Pulmonary tuberculosis

L de ManDept. of Physiotherapy

University of the Free State2012

DefinitionTuberculosis is an active infection

with the bacterium Mycobacterium tuberculosis

HistoryTuberculosis has been present in humans

since antquity

Tubercular decay in the spines of Egyptian mummies dating from 3000 – 2400 BC

460 BC Hippocrates identified phtisis as the most widespread disease of the times involving coughing up blood and fever, which was almost always fatal.

HistoryRobert Koch discovered the tuberculosis bacili in 1882 and received the Nobel Prize in medicine in 1905In 1946 the development of the antibiotic streptomycin made effective treatment and cure

possible

HistoryPrior to that the only treatment

besides going to a sanatorium, were surgical treatment – collapsing an infected lung to “rest” it and allow lesion to heal

HistorySurgery discontinued in 1950’s

Postoperative problem was postural due to lack of structural support

Due to overcompensation the patient developed posture of leaning away from the incision side

ThoracoplastyLeft lung collapse secondary to

thoracoplasty

EpidemiologyCurrent estimates: around ⅓ of

world’s population has latent TBBetween 2002 and 2020

1000 million will become newly infected

150 million will contract TB 36 million will die

Reasons for increase in incidenceDeveloped countries

o Immigration from high prevalence areas

o HIVo Social deprivation

(homelessness, poverty)o Increased proportion of

elderlyo Drug resistance

Developing countries

o Ineffective control programmes

o Lack of access to health care

o Poverty, civil unresto HIVo Increased populationo Drug resistance

EpidemiologyThe 22 countries account for 80%

of the TB cases in the world

Alphabetical list of countries1.Afghanistan 2. Bangladesh 3. Brazil 4. Cambodia 5. China 6. Democratic Republic of Congo 7. Ethiopia 8. India 9. Indonesia 10 Kenya 11. Mozambique

12. Myanmar

13. Nigeria

14. Pakistan

15. Philippines

16. Russia

17. South Africa

18. Tanzania

19. Thailand

20. Uganda

21. Viet Nam

22. Zimbabwe

EpidemiologyIn 2007, the country with the highest incidence rate was Swaziland, with 1200 cases per 100,000 people

versus

15 cases per 100,000 people in United Kingdom

PathologySpreads through cough, sneeze, any

other way of transmitting saliva – a single sneeze can release up to 40,000 droplets

(0,5 – 5µm in diameter)Primary TB = active disease on first

exposureMost infections result in a asymptomatic,latent infection

PathologyCombination of primary lesion

and regional lymph node involvement =

Ghon focus

PathologyPost-primary TB = active TBEarliest chest x-ray = an ill

defined opacity situated in one of the upper lobes

PathologyAs disease progress

consolidation, collapse, caseation,fibrosis and

cavitationOn chest x-ray – significant

displacement trachea and mediastinum

Pathology

Symptoms of active TBChronic cough HemoptisesFeverNight sweatsAppetite lossWeigt lossFatigue

Miliary TBBlood borne dissemination gives

rise to miliary TBClassic appearance on chest x-

ray = fine, 1 – 2 mm lesions distributed

throughout the lung fields

DiagnosisUssually confirmed by direct

microscopy = Ziel-Neelsen staining

Culture of samples is sputum

ManagementRifampicic and Isoniazid for 3

monthsOr Isoniazid for 6 monthsChemotherapyWere drug resistance is not

expected, a patient can be assumed to be non-infectious after 2 weeks of appropriate therapy.

Directly observed therapy (DOT)

Extra pulmonary TB

1. Lymphadenitis Lymph nodes of cervical and

mediastinal glands

Extra pulmonary TB

2. Gastrointestinal TB Any part of bowel can be infected Acute abdomen Narrowing, shortening, distortion of

bowel TB peritonitis

3. Pericardial disease Pericardial effusion Constrictive percarditis

Extra pulmonary TB

4. CNS disease Most important form and when

unrecgonised and untreated = fatal Recovery rate = 60% or less with

permanent neurological deficit• Usual local source = caseous focus in

meninges or brain

TB meningitis

Extra pulmonary TB

5. Bone and joint disease Spine is common site = Pott’s disease Vertebral collapse resulting in kyphosis Spinal cord compression Sinus formation Paraplegia (so called Pott's paraplegia) Prevention = Controlling the spread of tuberculosis infection • Therapy = Stabilisation and

decompression with\ spinal involvement

Physiotherapy Physio per se is not indicated Treat associated conditions or

complications that may have arisen through reactions to drugs

ReferencesBoon NA, Colledge NR, Walker

BR, Hunter JAA. 2006. Davidson’s Principles and Practise of Medicine. 20th Ed. Edinburgh London, Elsierivier Limited.

p 695-703.