1. Tuberculosis Information 4 CEU 1

2. Objectives 1. Define and describe, on a basic level, the concept of tuberculosis. 2. List signs and symptoms of tuberculosis infection. 3. List the consequences of tuberculosis. 4. Name 3 commonly use TB medications and their side effects. 2

3. TB introduction video 3

4. Identify the next 3 CXR Normal Miliary TB TB 4

5. A 5

6. B 6

7. C 7

8. Ans A Tuberculosis B Normal Chest C Millary TB on chest 8

9. Latent TB Latent TB means that you have the TB bacteria in your body, but your body’s defenses (immune system) fight the infection and try to keep it from turning into active TB. This means that you don't have any symptoms of TB right now and can't spread the disease to others. If you have latent TB, it can become active TB. 9

10. Active TB Active TB means that the TB bacteria are growing and causing symptoms. If your lungs are infected with active TB, it is easy to spread the disease to others. 10

11. Extrapulmonary TB If TB is only in other parts of the body (extrapulmonary TB), it does not spread easily to others. 11

12. Who is most at risk for TB? Some people are more likely than others to get TB. This includes people who: Have HIV or another illness that weakens their immune system. Have close contact with someone who has active TB, such as living in the same house as someone who is infected with TB. Care for a patient who has active TB, such as doctors or nurses. 12

13. Who are at high risk for TB Live or work in crowded places such as prisons, nursing homes, or homeless shelters, where other people may have active TB. Have poor access to health care, such as homeless people and migrant farm workers. Abuse drugs or alcohol. Travel to or were born in places where untreated TB is common, such as Latin America, Africa, Asia, Eastern Europe, and Russia. 13

14. What to do for people who are high risk for TB It is important for people who are at a high risk for getting TB to get tested once or twice every year. 14

15. What are the symptoms? Most of the time when people are first infected with TB, the disease is so mild that they don't even know they have it. People with latent TB don't have symptoms unless the disease becomes active. 15

16. Symptoms of active TB may include: A cough that brings up thick, cloudy, and sometimes bloody mucus from the lungs (called sputum) for more than 2 weeks. Tiredness and weight loss. Night sweats and a fever. A rapid heartbeat. Swelling in the neck (when lymph nodes in the neck are infected). Shortness of breath and chest pain (in rare cases). 16

17. Extrapulmonary tuberculosis Extrapulmonary tuberculosis (TB) is an infection caused by tuberculosis bacteria that have spread beyond the lungs. People from certain regions (such as southeast Asia), infants and very young children, and people infected with the human immunodeficiency virus (HIV) have an increased risk of developing extrapulmonary TB. The symptoms of the infection depend on the part of the body affected. 17

18. Areas most commonly infected include: Lymph nodes. Bones and joints. Reproductive or urinary tract organs. Tissues covering the brain and spinal cord (meninges). Extrapulmonary TB is usually treated with a combination of 4 medicines for 6 to 9 months, followed by another 4 to 7 months of treatment with 2 medicines. 18

19. Tuberculosis is either latent or active. 19

20. Latent TB Latent TB means that you have the TB bacteria in your body, but your body’s defenses (immune system) fight the infection and try to keep it from turning into active TB. This means that you don't have any symptoms of TB right now and can't spread the disease to others. If you have latent TB, it can become active TB. 20

21. Active TB Active TB means that the TB bacteria are growing and causing symptoms. If your lungs are infected with active TB, it is easy to spread the disease to others. 21

22. How is TB spread to others? Pulmonary TB (in the lungs) is contagious. It spreads when a person who has active TB breathes out air that has the TB bacteria in it and then another person breathes in the bacteria from the air. An infected person releases even more bacteria when he or she does things like cough or laugh 22

23. Extrapulmonary TB If TB is only in other parts of the body (extrapulmonary TB), it does not spread easily to others. 23

24. Who is most at risk for TB? Some people are more likely than others to get TB. This includes people who: Have HIV or another illness that weakens their immune system. Have close contact with someone who has active TB, such as living in the same house as someone who is infected with TB. Care for a patient who has active TB, such as doctors or nurses. 24

25. People who are high risk for TB It is important for people who are at a high risk for getting TB_______ to get tested once or twice every year. 25

26. Symptoms of active TB may include: A cough that brings up thick, cloudy, and sometimes bloody mucus from the lungs (called sputum) for more than 2 weeks. Tiredness and weight loss. Night sweats and a fever. A rapid heartbeat. Swelling in the neck (when lymph nodes in the neck are infected). Shortness of breath and chest pain (in rare cases). 26

27. (cont) Lymph nodes are part of the lymphatic system, which carries lymph fluid, nutrients, and waste material between the body tissues and the bloodstream. The lymphatic system is also an important part of the immune system, the body's defense system against disease. The lymph nodes (sometimes called lymph glands) filter lymph fluid as it flows through them, trapping bacteria, viruses, and other foreign substances, which are then destroyed by special white blood cells called lymphocytes. Lymph nodes may be found singly or in groups; they may be as small as the head of a pin or as large as an olive. Groups of lymph nodes can be felt in the neck, groin, and underarms. Many lymph nodes in the body cannot be felt. 27

28. (cont) When a part of the body is infected, the nearby lymph nodes become swollen as they collect and destroy the infecting organisms. For example, if a person has a throat infection, the lymph nodes in the neck may swell and become tender. 28

29. Frequently Asked Questions 29

30. Learning about tuberculosis (TB): tuberculosis (TB): What is tuberculosis? What is latent TB? What is active TB? What is extrapulmonary TB? What causes TB? What are the symptoms? How is it spread to others? When should I call a doctor? Can a test detect TB early? 30

31. Being diagnosed: How is active TB diagnosed? How is latent TB diagnosed? 31

32. Getting treatment: How is latent TB treated? How is active TB treated? What medicines are used to treat TB? When is surgery used? 32

33. Ongoing concerns: What can I do so that I don't get TB? How can the spread of TB be prevented? What are the complications? 33

34. Living with tuberculosis: What do I need to do if I have TB? 34

35. Cause Tuberculosis (TB) is caused by Mycobacterium tuberculosis, slow-growing bacteria that thrive in areas of the body that are rich in blood and oxygen, such as the lungs. 35

36. Symptoms If you have latent tuberculosis (TB), you do not have symptoms and cannot spread the disease to others. If you have active TB, you do have symptoms and can spread the disease to others. Which specific symptoms you have will depend on whether your TB infection is in your lungs (the most common site) or in another part of your body (extrapulmonary TB). There are other conditions with symptoms similar to TB, such as pneumonia or lung cancer. 36

37. Symptoms of active TB in the lungs Symptoms of active TB in the lungs begin gradually and develop over a period of weeks or months. You may have one or two mild symptoms and not even know that you have the disease. Common symptoms include: A cough with thick, cloudy, and sometimes bloody mucus from the lungs (sputum) for more than 2 weeks. Fever, chills, and night sweats. Fatigue and weakness. Loss of appetite and unexplained weight loss. Shortness of breath and chest pain. 37

38. Symptoms of an active TB infection outside the lungs Symptoms of TB outside the lungs (extrapulmonary TB) vary widely depending on which area of the body is infected. For example, back pain can be a symptom of TB in the spine, or your neck may get swollen neck when lymph nodes in the neck are infected. 38

39. What Happens Tuberculosis (TB) develops when Mycobacterium tuberculosis bacteria are inhaled into the lungs. The infection usually stays in the lungs, but the bacteria can travel through the bloodstream to other parts of the body (extrapulmonary TB). 39

40. Initial infection can be mild An initial (primary) infection can be so mild that you don't even know you have an infection. In a person who has a healthy immune system, the body usually fights the infection by walling off (encapsulating) the bacteria into tiny capsules called tubercles. The bacteria remain alive but cannot spread to surrounding tissues or other people. This stage is called latent TB, and most people never go beyond it. 40

41. A reaction to a tuberculin skin test is how most people find out they have latent TB. It takes about 48 hours after the test for a reaction to develop, which is usually a red bump where the needle went into the skin. Or you could have a blood test (QuantiFERON-TB Gold) that provides results in about 24 hours. Skin test 41

42. When TB becomes active If a person's immune system becomes unable to prevent the bacteria from growing, the TB becomes active. Of people who have latent TB, 5% (1 person in 20) will develop active TB within 2 years after the initial infection. Another 5% of people who have latent TB will develop active TB at some point in their life.1 42

43. People who have latent TB may be at risk for developing the active disease if they: Have a condition or disease that weakens their immune system, such as human immunodeficiency virus (HIV) infection, some cancers, or poorly controlled diabetes. Have poor access to health care, such as homeless people, migrant farm workers, or people who abuse alcohol or drugs. Take medications that contain corticosteroids for a long time or are taking tumor necrosis factor-alpha antagonists (used to treat rheumatoid arthritis or Crohn's disease). 43

44. (cont) Have a condition that results in an impaired immune system, which can occur in older adults, newborns, women who have recently given birth, or people who have had an organ transplant and are taking medications to prevent organ rejection. Have a chronic lung disease caused by breathing in tiny sand or silica particles (silicosis). Have celiac disease.2 Have had gastric bypass surgery or a gastrectomy. Are 10% or more under their healthy body weight. 44

45. Active TB in the lungs Active TB in the lungs (pulmonary TB) is contagious. TB spreads when a person who has active disease exhales air that contains TB-causing bacteria and another person inhales the bacteria from the air. These bacteria can remain floating in the air for several hours. Coughing, sneezing, laughing, or singing releases more bacteria than breathing. TB is more likely to spread in situations where: People are living together in crowded conditions. TB can spread rapidly in nursing homes, hospitals, homeless shelters, schools, military barracks, and prisons. People live in the same house with a person who has active TB. This increases the chance of inhaling TB-causing bacteria and developing an infection. TB is not spread by handling objects that have been touched by a person who has TB. 45

46. Generally, after 2 weeks of treatment with antibiotics, you cannot spread an active pulmonary TB infection to other people. Skipping doses of medication can delay a cure and cause a relapse. In these cases, you may need to start treatment over. Relapses usually occur within 6 to 12 months after treatment. Not taking the full course of treatment also allows antibiotic-resistant strains of the bacteria to develop, making treatment more difficult. With treatment 46

47. Without treatment, active TB can cause serious complications, such as: Pockets or cavities that form in the lungs. These damaged areas may cause bleeding in the lungs or may become infected with other bacteria and form pockets of pus (abscesses). A hole that forms between nearby airways in the lungs (bronchopleural fistula). Difficulty breathing because of blocked airways. TB can be fatal if it is not treated. Without treatment, active TB can cause serious complications, such as: 47

48. Infants and children and people with HIV or AIDS who have active TB need special care. TB in certain groups of people 48

49. What Increases Your Risk People are at increased risk of infection with tuberculosis (TB) when they: Have close contact (such as living in the same house) with someone who has active TB, which can be spread to others. Active TB is very contagious. Care for people who have untreated TB, such as health professionals. 49

50. (cont) Live or work in crowded conditions where they can come into contact with people who may have untreated active TB. This includes people who live or work in prisons, nursing homes, military barracks, or homeless shelters. Have poor access to health care, such as homeless people, migrant farm workers, or people who abuse alcohol or drugs. Travel to or from regions where untreated TB is common, such as Latin America (countries in Central America, South America, and the Caribbean), Africa, Asia, Eastern Europe, and Russia. 50

51. (cont) People who have an infection that cannot spread to others (latent TB infection) are at risk of developing active TB if they: Have a condition or disease that weakens the immune system, such as human immunodeficiency virus (HIV) infection, some cancers, or poorly controlled diabetes. Have poor access to health care, such as homeless people, migrant farm workers, or people who abuse alcohol or drugs. Take medications that contain corticosteroids for a long period of time or are taking tumor necrosis factor-alpha antagonists (used to treat rheumatoid arthritis or Crohn's disease).. 51

52. (cont) Have a condition that results in an impaired immune system, which can occur in older adults, newborns, women who have recently given birth, or people who have had an organ transplant and are taking medications to prevent organ rejection. Have a chronic lung disease caused by inhaling sand-like dust (silicosis).Have celiac disease.2 Have had gastric bypass surgery or a gastrectomy. Are 10% or more under their healthy body weight. 52

53. Call your doctor immediately if you have: Symptoms (such as an ongoing cough with fever, fatigue, and weight loss) that could be caused by tuberculosis (TB). Been in close contact with someone who has untreated active TB, which can be spread to others, or you have had lengthy close contact with someone you think has untreated active TB. Blurred vision or color blindness and are taking ethambutol for TB. Yellowing of your skin and the whites of your eyes (jaundice) or you have abdominal pain and you are taking isoniazid or other medications for TB. When To Call a Doctor 53

54. Have recently had a TB skin test and you have a red bump at the needle site. You need to have a reaction measured by a health professional within 2 to 3 days after the test. This measurement is important in deciding whether you need more tests or treatment. Call your doctor if you: 54

55. Watchful Waiting Watchful waiting is a wait-and-see approach. If you get better on your own, you won't need treatment. If you get worse, you and your doctor will decide what to do next. If you have symptoms of TB (an ongoing cough with fever, fatigue, and weight loss), you should not wait to get treatment. Contact your doctor or other health professional as soon as possible. 55

56. If you have been exposed to someone who has active TB, don't wait to see if you develop symptoms. Contact your doctor or other health professional to get a tuberculosis skin test. 56

57. Health professionals and public health agencies can help you discover whether you have tuberculosis (TB). These include: Your local public health department. Primary care doctors (general practitioner, family medicine doctor, internist, pediatrician). Pulmonologists, which are doctors who specialize in treating lung problems. Infectious disease specialists. Who To See 57

58. Health professionals and public health agencies can also help you with treatment. They include: Your local public health department, which often has a TB specialist. Primary care doctors who know about treating TB. Pulmonologists, which are doctors who specialize in treating lung problems. Infectious disease specialists. Other specialists to treat complications. 58

59. If you have multidrug-resistant TB, you may need to go to a hospital that specializes in treating this type of TB. 59

60. Diagnosing active TB in the lungs Doctors diagnose active tuberculosis (TB) in the lungs (pulmonary TB) by using a medical history and physical examination, and by checking your symptoms (such as an ongoing cough, fatigue, fever, or night sweats). 60

61. Doctors will also look at the results of: Sputum cultures. Testing mucus from the lungs (sputum culture) is the best way to diagnose active TB. If TB bacteria grows from your samples, sensitivity testing is done on the bacteria. These tests will show which medications will kill the bacteria. Results of sensitivity tests can take between 1 and 6 weeks because TB-causing bacteria grow very slowly. Your doctor may start treatment before results are returned if it's likely that you have TB. Researchers are working on new tests that may give quicker results. 61

62. Chest X-rays. A chest X-ray cannot diagnose active TB. A chest X-ray usually is done if you have: A positive tuberculin skin test (also called a TB skin test, PPD test, or Mantoux test). Symptoms of active TB, such as a persistent cough, fatigue, fever, or night sweats. An uncertain reaction to the tuberculin skin test because of a weakened immune system, or to a previous bacilleCalmette-Guerin (BCG) vaccination. 62

63. Diagnosing latent TB in the lungs A tuberculin skin test will show whether you have latent TB. The test also will show if you have ever had a TB infection. See an illustration of a tuberculin skin test. 63

64. (cont) QuantiFERON-TB Gold is a blood test that has been approved by the U.S. Food and Drug Administration (FDA) to help detect latent TB.3 It can help diagnose TB when results from a tuberculin skin test are uncertain. The test can also tell if a person who has had a BCG vaccination has a TB infection. It requires only one visit to the doctor or clinic, instead of two visits as required for the tuberculin skin test. 64

65. Diagnosing TB in other parts of the body (extrapulmonary TB) requires more testing. You may have: A sample of the affected area taken out (biopsy). The sample is sent to a lab to look for TB-causing bacteria. A urine culture to look for TB infection in the kidneys (renal TB). A sample of fluid around the spine (cerebrospinal fluid) taken to look for a TB infection in the brain (TB meningitis). A CT scan to diagnose TB that has spread throughout the body (miliary TB) and to detect lung cavities caused by TB. An MRI scan to look for TB in the brain or the spine. Diagnosing TB outside the lungs 65

66. Testing for HIV infection is often done at the time of TB diagnosis. You may also have a blood test for hepatitis.4 In addition 66

67. During treatment, sputum tests are done once a month—or more often—to make sure the antibiotics are working. You may have a chest X-ray at the end of treatment to use as a comparison in the future. Tests during TB treatment 67

68. You may have tests to see if TB medications are harming other parts of your body. These tests may include: Liver function tests. Eye tests, especially if you are taking ethambutol for TB treatment. Hearing tests, especially if you are taking streptomycin for TB treatment. 68

69. All cases of TB are reported to the local or state health department because the disease can spread to others and cause outbreaks. Major health authorities keep track of TB outbreaks and encourage early testing for people who are at risk for developing the disease. Early Detection 69

70. The Centers for Disease Control and Prevention (CDC) recommend TB testing for people who:5 Have a human immunodeficiency virus (HIV) infection or another condition that puts them at risk for TB. Spend a lot of time with a person who has active TB disease, which can be spread to others. Inject illegal drugs. Were born in parts of the world where tuberculosis is common, such as Latin America and the Caribbean, Africa, Asia, Eastern Europe, and Russia. 70

71. (cont) Live or work in nursing homes, homeless shelters, migrant farm camps, prisons, or jails. People who have a high risk for developing TB usually have a skin test (tuberculin test) on a regular basis. Health professionals often are given a tuberculin skin test when they begin work in a hospital or nursing home, with retesting every 6 to 12 months. 71

72. Doctors treat tuberculosis (TB) with antibiotics to kill the TB bacteria. These medications are given to everyone who has TB, including infants, children, pregnant women, and people who have a weakened immune system. People who have TB that cannot be spread to others (latent TB) also receive treatment to prevent the infection from becoming active. Treatment Overview 72

73. When treating active TB, health experts recommend:6 Using more than one medication to prevent multidrug-resistant TB. The standard treatment begins with four medications given for 2 months. Continuing treatment for 4 to 9 months or longer if necessary. The number of medicines used during this time depends on the results of sensitivity testing. Using directly observed therapy (DOT). This means visits with a health professional who watches you every time you take your medication. A cure for TB requires you to take all doses of the antibiotics. These visits ensure that people follow medication instructions, which is helpful because of the long treatment course for TB. 73

74. Trying a different combination of medications if the treatment is not working because of drug resistance (when tests show that TB-causing bacteria are still active).Using different treatment programs for people infected with the human immunodeficiency virus (HIV), people infected with TB bacteria that are resistant to one or more medicines, pregnant women, and children. Drug resistance 74

75. When treating latent TB, experts recommend:1 Using one medicine to kill the TB bacteria and prevent active TB. The standard treatment is isoniazid taken for 9 months. For people who cannot take isoniazid for 9 months, sometimes a 6-month treatment program is done. Treatment with rifampin for 4 months. This is an acceptable alternate treatment, especially for people who have been exposed to bacteria that is resistant to isoniazid. 75

76. Treatment for extrapulmonary tuberculosis Treatment for tuberculosis outside the lungs (extrapulmonary TB) usually is the same as for pulmonary TB. You may need other medications or forms of treatment depending on where the infection is in the body and whether complications develop. You may need treatment in a hospital if you have: Severe symptoms. TB that is resistant to multiple-drug therapy. 76

77. What To Think About For active TB, there are different treatment recommendations for people with HIV and TB, people with drug-resistant TB, children with active TB, and pregnant women with active TB. If you miss doses of medication or you stop treatment too soon, your treatment may go on longer or you may have to start over. This can also cause the infection to get worse or lead to antibiotic-resistant infections that are much harder to treat. A cure for TB requires you to take all doses of the antibiotics. This may mean daily visits with a health professional who watches you take the medication. This is known as directly observed therapy (DOT). 77

78. Taking all of the medications is especially important for people who have an impaired immune system. They may be at an increased risk for a relapse because the original TB infection was never cured. Relapses usually occur within 6 to 12 months after treatment. Treatment for relapse is based on the severity of the disease and which medications were used during the first treatment. 78

79. Doctors also use medication treatment to prevent people with a latent TB infection from developing active TB. 79

80. Health experts recommend this for people who have a positive tuberculin skin test but no symptoms of TB. Treatment is especially important for people with latent TB who: Have HIV infection or AIDS. Have close contact with a person who has active TB. Have a chest X-ray that suggests a TB infection, but have not had a complete course of treatment. Inject illegal drugs. Have a medical condition or take medicine that weakens the immune system. Have had a tuberculin skin test within the past 2 years that was negative but now the skin test is showing a TB infection (positive). 80

81. Prevention Avoid getting active TB Active tuberculosis (TB) is an infection that is spreading in a person's body, and it is very contagious. The World Health Organization (WHO) estimates that one-third of the world's population is infected with the bacteria that causes TB. To avoid getting an active TB infection: Do not spend long periods of time in stuffy, enclosed rooms with anyone who has active TB until that person has been treated for at least 2 weeks. Use protective measures, such as face masks, if you work in a facility that cares for people who have untreated TB. If you live with someone who has active TB, help and encourage the person to follow treatment instructions. 81

82. Prevent latent TB from becoming active Usually, treatment with isoniazid for about 9 months or rifampin for 4 months can prevent a latent TB infection from developing into active TB. Treatment is recommended for anyone with a skin test that shows a TB infection, and is especially important for people who: Are known to or are likely to be infected with the human immunodeficiency virus (HIV). Have close contact with a person who has active TB. Have a chest X-ray that suggests a TB infection, and have not had a complete course of treatment. Inject illegal drugs. Have a medical condition or take medications that weaken the immune system. Have had a tuberculin skin test within the past 2 years that did not show a TB infection but now a new test indicates an infection. 82

83. A TB vaccine (bacilleCalmette-Guerin, or BCG) is used in many countries to prevent TB. However, this vaccination is almost never used in the United States because: The risk of getting TB is low in the U.S. The vaccine is not effective in adults who receive it. The BCG vaccine may cause a tuberculin skin test to indicate a TB infection even if a person is not infected with TB. This complicates the use of the tuberculin skin test to check people for TB. Can the TB vaccine help? 83

84. An Overview of Tuberculosis Medication In most people, medication will cure tuberculosis if the correct drugs are taken for the right amount of time. Tuberculosis treatment usually combines several different antibiotic medications that are given for at least 6 months, and sometimes for as long as 12 months. This is because there are many tuberculosis bacteria (Mycobacterium tuberculosis) that need to be killed. Taking several medicines will do a better job of killing all of the bacteria, and will also help prevent them from becoming resistant to the medicines (see Drug-Resistant TB). 84

85. Specific Medicines Used for Tuberculosis The most common drugs used for active tuberculosis are: Isoniazid (INH) Rifampin (RIF) Ethambutol Pyrazinamide. For a person with latent tuberculosis, treatment usually consists of taking isoniazid for at least six months. 85

86. Side Effects of Tuberculosis Drugs Occasionally, the medications used to treat tuberculosis may cause side effects. Some side effects cause minor problems; others are much more serious. If you have a serious side effect from your medications, call your doctor or nurse immediately. You may be told to stop taking your medicine or to return to the clinic for tests. Minor side effects of tuberculosis medications can include: Orange urine, saliva, or tears. The doctor or nurse may advise you not to wear soft contact lenses because they may get stained. Sensitivity to the sun. This means you should use a good sunscreen, and cover exposed areas so you don't burn. Reduced effectiveness of birth control pills and implants. Women who take rifampin should use another form of birth control. 86

87. Serious side effects from TB medications may include, but are not are limited to: No appetite Nausea Vomiting Yellowish skin or eyes (jaundice) Fever for three or more days Abdominal pain Tingling fingers or toes 87

88. (Cont) Skin rash Easy bleeding Aching joints Dizziness Tingling or numbness around the mouth Easy bruising Blurred or changed vision Ringing in the ears (tinnitus) Hearing loss. Drinking alcoholic beverages (wine, beer, and liquor) while taking isoniazid can be dangerous. Check with your doctor or nurse for more information. 88

89. The Importance of Finishing Your Medication Tuberculosis bacteria die very slowly. It takes at least six months for the tuberculosis medications to kill all the TB bacteria. You will probably start feeling well after only a few weeks of treatment, but beware -- the TB bacteria are still alive in your body. You must continue to take your medicine until all the TB bacteria are dead, even though you may feel better and have no more symptoms of active TB. 89

90. If you don’t continue with your TB med If you don't continue taking your TB drugs, or you aren't taking your medicine regularly, this can be very dangerous. The TB bacteria will grow again, and you will remain sick for a much longer time. 90

91. Drug resistant TB The bacteria may also become resistant to the medicines you are taking. If this happens, the person has what is called drug-resistant TB. Some people have a form of the disease that is resistant to two or more drugs. This is called multidrug-resistant TB, or MDR-TB. This form of TB is much more difficult to cure. 91

92. Remembering to Take the Medication The only way to get well is to take your tuberculosis medications exactly as your doctor or nurse tells you to. This may not be easy. You will be taking your medicine for a long time (six months or longer), so you should get into a routine. Here are some ways to help remember to take your medicine: 92

93. Directly observed therapy (DOT) Participate in the directly observed therapy program (DOT) at your health department. Take your pills at the same time every day. For example, you can take them before eating breakfast, during a coffee break, or after brushing your teeth. Ask a family member or a friend to remind you to take your pills. Mark off each day on a calendar as your take your medicine. Put your pills in a weekly pill dispenser. Keep it by your bed or in your purse or pocket. If you forget to take your medications one day, skip that dose and take the next scheduled dose. Tell your doctor or nurse that you missed a dose. You may also call your doctor or nurse for instructions. 93

94. (cont) You may need new, different medicines to kill the tuberculosis bacteria if the old products no longer work. These new tuberculosis medications must be taken for a longer time and usually have more serious side effects. Even with treatment, however, between four and six out of 10 patients with multidrug-resistant TB will die, which is the same rate seen in TB patients who are not treated. 94

95. Home Treatment Home treatment for tuberculosis (TB) focuses on taking the medications correctly to reduce the risk of developing multidrug-resistant TB. Keep all your medical appointments, take your medications as prescribed, and report any side effects of the medications, especially vision problems. If you plan to move during the time that you are being treated, let your health professional know so that arrangements can be made for you to continue the treatment. 95

96. Home treatment includes: Not going to work or school while you can spread the TB infection. Sleep in a bedroom by yourself until you can no longer infect other people. Opening windows in a room where you must stay for a while, if the weather allows it. This can help get rid of TB bacteria from the air in the room. Eating a balanced diet to provide your body with the nutrients that you need to fight the infection. If you need help, ask to talk with a registered dietitian. Covering your mouth when you sneeze or cough. Until you have been on antibiotics for about 2 weeks, you can easily spread the disease to others. After coughing, dispose of the soiled tissue in a covered container. Talk with your health professional about other precautions you can take to prevent the spread of TB. 96

97. If you have been exposed to TB If you live with someone who has active TB or you know that you have been exposed to someone who has the disease, see your health professional for testing. A tuberculin skin test (also called a TB skin test, PPD test, or Mantoux test) that indicates a TB infection means you need treatment to prevent active TB. 97

98. Medications Active tuberculosis (TB) Several antibiotics are used at the same time to treat active tuberculosis (TB) disease. For people who have multidrug-resistant TB, treatment may continue for as long as 24 months. These antibiotics are given as pills or injections. 98

99. Extra pulmonary TB TB disease that occurs outside the lungs (extrapulmonary TB) usually is treated with the same medications and for the same length of time as active TB in the lungs (pulmonary TB). However, TB throughout the body (miliary TB) or TB that affects the brain or the bones and joints in children may be treated for at least 12 months. 99

100. Corticosteroidmedications Corticosteroid medications also may be given in some severe cases to reduce inflammation. They may be helpful for children at risk of central nervous system problems caused by TB and for people who have conditions such as high fever, TB throughout the body (miliary TB), pericarditis, or peritonitis. 100

101. Latent TB One antibiotic usually is used to treat latent TB infection, which cannot be spread to others but can develop into active TB disease. The antibiotic is taken for 4 to 9 months. 101

102. Medication Choices Multiple-drug therapy to treat TB usually involves taking four antibiotics at the same time. This is the standard treatment for active TB. The four most commonly chosen medications are:7 Isoniazid (IHN, Nydrazid). Rifampin (Rifadin, Rimactane). Pyrazinamide. Ethambutol (Myambutol). 102

103. Doctors sometimes use other medicines if treatment isn't effective or the person is infected with drug-resistant TB bacteria. Other medication choices include:7 Rifapentine (Priftin). Streptomycin (STM). Ethionamide (Trecator-SC). Cycloserine (Seromycin). Capreomycin (Capastat Sulfate). Levofloxacin (Levaquin, Quixin). Moxifloxacin (Avelox, Vigamox). 103

104. What To Think About It is important to take all doses of the treatment medications. This ensures a cure and reduces the risk of a relapse of the disease and the development of antibiotic-resistant bacteria. It will also help prevent the spread of TB to people around you. 104

105. Surgery Surgery is rarely used to treat tuberculosis (TB). However, it may be used to treat complications of an infection in the lungs or another part of the body. 105

106. Surgery is used to: Repair lung damage, such as serious bleeding that cannot be stopped any other way, or repeated lung infections other than TB. Remove a pocket of bacteria that cannot be killed with long-term medication treatment. Surgery has a high success rate, but it also has a risk of complications, which may include infections other than TB and shortness of breath after surgery. 106

107. Surgery for TB outside the lungs Surgery occasionally may be needed to remove or repair organs damaged by TB outside the lungs (extrapulmonary TB) or to prevent other rare complications, such as: TB infection of the brain (TB meningitis). Your doctor may surgically place a tube (shunt) that drains excess fluid from the brain to prevent a buildup of pressure that can further damage the brain. TB infections of the heart (TB pericarditis). Your surgeon may partially remove or repair the infected sac around the heart. TB infection of the kidneys (renal TB). Your surgeon may need to either remove your infected kidney or repair the kidney or other parts of the urinary system. TB infection of the joints. You may need surgery to repair damaged areas of your spine or joints (orthopedic surgery). 107

108. Nursing Process: Tuberculosis Tuberculosis (TB) is a chronic infections of the lung caused by a Mycobacterium infection, resulting in the development of tubercles in the lungs. Tubercles are the nodules seen on a chest x-ray (CXR), and consist of lymphocytes and epithelioid cell cells. Mycobacterium enters the body through inhaled droplets 108

109. Cough, hemoptysis Fever, chills Weight loss Night sweats Weakness Assessment 109

110. Planning and Implementation Place patient in a negative flow room Oxygen administration and chest physiotherapy Administer treatment regimens for TB Encourage adequate nutritional and fluid intake Encourage frequent rest periods 110

111. Evaluation and Outcomes The patient will: Maintain adequate oxygenation Effectively overcome tuberculosis infection Maintain adequate nutritional and fluid intake Understand tuberculosis transmission and treatments 111

112. Nursing Considerations Patients with immunologic disorders, such as human immunodeficiency virus and cancer, are at higher risk for contracting tuberculosis Multiple drug resistant tuberculosis (MDR-TB) is increasing; if a patient on proper drug therapy is not responding to therapy, non-traditional drug therapies may be necessary 112

113. Nursing Consideration (cont) Visitors need to understand and comply with droplet precautions Health care workers require fit testing of particulate respirators to make certain droplets are not inhaled. 113

114. Post test review 114

115. What are the clinical presentations of TB? Primary: asymptomatic (positive ppd) Secondary: symptomatic Miliary: organ destruction (negative ppd) 115

116. How is it diagnosed in a lab? PPD test, ziehneelson stain 116

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118. What are the two species of mycobacterium? M. Tuberculosis M. leprae 118

119. What technique do you use to diagnose mycobacterium? Acid-fast stainRed stain carbolfuchsinAcid alcohol 119

120. What oxygen requirements does M. tuberculosis have? It is an obligate aerobe, which is why it is found in the lungs so often. 120

121. What is the one class of lipid that only acid-fast organisms have? mycosides 121

122. What are the mycosides? Mycolic acidMycosideCord factorSulfatidesWax D 122

123. What mycoside is only found in virulent strains of TB? Cord factor.Inhibits neutrophil migration and damages mitochondria.Contributes to weight loss via the release of TNF 123

124. Tumor necrosis factor (TNFsuperfamily, member 2) 124

125. TNF Tumor necrosis factor (TNF, cachexin or cachectin and formally known as tumor necrosis factor-alpha) is a cytokine involved in systemic inflammation and is a member of a group of cytokines that stimulate the acute phase reaction. The primary role of TNF is in the regulation of immune cells. TNF is able to induce apoptotic cell death, to induce inflammation, and to inhibit tumorigenesis and viral replication. Dysregulation of TNF production has been implicated in a variety of human diseases, as well as cancer.[1] Recombinant TNF is used as an immunostimulant under the INNtasonermin. 125

126. Question what is the Ghon’s complex? what does it look like? 126

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128. 128

129. What are the clinical symptoms of asymtomatic primary infection with TB? Tiny tubercles (calcified, dormant). (called a Ghon focus)Only PPD will give this away. 129

130. What is the first option for a TB infection? Facultative intracellular growthMay spread throughout the body inside monocytes 130

131. What is the second option for a TB infection? Cell-mediated immunityGranuloma is created within the lung, causes necrosis is the result.Bacteria are kept at bay but still viable, waiting for the host to weaken 131

132. What does the PPD test determine? Purified Protein DerivativeDetermines whether or not a person has been infected with TB. Considered to have latent TB. 132

133. What is BCG? Bacillus Calmette-Guerin vaccine for TBUsed in other countries, may give a false positive PPD test. 133

134. Anergic Infection with TB does not show up in PPD test. AIDS, malnutrition... ect. 134

135. Anergy Anergy is a term in immunobiology that describes a lack of reaction by the body's defense mechanisms to foreign substances, and consists of a direct induction of peripheral lymphocytetolerance. An individual in a state of anergy often indicates that the immune system is unable to mount a normal immune response against a specific antigen, usually a self-antigen. Lymphocytes are said to be anergic when they fail to respond to their specific antigen. Anergy is one of three processes that induce tolerance induction, modifying the immune system to prevent self-destruction (the others being clonal deletion and immunoregulation).[1] 135

136. In what group does symptomatic primary tuberculosis occur? In immunocompromised patients. 136

137. Reactivation or secondary tuberculosis Most common cases of TB occur after the bacteria have been dormant for some time. It can happen in any organ system. (Infected patients have a 10% chance per year of this reactivation) 137

138. What is the most common site of TB reactivation? Lungs, apical around the clavicles. (Oxygen tension is highest) 138

139. What are common sites of TB reactivation? PulmonaryPlueral and pericardialLymph nodes (second most common)KidneySkeletalJoints (one)CNS 139

140. What is scrofula? Lymph node TB Lesions seen in primary tuberculosis: has both lung and lymph node lesions 140

141. What is sterile pyuria? Patients with red and white blood cells in urine, but no TB on gram stain? because they take so long to culture 141

142. What is Pott's disease? TB destroys intervertebral discs and adjacent vertebral bodies. 142

143. What is miliary TB? Tiny granulomas are disseminated all over the body.Happens in the elderly and in children. 143

144. Three steps in diagnosing TB? PPD skin testChest X-raySputum acid-fast stain and culture (indicates active infection) 144

145. What is a typical mycobacterial disease in AIDS patients? Mycobacterium avium-intracellulare (MIA or MAC) 145

146. Where can you grow Mycobacterium leprae? Footpads of mice, armadillos, and in monkeys 146

147. Two big characteristics of a leprosy infection: 1.Bug appears to grow better in cooler temps close to the skin 2.The severity of the disease is dependent on the hosts cell mediated immune response to the bacilli 147

148. What method of infection does leprosy take? facultative intracellular existence 148

149. What does leprosy damage? Skin NervesEyesNoseTestes 149

150. What is lepromatous leprosy? Severest form of leprosy, the patient cannot mount a T cell response.Problem with T-supressor cells? 150

151. What is leonine facies? Patient's face looks like a lion from lepromatous bumps and lesions. 151

152. Saddlenose deformity Nasal cartilage is destroyed from lepromatous leprosy. 152

153. What is tuberculoid leprosy? Patients with TL can mount a cell mediated defense against the bacteria, so damage is not excessive. sometimes self limiting 153

154. What does a patient with tuberculoid leprosy express? Localized superficial, unilateral skin and nerve involvement.Nerves are enlarged. 154

155. Lepromin skin test Like the PPD skin test, but more diagnostic. Determines if the patient can launch a T-cell response. 155

156. Clinical manifestations of active TB in CXR Clinical manifestations of active TB in CXR1. Primary TB pnm2. Reactivation of TB pnm3. Miliary TB 156

157. 1. middle or lower lobe consolidation2. apical scarring and cavitation, fibrocavitary apical (upper lobe dz)3. small millet seed lesions (2-4mm) wide dissemination due to hematogenous spread (acute or insidious) usually seen in immunocompromised, dm, alcholic, primary tb, malnourished pt. 157

158. Describe Pott's Disease Extra pulmonary TB affecting the vertebral column. 158

159. Scrofula Extra pulmonary TB affecting the lymph nodes of the neck . 159

160. Diagnostic studies in suspected cases of active TB (4) 1. Acid fast (AFB)-sputum smear and culture 3x 2.CXR-Ghon complex3. CT scan4. PCR 160

161. First line of anti TB medications (5) 1. Isoniazid (INH)2. Rifamprin (RIF)3. Pyrazinamide (PZA)4. Ethambutol (EMB)5. Streptomycin (STM) 161

162. IsoniazidDescribe Adverse effects (5)Considerations with Rx 1. Hepatitis, peripheial neuropathy, lupus like syndrome, abdominal pain, acidosis. 2. peripheral neuropathy prevented by B6 pyridoxine. recommend take a baseline LFTs before rx. (Liver function tests before giving medications 162

163. Rifamprin (RIF) Adverse effect (5)Contraindications (2) 1. Thrombocytopenia, orange colored secretions, GI upset, hypersenstivity, fever. 2. patients taking protease inhibitors, NNRTIs (Reverse transcriptase inhibitors(RTIs) are a class of antiretroviral drug used to treat HIV infection, tumors[1], and cancer[2]. RTIsinhibit activity of reverse transcriptase, a viral DNA polymerase enzyme that retroviruses need to reproduce.) 163

164. Pyrazinamide (PZA)adverse effects (4)Indications for pregnancy 1. GI, hepatitis, arthritis, hyperuremia 2. can be given after the 1st trimester 164

165. Ethambutoladverse effect (3) 1. opticneuritis2. perpherialneuropathy3. GI 165

166. Streptomycin (STM)adverse effects (2) 1. ototoxicity2. nephrotoxicity 166

167. Treatment of Latent TB infection (LTBI) for likely INH sensitive cases INH 300mg PO qd + pyridoxine 25mg PO qd x 9 months 167

168. Treatment of Latent TB infection (LTBI) for abnormal CXR or +HIV INH 300mg PO qd + pyridoxine 25mg PO qd x 12 months 168

169. Treatment of Latent TB infection (LTBI) for contact case in INH resistant Treatment of Latent TB infection (LTBI) for contact case in INH resistant 169

170. Post test 170

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172. The End 172