Tools of EPTB (contd.)
Gastro-intestinal TB
• Barium examination of small and large bowel
• Colonoscopy followed by biopsy & histopathology
Spinal TB (Pott’s disease)
• Plain X-ray spine usually diagnostic – shows erosion of
anterior edges of sup. & inf. borders of adjacent vertebral
bodies with narrowing of disc space
• CT scan or MRI (more specific)
• Confirmed by aspiration of abscess or bone biopsy followed
by histopathology & culture
 Dx Tools of EPTB (contd.)
Joint TB
• X-ray of joint - bone erosion, joint space narrowing &
ultimately joint destruction
• Confirmation by synovial biopsy & histopathology
Genito-urinary TB
• Urine analysis gives abnormal result in 90% of cases,
revealing pyuria and haematuria. Sterile pyuria first raises
the suspicion of Renal TB.
• AFB/Xpert MTB/RIF from centrifuge urine specimen helps
in diagnosis
• Culture of three consecutive morning urine specimens
yields a definitive diagnosis in nearly 90% cases
 Dx Tools of EPTB (contd.)
Hepatic And splenic TB
• Ultrasound or CT scan and guided FNAC give diagnosis in
most of the cases.
 Aims of treatment
Short Course Chemotherapy (SCC) is the recommended
treatment for tuberculosis. The aims of treating TB are:
• To render the patient non-infectious, break the chain of
transmission and decrease pool of infection.
• To cure the TB patient
• To prevent death from active TB or late effects (disability)
• To prevent relapse of TB
• To prevent the development of acquired drug resistance
 Classification based on anatomical site

Pulmonary TB (PTB)
• Any bacteriologically or clinically diagnosed case of TB
involving the lung parenchyma or the tracheobronchial tree
• A patient with both pulmonary and extra-pulmonary TB
should be classified as a case of PTB
Extra-pulmonary TB (EP TB)
• Any bacteriologically or clinically diagnosed case of TB
involving organs other than the lungs such as pleura, lymph
nodes (mediastinal, hilar, cervical etc.), larynx, meninges,
abdomen, genitourinary tract, spine, bones and joints, skin
etc.
 Classification based on drug resistance
Mono resistance Refers to resistance to one first line anti-TB drug only.

Poly-resistance Refers to resistance more than one first line drug, other than Isoniazid and
Rifampicin together.

Multi-drug Refers to resistance to at least Isoniazid and Rifampicin together, the most
Resistance potent anti-TB agents, with or without resistance to other first line drugs.
TB(MDR-TB)

Extensively Refers to MDR TB with additional resistance to Moxifloxacin or

Drug Resistance Levofloxacin and to one of two other group A drugs(BDQ/LZD)
Tb(XDR-TB)

Rifampicin Refers to resistance to Rifampicin, detected using phenotypic or genotypic

Resistance(RR) methods.
 Treatment category for all TB patients
(UPDATED)

New TB patients
• Never been treated for TB or have taken ATT for <1 month

Previously treated TB patients

• Received >1 month ATT in the past
• Based on the outcome of their most recent course of
treatment, they are sub-classified as - Relapse, Treatment after
failure, Treatment after loss to follow up and Other previously treated
 New TB patients (UPDATED)

All Drug Sensitive TB (DS TB) patients, whether bacteriologically

confirmed or clinically diagnosed, will receive the standard Treatment
Regimen comprising of 4 drugs – HRZE - for the initial 2 months
(Intensive Phase) and 2 drugs – HR - for the remaining 4 months
(Continuation Phase).

May be extended in certain forms of EP-TB like CNS TB, Skeletal

TB, Disseminated TB etc. based on clinical decision of the treating
physician on a case-to-case basis
 Previously Treated TB Patients (UPDATED)

Relapse Patient previously been treated for TB, were declared cured or
treatment completed , and now diagnosed with a recurrent
episode of TB.

Treatment Patients are those who have previously been treated for TB and
after failure whose treatment failed at the end of treatment.

Treatment Patients have previously been treated for TB and were

after loss to declared lost to follow up at the end of treatment.
follow up

Other Patients have previously been treated for TB but whose

previously outcome of treatment at the end of their treatment is unknown
treated or undocumented.
 Previously Treated TB Patients (contd.)
(UPDATED)

All cases will be subjected to drug susceptibility testing (DST) and

the regimen decided based on the DST results.

If DST shows that patient is susceptible to both rifampicin and

isoniazid, all bacteriologically confirmed previously treated
pulmonary as well as extra-pulmonary TB patients will be given
Cat.1 regime.

May be extended in certain forms of EP-TB like CNS TB, Skeletal

TB, Disseminated TB etc. based on clinical decision of the treating
physician on a case-to-case basis.
 Previously Treated TB Patients (contd.)
(UPDATED)

All clinically diagnosed pulmonary TB cases with a history of

previous treatment (PT Cases) will be given a 4-drug regimen for 6
months (6HRZE).

If DST shows Rifampicin-susceptible but Isoniazid-resistant TB (Hr-

TB) or INH DST result not available/not done, are given a 5-drug
regimen for 6 months [6 (H)REZ- Lfx].

Patients with additional resistance patterns need to be managed

accordingly.
 Treatment for Extra-Pulmonary TB
Patient (UPDATED)

All TB patients will receive the same treatment as pulmonary TB patient and the total
duration of treatment too will remain the same, i.e initial 2 months of intensive phase
followed by 4 months of continuation phase.

For certain complicated/severe forms of EP-TB a total of 12 months of treatment may

be considered by the treating physicians. i.e.,2 months of IP(HRZE) followed by up to
10 months of continuation phase to be decided at the end of 6 months of treatment.

EP-TB Patients who do not improve at the end of 6 months must be investigated for
drug resistant TB and should be referred to specialist physicians or medical college
hospital or NIDCH.
Treatment for Extra-Pulmonary TB
Patient (contd.) (UPDATED)
TB Lymphadenitis
• Duration - 6 months initially, then based on clinical judgment
of the treating physician, the continuation phase may be
extended upto10 months
• Should also be investigated for DR-TB at the end of 6 months
of treatment

Osteo-articular TB and Spinal TB (Pott’s disease)

• Duration - 12 month
Treatment for Extra-Pulmonary TB
Patient (contd.) (UPDATED)
TB Meningitis
• Duration - 12 months because of the uncertain penetration of
the BBB by some anti-TB drugs
• All patients with TB meningitis (and TB pericarditis), an
initial adjuvant corticosteroid therapy with dexamethasone or
prednisolone, tapered over 6-8 weeks, should be used
• The drug most frequently used is prednisolone, in a dosage of
0.5 – 1 mg/kg daily, increased up to 2 mg/kg daily in the case
of severely ill patients, for 4 weeks
• The dose should then be gradually tapered down @ 2.5 - 5
mg every week over 4 to 8 weeks, 1-2 months in total
duration.
 Standardized Treatment Regimen
(UPDATED)
TB Diagnostic Type of patient Treatment Treatment
category
Intensive phase Continuation phase
(Daily) ( Daily)
New Case Bacteriologically
Positive PTB patient
(never been
treated for TB or
Bacteriologically
have taken ATT
Negative PTB Patients
for < 1 month)
2 (HRZE) 4 (HR)
Extra pulmonary TB

TB/HIV co infected
 Standardized Treatment Regimen
(UPDATED)
Treatment
TB Diagnostic
category Type of patient Intensive phase Continuation phase
(Daily) (Daily)

Previously Treated If no resistance to TB Drugs

Cases (received >1 ( both H and R Sensitive
month ATT in the pulmonary and extra 6 HRZE
past) pulmonary TB Cases)
Clinically diagnosed PTB 6 HRZE
Complicated Extra
pulmonary cases( TB
Meningitis, Neurological TB, 12 HRZE- Lfx
Bone TB, Non Resolving
Lymph Node)
If Rif susceptible and INH
resistant or unknown in
bacteriologically confirmed 6 (H)RZE-Lfx
PTB & EP-TB
 Drug Doses
Weight (kg) Intensive Continuation INH Resistant
phase phase +
Complicated EP-TB
4 FDC Daily 2 FDC Daily 4 FDC Levofloxacin
(first 2 month) (next 4month) (6 month) 250mg (6
month)
30-37 2 Tablets 2 Tablets 2 tablets 2 tablets

38-54 3 tablets 3 tablets 3 tablets 3 tablets

55-70 4 tablets 4 tablets 4 tablets 4 tablets

> 70 5 tablets 5 tablets 5 tablets 5 tablets

 Follow up sputum examination in
pulmonary smear +ve TB patients
(UPDATED)
Phase of Sputum smear If Smear If smear Positive
treatment examination at Negative

Test on Xpert MTB/Rif

❖ If Rif sensitive, start Pt on
Intensive End of Month 2 Start pt on CP CP
phase (IP) ❖ If resistant, declare
Treatment failure and start
DR TB management.
End of Month 5 Continue CP Declare Treatment failure
and evaluate drug
Continuation resistance.
phase (CP)
End of Month 6 Declare cure Declare Treatment failure
and evaluate drug
resistance.
 Management of New smear +ve cases after interrupting
treatment (UPDATED)
Length of Length of GeneXpert Record Re-Register Treatment
treatment Interruption Treatment
outcome

Continue treatment and

compensate for missed
Less then Not required NO NO doses. Total number of
1 month dosed planned for initial
and cont phase should be
given.

Less than MTB Not NO NO Continue treatment and

1 month detected compensate for missed
More than doses.
1 month
MTB detected Restart Treatment and
but Rif NO NO complete full course
sensitive
RR detected Yes(as DR Start DR TB Mx
NO TB)
 Management of New smear +ve cases after interrupting
treatment (contd.) (UPDATED)
Length of Length of Gen Xpert Record Re-Register Treatment
treatment Interruptio Treatment
n outcome

Less than 2 MTB not NO NO Continue treatment and

month detected compensate for missed
doses
NO ( if Rx < 5 NO
months)
More than MTB Detected Yes ( if Rx >5 Register as •If R & H sensitive, Start
1 month months) ,as Treatment CAT 1.
Failure after failure •If H Resistant or
unknown then retreatment
regimen with Lfx

More than MTB detected Yes ,record as As TALF Depends on Xpert

2 month lost to F/U MTB/Rif
If RR detected Lost to F/U As DR TB DR TB Mx

MTB not Lost to F/U As TALF On clinical evaluation

detected
TB IN SPECIAL SITUATIONS
 LIVER DISORDER
• Patients with past history of acute hepatitis and
excessive alcohol consumption, provided there is no
clinical evidence of chronic liver disease i.e., a
normal liver function; can receive the usual regimen.
• Should be closely monitored.
• Hepatotoxic reactions to anti-TB drugs may be more
common among these patients and should therefore,
be anticipated and regularly evaluated.
 Drug-Induced Hepatitis

• Anti-TB drugs can cause liver damage. Pyrazinamide is the

most hepatotoxic, followed by Isoniazid and Rifampicin
1
• Hepatitis during TB treatment may be due to the effect of
anti-TB drugs but may also be due to other cause/s. It is
2 important to rule out other causes before concluding that the
hepatitis is drug-induced

• If the diagnosis of drug-induced hepatitis is made, the anti-

TB drugs should be stopped and withheld until the jaundice
3 or hepatic symptoms have resolved and liver function tests
have returned to normal.
 Drug-Induced Hepatitis (contd.)

• In most cases, the patient can be restarted on the

4 same drugs without the recurrence of hepatitis

• This can be done either gradually (drugs reintroduced one

after the other; less hepatotoxic to more hepatotoxic) or all at
5 once (if mild hepatitis).

• However, if the hepatitis produced severe jaundice, it is

6 advisable to avoid Rifampicin and Pyrazinamide altogether.
 Drug-Induced Hepatitis (contd.)
(UPDATED)
The alternative regimen depends on the suspected
drug causing the toxic hepatitis, suggested regimens
in such patients are as follows, if:

➢ Pyrazinamide is involved: 2 HRE 7 HR or 9HRE

➢ Isoniazid is involved: 9 RZE

➢ Rifampicin is involved: 9 Lfx-HZE

➢ Pyrazinamide and Rifampicin are involved: 10 Lfx-HE

 Minor Adverse Drug Reactions
• Visual impairment :
o Drug responsible – Usually Ethambutol
o Mx -
➢ Loss of red green colour distinction is usually the first
sign. In this case stop the drug permanently
➢ Usually reversible after discontinuation of the drug
• Itching with minor skin rash :
o Drug responsible – All drugs
o Mx -
➢Rule out other causes of itching not related to drugs
➢Add oral antihistamine
 Minor Adverse Drug Reactions (contd.)

• Itching with moderate to severe skin rash :

o Drug responsible – All drugs
– Mx –
➢Stop all anti TB drugs
➢In severe rash, oral/ IV anti histamine + IV/IM
Corticosteroids (eg. Dexamethasone 5mg TDS)
➢Once rash is resolved, determination of the causative drug by
re-challenging with sequential introduction of anti TB drugs
in following order – H>R>Z>FQ>E
➢Drug causing Steven-Johnson Syndrome should never be
introduced
 Minor Adverse Drug Reactions
(contd.)

Drug Challenging Dose (Example)

Day 1 Day 2 Day 3
Isoniazid 50 mg 100 mg 300 mg
Rifampicin 75 mg 300 mg Full dose
Pyraziamide 250 mg 500 mg 1 gm
Ethambutol 100 400 Full dose
 Acute Viral Hepatitis

• TB treatment should be deferred until the acute hepatitis has

1
resolved.

• Once resolved, can receive the usual anti-TB regimens provided

2 no clinical and bio-chemical evidence of liver impairment.

• Hepatotoxicity to anti-tuberculosis drugs may be more common

3 among these patients and should therefore be closely monitored
with routine LFTs.
• If unstable and persistent hepatitis, treat with →Isoniazid,
Rifampicin plus Ethambutol for 8 months and avoid
4 →Pyrazinamide.
 Chronic Liver Disease

• Patients with chronic liver disease should not

receive Pyrazinamide.
1

• Isoniazid plus Rifampicin plus Ethambutol can

be used for a total treatment duration of 9
2 months (2HRE/7HR).
 TB in Renal Insufficiency
• Recommended initial TB treatment regimen
for patients with renal failure or severe renal
insufficiency is Isoniazid, Rifampicin,
Pyrazinamide and Ethambutol (HRZE) for 2
1 months, followed by Isoniazid and Rifampicin
(HR) for 4 months

• Isoniazid and Rifampicin are eliminated by

biliary excretion, so no change in dosing is
2 necessary
TB in Renal Insufficiency (contd.)
• Ethambutol and Pyrazinamide have significant
renal excretion; dosing adjustments are
required.
3 • Three times/week at the following doses:
Pyrazinamide (25mg/kg) & Ethambutol (15
mg/kg) specifically in late stages of renal
disease (stage 4 and stage 5).

• While receiving Isoniazid, patients with severe

renal insufficiency or failure should receive
4 Pyridoxine 10 mg daily in order to prevent
peripheral neuropathy.
 TB in Diabetics
• Co-morbidity with TB and Diabetes tends to worsen
the outcomes of both the diseases and there is
increased morbidity and mortality in patients who
1 have TB & diabetes co-morbidity

• Early diagnosis and management of TB in

diabetics as well as diagnosis and proper glycemic
control of diabetes in patients with TB is
2 important to improve outcome of TB treatment
 TB in Diabetics (contd.)
• Treatment of TB is the same as for non-diabetics. It is
important to assess renal function and patients with
renal function impairment should be managed as
3 described previously

• During the course of anti-TB treatment, blood sugar

levels due to diabetes should be strictly controlled,
preferably with insulin
4
 TB in Pregnancy
• Anti-TB treatment should be started as soon as the diagnosis is made, and
the full course of treatment should be given. Most anti-TB drugs are safe to
use during pregnancy.

• All pregnant women should also receive preventive treatment for isoniazid-
related peripheral neuropathy. For this, they should be given oral Vit B6
(Pyridoxine) at a dosage of 10 mg/day along with their anti-TB drugs for the
entire duration of treatment.

• Rifampicin can increase the metabolism of vitamin K, resulting in clotting

disorders. Prophylactic administration of vitamin K to the mother and the
neonate is recommended to prevent the risk of post-natal haemorrhage when
the mother has received rifampicin during pregnancy

• In Previously Treated pregnant cases, fluoroquinolones like Lfx should be

avoided and instead, 4FDC (RHEZ) for 6 months should be prescribed.
 TB in Pregnancy (contd.)
• FOR THE MOTHER:
➢ Vitamin K; PO: 10 mg/day for the 15 days prior to
expected date of delivery

• FOR THE NEW-BORN INFANT:

➢ Prophylactic IM vitamin K to prevent haemorrhagic
disease of the new-born.
➢ Vitamin K; IM: 1 mg as a single dose, the day of birth
Previous Year Question Assessment
• 1) Give a brief account on role of GeneXpert in diagnosis
of Tb
• 2) A 45-year-old man has presented with weakness of both
lower limbs & difficulty in urination for three months. He
has been given anti-TB drugs empirically for one month
without considerable improvement. He has received Cat-1
anti-TB for pulmonary TB 10 years ago. Evaluate, Inv.,
supportive Rx
• 3) A 25-year-old man presents with a discharging sinus on
the left side of the neck at four months of cat-1 anti-TB
drugs. How will you manage the patient?
• 4) How would you manage a case of smear positive
pulmonary TB who developed jaundice on 10th day of anti-
TB treatment?
• 5) A 20-year-old lady developed jaundice while on anti-TB
drugs. How will you manage her?
• 6) Discuss the diagnosis & management of miliary TB
• 7) How would you diagnose a case of latent TB?
• 8) Write down the management of anti-TB drug reaction
• 9) Briefly discuss the anti-TB treatment in patient with
Hepatitis
• 10) Outline the management of patient with tubercular
pericardial effusion who has developed jaundice at two
weeks of taking anti-TB drugs
• 11) Outline the management of drug-induced hepatitis in a
patient with tuberculous pericardial effusion
• 12) Discuss the indications of GeneXpert test for diagnosis
of TB
• 13) What is XDR TB? Write down its treatment strategy
• 14) A 35 year old woman with TB lymphadenitis developed
severe itching with rash after starting Cat-1 anti-TB therapy.
How will you manage her?
• 15) A 30-year-old woman presented with recurrent fainting
attacks, weakness and vomiting. She also complains of
vertigo on standing. She gives history of taking anti-TB
treatment about 2 years back. Checklist of clinical
information, Inv., Rx
• 16) How will you manage a sputum positive TB patient who
showed no improvement on follow up after one month?
• 17) How would you manage a 30-year-old woman with
PTB not responding to cat-1 anti-TB therapy?
• 18) A smear positive PTB patient bon cat-1 treatment for
two months with no clinical improvements. How would you
evaluate & mange him?
• 19) A 26-year-old woman presented with fever & ascites for
3 months. She is on anti-TB therapy without any response
for 2 months. How would you evaluate her clinically &
proceed to investigate?
• 20) How would you diagnose cryptic TB?
• 21) Enumerate the principles of treatment of drug resistant
TB
• 22) How would you treat & monitor abdominal Tb in a 40-
year-old man with cirrhosis of liver?
• 23) How would you manage a patient with MDR TB?
• 24) How would you evaluate a suspected patient with MDR
TB?
• 25) How would you manage a patient developing jaundice
two weeks after anti-TB therapy?
• 26) Discuss the management of complication of tubercular
meningitis
• 27) How sputum examination helps in monitoring response
to therapy in patient with PTB?
• 28) How would you treat a smear positive PTB in a patient
with stage 4 CKD?
• 29) How will you manage a pregnant woman with PTB?
• 30) How will you manage a smear positive TB patient who
presented with severe jaundice one month after starting cat-
1 anti-TB drugs?
• 31) How will you diagnose smear negative PTB?
• 32) Discuss fallacies of Tuberculin test in the diagnosis of
TB
 Answers
1) Slide 51
2) Aim of evaluation
a) Whether this episode is TB or not
If TB – Need to check the regimen
- Need to exclude drug resistant TB
If not TB – Need to diagnose the D/D of spinal cord compression
i) Compressive eg. Trauma, Malignancy
ii)Non-compressive eg. MS, TM
b) Assessment of urgent neurological complications due to spinal cord
compression
 Answers (contd.)
Evaluation : Inv.:
Age – 45 yrs CBC with ESR with PBF
Sex – Male Urine R/E
Presenting complains - Weakness of both lower limbs & Chest X-ray, ECG
difficulty in urination for 3 months CRP
Past history – PTB 10 yrs back X-ray Lumbosacral spine B/V
Drug history – Cat 1 ATT 10 years back MRI of LS spine with whole spine screening
- Empirical ATT for 1 month MT
History of present illness – RBS, SGPT, Creatinine
Onset S. Calcium, ALP
Duration: 3 months USG with PVR
Progression DST
Any H/o - Trauma
- Back pain, specially at night Few special Inv.
- Weight loss, Night sweat, Fever CT guided FNAC from spinal lesion
- Cough Colonoscopy & endoscopy
- Anorexia, nausea , GI symptoms MRI brain & spine, VEP
- Visual problems Protein electrophoresis
- Features of hypercalcemia CSF analysis
ATT drug history – Check
Dose
Compliance
Adverse effect
 Answers (contd.)
• Supportive Rx
Bed rest
Catheterization
If spinal cord compression is present – Steroid & urgent
referral to neurosurgeon/spine surgeon for relief of
compression
Further Rx according to Inv. findings
THANK YOU ALL