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TUBERCULOSIS
Prof.dr.Tamsil Syafiuddin,SpP(K)
Pulmonary Department
Faculty of Medicine
Universitas Islam Sumatera Utara
Levels of competence
OUT PUT
IN PUT System/Faculty of Medicine
(Dokter) TB
Definition
Tuberculosis infection means that
Mycobacterium tuberculosis has infected a
host but is not causing disease
reservoirs
Child
Young adult
DM Adult
NATURAL HISTORY HIV
The scientific thinking Data:
Batuk
Umur muda
Batuk darah
Riwayat demam
Napsu makan
Analysis
TB ?
Foto
toraks Planning
The scientific thinking Data:
Batuk
Umur tua
Batuk darah
Riwayat demam
Napsu makan
Analysis
TB ?
DM,HIV AIDS ?
Planning
Foto Toraks
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
reservoirs
Child
Young adult
DM Adult
NATURAL HISTORY HIV
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
Reason for treatment cessation
(Syafiuddin T et al, 2003)
4%
4%
4%
filling good
money
51 % doctors
36 % advers drug
others
+ + + + +
Time
Lag phase :
Cessation of microbial metabolism
in period of time
Drug administration
SYMPTOMS
DIAGNOSIS
TREATMENT
OUT COME
Cardiovascular diseases
( 1 st rank )
Tuberculosis
( 2 nd rank )
Pneumonie
( 3 rd rank )
Asthma, bronchitis chronic
and emphysema
( 6th rank )
Pulmonary TB (Indonesia)
5 juta
4 juta
3 juta
2 juta
Deklarasi WHO:
1 juta Penemuan Mulai adanya Penemuan TB merupakan
basil TB sanatorium OAT I kedaruratan global
(1882) (1900) (1945) (1993)
1850 1900 1950 2000 2050
11 %
35 % <1 month
1-2 month
25 %
3-5 month
>6 month
29 %
reservoirs
Child
Young adult
DM Adult
NATURAL HISTORY HIV
Duration of treatment (Syafiuddin T et al, 2003)
11 %
24 %
< 1 bulan
2 month
39 % 3 month
26 % 4-5 mnth
6%
8%
Bidan/perawat/
mantri
Dokter Umum
35 %
Spesialis/PPDS
51 % Paru
Spesialis lain
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
Clinically (+)
History (-)
Radiology (+)
1 st Category Laboratory (-)
Suspected pulmonary Tb
Clinically (+)
History (+)
Radiology(+)
Laboratory(-) 1 st Category
Clinically (+)
Radiology (+)
History (+)
2 nd Category Laboratory (+)
Pulmonary Tb
Clinically (+)
Radiology (+)
History ( - )
1 st Category
Laboratory (+)
Clinically (-)
Radiology (-) or (+)
History (+)
No treatment Laboratory (-)
Post pulmonaryTb
Clinically ( +)
Radiology (+)
History (+) Symptomatic
Laboratory (-)
Guideline of anti tb drugs
(tb control program in Indonesia,
based on WHO recommendation)
4 th Category : ( H long-life ? )
(Chronic tb)
Treatment Principles
Regiment must contain multiple drugs to
which the TB is susceptible
3 rd Category