Prof.dr.

Tamsil Syafiuddin,SpP(K)
Pulmonary Department
Faculty of Medicine
Universitas Islam Sumatera Utara
PULMONARY
TUBERCULOSIS
Levels of competence
Standar Kompetensi Dokter , Konsil Kedokteran Indonesia, 2006
Standar Kompetensi Dokter , Konsil Kedokteran Indonesia, 2006
Level of competence 4:
Mampu membuat diagnosis klinik berdasarkan
pemeriksaan fisik dan pemeriksaan tambahan
yang diminta oleh dokter (misalnya: pemeriksaan
laboratorum sederhana atau X-ray).
Dokter dapat memutuskan dan mampu menangani
problem itu secara mandiri hingga tuntas.
TB
PROBLEMS
IN PUT
OUT PUT
(Dokter)
System/Faculty of Medicine
Medical Education as a System
Definition
Tuberculosis infection means that
Mycobacterium tuberculosis has infected a
host but is not causing disease

Tuberculosis disease or tuberculosis
means the disease caused by M.
tuberculosis
Epidemiology
WHO estimates >8 million new cases of
tuberculosis per year
Estimated that 19-43% of the worlds
population is infected with M. tuberculosis
Infected persons serve as reservoirs for
activated disease to occur
Among infectious diseases, TB remains
the second leading killer of adults in the world

More than 2 million TB-related deaths each year
Tuberculosis (TB) is The Ancient Killer The Great
Imitator The Giant Poverty Producing Mechanism
( Guzman et al 1999 )
Indonesia : 3rd in the World MDR-TB 12 20% / year ,
mortality 175.000 / year , 500 / day
( WHO Report 2000 )
Pulmonary TB (Indonesia)
Source
Child
Young adult
Adult
DM
HIV
NATURAL HISTORY
reservoirs
Data:
Analysis
Planning
TB ?
Batuk
Umur muda
Foto
toraks
The scientific thinking
Batuk darah
Riwayat demam
Napsu makan
Data:
Analysis
Planning
TB ?
Batuk
Umur tua
DM,HIV AIDS ?
Foto Toraks
The scientific thinking
Batuk darah
Riwayat demam
Napsu makan
Tuberculosis
History
Evidence dating back to 2400 BC
Called pthisis: Greek for consumption
Herman Brehmer: botany student from
Poland with TB, returned from Himalayans
cured; doctoral dissertation in 1854 entitled
Tuberculosis is a Curable Disease
1882: Robert Koch identified organism with
newly developed staining technique
Advent of x-ray technology in 1895 allowed for
assessment of severity and progression of
disease

Tuberculosis
History
Early 20th century: French bacteriologists
Calumet and Guerin developed technique that
led to BCG vaccine
Advent of anti-TB chemotherapy
1940 actinomycin
1943 streptomycin
1950s combination therapy
2003 - fix dosed combination
2008 UISU students
Pathogenesis
M. tb ingested by macrophages in alveoli
May survive and multiply
Spread by lymphatics to hilar nodes
Cellular immunity develops 2-12 wks after
infection and usually limits M. tb growth in
granulomas which are small, inapparent
Active disease seen in 10%, with half
within the first 2 years
Source
Child
Young adult
Adult
DM
HIV
NATURAL HISTORY
reservoirs
Pulmonary Disease
Symptoms of cough which starts non-
productive and becomes sputum
Other symptoms include pleuritic pain,
hemoptysis
Physical exam is usually not helpful
Chest X ray findings are important
primary disease with middle, lower lung infiltrates
with hilar adenopathy
reactivation with upper lobe disease and
cavitation

Diagnosis of Tuberculosis
Clinical finding
Requires positive PPD skin test and/or
Chest X ray findings consistent with TB
With confirmation by positive direct and
culture AFB from specimen
pulmonary disease with sputum collection (3
single specimens) or gastric aspirates in child or
bronchoscopy in rare instances
specimens from urine, nodes, etc. if extra
pulmonary site is suspected
filling good
money
doctors
advers drug
others
TSY, World TB Day 2003.
Reason for treatment cessation
(Syafiuddin T et al, 2003)
51 %
36 %
4 %
4 %
4 %
10
6

Time
Pattern of Myc. tbc resistance
(Basic theory of multiple drugs adm.)
+ + + + +
Rise & fall phenomena
Lag phase :
Cessation of microbial metabolism
in period of time
Myc. tbc (72 hours )
Once a day Once for three day
Drug administration
SYMPTOMS
DIAGNOSIS
TREATMENT
OUT COME
PROBLEMS and NATURAL HISTORY
Pulmonary TB (Indonesia)
Delays of diagnosis:
Patients delays : 4.78 Moths
Doctors delays : 3.64 Moths
Clinical Manifestations
Systemic-fever, malaise, night sweats, wt
loss
Extrapulmonary- disseminated (HIV and
immune compromise) with multiorgan
involvement
lymph node, pleura, GU, bone, CNS, GI,
pericardial
Diagnosis of Tuberculosis
Use of skin test of 5 U tuberculin PPD given
intradermal
>5 mm induration is positive for infection for
contacts of TB cases, HIV, Xray fibrosis (old
disease), immune suppression
>10 mm induration is positive for persons in
high prevalence countries, IDU, prisons and
jails, medical conditions, children < 4 y/o
exposed to adults in high risk categories
> 15 mm induration with no risk factors for TB

National Mortality Rate
Cardiovascular diseases
( 1
st
rank )
Tuberculosis
( 2
nd
rank )
Pneumonie
( 3
rd
rank )
Asthma, bronchitis chronic
and emphysema
( 6
th
rank )
( SKRT DepKes RI 1992)
Pulmonary TB (Indonesia)
3
rd
rank in the world
2
nd
rank cause of death
lost of cases
Multi drug resistance cases
Pulmonary remodelling cases
* One new TB case / minute
* One new infectious TB case / 2 minutes
* One TB died / 4 minutes
Pulmonary TB (Indonesia)
1 juta
2 juta
3 juta
4 juta
5 juta
1850 2050 2000 1950 1900
Penemuan
basil TB

(1882)
Mulai adanya
sanatorium

(1900)
Penemuan
OAT I

(1945)
Deklarasi WHO:
TB merupakan
kedaruratan global

(1993)
Perkiraan kecenderungan jumlah kematian akibat TB
di seluruh dunia menjelang abad 21
I nt J Tuberc Lung Dis 1998; 2(9): 696-703.
World TB Day 2003 Rozaimah Zain-Hamid
MERUPAKAN MASALAH NASIONAL
bahkan GLOBAL EMERGENCIES
PREVALENSI TB TIDAK DAN
ANGKA KEMATIAN YANG TINGGI
World TB Day 2003 Rozaimah Zain-Hamid
TSY, World TB Day 2003.
<1 month
1-2 month
3-5 month
>6 month
25 %
29 %
35 %
11 %
Duration of symptoms
(Syafiuddin T et al, 2003)
Source
Child
Young adult
Adult
DM
HIV
NATURAL HISTORY
reservoirs
< 1 bulan
2 month
3 month
4-5 mnth
TSY, World TB Day 2003.
Duration of treatment (Syafiuddin T et al, 2003)
24 %
26 %
39 %
11 %
Bidan/perawat/
mantri
Dokter Umum
Spesialis/PPDS
Paru
Spesialis lain
World TB Day 2003 Rozaimah Zain-Hamid
TENAGA MEDIS YANG PERTAMA KALI
MEMBERIKAN PENGOBATAN KEPADA
PENDERITA TB PARU
Syafiuddin T dkk, 2003
51 %
35 %
8 %
6 %
Pulmonary tuberculosis
(Indonesia)
3
Rd
rank in the world
2
nd
rank cause of deads
Higher on lost of cases
Pulmonary remodelling cases
Multi drug resistance cases
Perception
Diagnosis
Tuberculosis
( MHLC 96 - 97 )
Insurance Private
Lost of cases 65 % 68 %
Tuberculosis
Treatment
Requires multidrug regimen
Susceptibility testing of initial isolates
critical
The American Thoracic Society and CDC
recommend initial therapy be given with
four drugs:
isoniazid, rifampin, pyrazinamide and
ethambutol or streptomycin
Pulmonary tuberculosis
Clinical examination
Radiologic examination
Laboratoric examinatioon
History
Pulmonary tuberculosis
Clinical examination
Age
Respiratory problems
Pulmonary tuberculosis
Radiologic examination
Cloudy swelling
Multiform
Pleural effusion
Pulmonary tuberculosis
Laboratory examination
Direct smear
Culture
Mantoux test
DNA test
Pulmonary tuberculosis
Suspected pulmonary Tb
Pulmonary Tb
Post pulmonary Tb

Suspected pulmonary Tb
Clinically (+)
History (+)
Radiology(+)
Laboratory(-)
Clinically (+)
History (-)
Radiology (+)
Laboratory (-)
1
st
Category
1
st
Category
Pulmonary Tb
Clinically (+)
Radiology (+)
History ( - )
Laboratory (+)
Clinically (+)
Radiology (+)
History (+)
Laboratory (+) 2
nd
Category
1
st
Category
Post pulmonaryTb
Clinically ( +)
Radiology (+)
History (+)
Laboratory (-)
Clinically (-)
Radiology (-) or (+)
History (+)
Laboratory (-)
No treatment
Symptomatic
3
rd
Category :
Guideline of anti tb drugs
(tb control program in Indonesia,
based on WHO recommendation)
1
st
Category : ( 2 HRZE/ 4 H3R3 )

( 2 HRZE/ 4 HR )
2
nd
Category : ( 2 HRZES + HRZE/ 5 H3R3E3 )
( 2 RHZES/ 5 RHE ) (Relapse, failure, AFB + )

3
rd
Category : ( 2 HRZ/ 4 H3R3 )
( 2 HRZ/ 4 HR)
(New cases, AFB - )
4
th
Category : ( H long-life ? )
(Chronic tb)
(New cases, AFB + ,
AFB , Ro +, severe illness)
Treatment Principles
Regiment must contain multiple drugs to
which the TB is susceptible

Drugs must be taken regularly

Drugs must be continued for sufficient time
Doses of anti tb drugs
(tb control program in Indonesia,
based on WHO recommendation)
1
st
Category
Intensive : H 300 mg , R 450 mg, Z 1500 mg, E 750 mg
phase
Intermittent : H 600 mg , R 450 mg
phase
2
nd
Category
Intensive : H 300 mg , R 450 mg, Z 1500 mg, E 750 mg
phase S 750 mg
Intermittent : H 600 mg , R 450 mg
phase
Doses of anti tb drugs
(tb control program in Indonesia,
based on WHO recommendation)
3
rd
Category
Intensive : H 300 mg , R 450 mg, Z 1500 mg,
phase
Intermittent : H 600 mg , R 450 mg
phase