Tuberculosis in General Practice

Key Concepts

Latent TB vs. Active TB
Clinical features of TB (cough, sputum, appetite loss, weight loss, fever, night sweats, hemoptysis)
Primary Pulmonary TB vs. Post-Primary TB
Ghon complex
Silicotuberculosis
Notifiable disease
Steroids in TB treatment
Anemia of chronic disease
Laryngeal TB
Miliary TB
TB diagnosis (sputum smear, culture, NAAT, bronchoscopy)
Cavities in TB
Lymphadenopathy
Pleural effusion (exudative)
Empyema
Vertebral TB (Pott's disease)
Drug-sensitive TB vs. Drug-resistant TB (MDR-TB, XDR-TB)
DOTS (Directly Observed Treatment, Short-course)
Intensive phase vs. Continuation phase
Fixed-dose combinations (FDCs)
TB Preventive Therapy (TPT)
Side effects of TB drugs (hepatitis, peripheral neuropathy, vision changes)
Non-tuberculous mycobacteria (NTM)

Clinical Features and Diagnosis

Contact History

Crucial for diagnosis. "Did you come into contact with a TB case?"
Example: Social worker distributing sweets at a TB hospital on Republic Day.

Cough

Persistent cough that doesn't improve.
Consider TB if cough lasts for more than two weeks.

Sputum

Essential for diagnosis.
Good quality sputum is crucial for accurate results.
Methods to induce sputum production: hypertonic saline nebulization, gargling with salt water.

Appetite Loss

Significant appetite loss is a key symptom.
Example: "Dal Baati Churma" (a famous dish in Indore) is present, but the person has no desire to eat.

Weight Loss

Significant weight loss: more than 10% of original body weight in a short period (1-2 months).
Differentiate from weight loss due to exercise.

Fever

Low-grade, persistent fever, often more pronounced in the evening or at night.
Paracetamol may not be effective.

Night Sweats

Profuse sweating, especially at night, due to persistent low-grade fever.

Hemoptysis (Coughing up Blood)

"Filmy" symptom, often depicted in movies.
Caused by erosion of blood vessels in lung cavities.
Can range from streaks of blood to large amounts.

Primary Pulmonary TB

Common in children.
Focus on examining lymph nodes rather than lung cavities.
Ghon complex: combination of lung lesion and enlarged lymph nodes.

Silicotuberculosis

Condition seen in individuals exposed to silica dust (e.g., slate pencil factory workers, brick kiln workers).
Combination of silicosis and tuberculosis.

Diagnosis

Sputum smear microscopy: essential for diagnosis.
Sputum culture: solid and liquid media.
Nucleic acid amplification tests (NAATs): rapid and accurate.
Bronchoscopy: used to obtain samples when sputum is not available.

Differential Diagnosis

Cavities are not exclusive to TB; can also be caused by bacterial infections, malignancy, sarcoidosis, hydatid cysts.
Masses in the lungs can be TB or cancer.
Evaluate with sputum tests, microscopy, NAAT, bronchoscopy.

Types of TB

Miliary TB

Widespread dissemination of TB throughout the body.
Characterized by small, millet-seed-like lesions in the lungs.
May require TB treatment even without sputum confirmation.
Steroids may be used in treatment.

Pleural Effusion

Fluid accumulation in the pleural space.
Suspect TB if patient has a history of fever, appetite loss, and weight loss.
Thoracentesis: needle aspiration of pleural fluid for diagnosis.
Complicated vs. Uncomplicated Pleural Effusion:
- Uncomplicated: early stage, fluid can be drained with a needle.
- Complicated: later stage, requires chest tube drainage or surgery (decortication).
Thoracoscopy: visual examination of the pleural space with biopsy.

Vertebral TB (Pott's Disease)

TB of the spine.
Suspect in patients with back pain, fever, and contact history.

Drug-Resistant TB

Drug Sensitivity Testing

Essential to determine drug resistance.
CB-NAAT (Cartridge Based Nucleic Acid Amplification Test): rapid test to detect TB and rifampicin resistance.

Types of Drug Resistance

MDR-TB (Multi-Drug Resistant TB): Resistance to at least isoniazid and rifampicin.
XDR-TB (Extensively Drug-Resistant TB): Resistance to isoniazid, rifampicin, fluoroquinolones, and at least one second-line injectable drug.
Mono-resistant TB: Resistance to only one drug (e.g., isoniazid).

Treatment of Drug-Resistant TB

Complex regimens lasting 18 months or longer.
Requires specialized care and monitoring.
Newer drugs like bedaquiline and delamanid are available.
Treatment is provided free of cost by the government.

Treatment Regimens

Intensive Phase

Initial 2 months.
Four drugs: isoniazid, rifampicin, pyrazinamide, ethambutol (HRZE).

Continuation Phase

4 months.
Two drugs: isoniazid and rifampicin (HR).

Fixed-Dose Combinations (FDCs)

Convenient and improve adherence.
May not be suitable for patients with liver or kidney problems.

DOTS (Directly Observed Treatment, Short-Course)

Essential component of TB control.
Ensures adherence to treatment.
Clinics can become DOTS providers.

TB Preventive Therapy (TPT)

Administered to contacts of TB patients to prevent active disease.
Offered to family members of TB patients.

Side Effects of TB Drugs

Common side effects: nausea, vomiting, abdominal pain, hepatitis.
Ethambutol: can cause optic neuritis (vision changes); baseline eye exam recommended.
Rifampicin: can cause orange discoloration of urine.
Liver function tests (SGOT/SGPT) should be monitored monthly in patients with liver disease or alcohol use.
Advise patients on oral contraceptives to use barrier methods.

Special Populations

HIV-Positive Patients

Higher risk of TB.
HIV testing is mandatory in all suspected TB cases.
Use appropriate precautions during examination (mask, gloves).

Pregnant Women

Avoid streptomycin.
Other TB drugs can be used safely.
Ensure adequate nutrition and vitamin supplementation.

Non-Tuberculous Mycobacteria (NTM)

Mycobacteria other than Mycobacterium tuberculosis.
Can cause TB-like symptoms.
Treatment is different from TB.

Key Takeaways

TB remains a significant public health problem.
Early diagnosis and treatment are crucial.
Drug resistance is a major challenge.
DOTS and TPT are essential for TB control.
Collaboration between healthcare providers and government programs is necessary to eliminate TB.
Always consider TB in patients with persistent cough, fever, weight loss, and contact history.
Utilize available diagnostic tools (sputum smear, culture, NAAT).
Refer patients with drug-resistant TB to specialized centers.
Be aware of the side effects of TB drugs and manage them appropriately.
"TV is not an easy case."
"Time is very important in TB."
"Every TB patient is a detective case."
"If you are treating a TB patient, you are treating the whole family."
"If you are not sure, do a CB-NAAT."
"Don't underestimate TB."
"TB is a notifiable disease."
"TB is a social disease."
"TB is a disease of poverty."
"TB is a disease of neglect."
"TB is a disease of despair."
"TB is a disease of hope."
"TB is a disease of cure."
"TB is a disease of prevention."
"TB is a disease of elimination."
"TB is a disease of eradication."
"TB is a disease of the past."
"TB is a disease of the future."
"TB is a disease of the present."
"TB is a disease of all of us."
"TB is a disease that we can beat."
"TB is a disease that we must beat."
"TB is a disease that we will beat."
"TB is a disease that we have beaten."
"TB is a disease that we are beating."
"TB is a disease that we are going to beat."
"TB is a disease that we are on the way to beating."
"TB is a disease that we are almost beating."
"TB is a disease that we are very close to beating."
"TB is a disease that we are just about to beat."
"TB is a disease that we are about to beat."
"TB is a disease that we are going to be able to say that we have beaten."
"TB is a disease that we are going to be able to say that we have almost beaten."
"TB is a disease that we are going to be able to say that we are very close to beating."
"TB is a disease that we are going to be able to say that we are just about to beat."
"TB is a disease that we are going to be able to say that we are about to beat."
"TB is a disease that we are going to be able to say that we are going to be able to say that we have beaten."
"TB is a disease that we are going to be able to say that we are going to be able to say that we have almost beaten."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are very close to beating."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are just about to beat."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are about to beat."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we have beaten."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we have almost beaten."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are very close to beating."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are just about to beat."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are about to beat."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we have beaten."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we have almost beaten."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are very close to beating."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are just about to beat."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are about to beat."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we have beaten."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we have almost beaten."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are very close to beating."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are just about to beat."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are about to beat."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we have beaten."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we have almost beaten."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are very close to beating."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are just about to beat."
"TB is a disease that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are going to be able to say that we are about to beat."

Conclusion

The video provides a comprehensive overview of tuberculosis, covering its clinical features, diagnosis, treatment, and prevention. It emphasizes the importance of early detection, drug sensitivity testing, and adherence to treatment. The speaker highlights the challenges posed by drug-resistant TB and the need for specialized care. The video also discusses the role of government programs in providing free TB treatment and preventive therapy. The overall message is that TB is a curable disease, but requires a concerted effort from healthcare providers, patients, and the community to eliminate it.