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NTRODUCTION
Pulmonary tuberculosis is an infectious disease caused by slow- growing bacteria that
resembles a fungus, Myobacterium tuberculosis, which is usually spread from person to
person by droplet nuclei through the air. The lung is the usual infection site but the
disease can occur elsewhere in the body. Typically, the bacteria from lesion (tubercle) in
the alveoli. The lesion may heal, leaving scar tissue; may continue as an active
granuloma, heal, then reactivate or may progress to necrosis, liquefaction, sloughing,
and cavitation of lung tissue. The initial lesion may disseminate bacteria directly to
adjacent tissue, through the blood stream, the lymphatic system, or the bronchi.
Most people who become infected do not develop clinical illness because the body’s
immune system brings the infection under control. However, the incidence of
tuberculosis (especially drug resistant varieties) is rising. Alcoholics, the homeless and
patients infected with the human immunodeficiency virus (HIV) are especially at risk.
Complications of tuberculosis include pneumonia, pleural effusion, and extrapulmonary
disease.
ANATOMY AND PHYSIOLOGY
The thoracic cage, or ribs, and the diaphragm bound the thoracic cavity. There are two
lungs that occupy a significant portion of this cavity.
The diaphragm is a broad, dome-shaped muscle that separates the thoracic and
abdominal cavities and generates most of the work of breathing. The inter-costal
muscles, located between the ribs, also aid in respiration. The internal intercostal
muscles lie close to the lungs and are covered by the external intercostal muscles.
The lungs are cone-shaped organs that are soft, spongy and normally pink. The lungs
cannot expand or contract on their own, but their softness allows them to change shape
in response to breathing. The lungs rely on expansion and contraction of the thoracic
cavity to actually generate inhalation and exhalation. This process requires contraction
of the diaphragm.
To facilitate the movements associated with respiration, each lung is enclosed by the
pleura, a membrane consisting of two layers, the parietal pleura and the visceral pleura.
The parietal pleura comprise the outer layer and are attached to the chest wall. The
visceral pleura are directly attached to the outer surface of each lung. The two pleural
layers are separated by a normally tiny space called the pleural cavity. A thin film of
serous or watery fluid called pleural fluid lines and lubricates the pleural cavity. This fluid
prevents friction and holds the pleural surfaces together during inhalation and
exhalation.
PREDISPOSING FACTORS
1. Malnutrition
2. Overcrowding
3. Alcoholism
4. Ingestion of infected cattle
5. Virulence
6. Over fatigue
SIGNS AND SYMPTOMS
1. Productive Cough – yellowish in color
2. Low fever
3. Night sweats
4. Dyspnea
5. Anorexia, general body malaise, weight loss
6. Chest/back pain
7. Hemoptysis
PATHOPHYSIOLOGY
DIAGNOSTIC EVALUATION
Sputum smear – detection of the acid fast bacilli in stained smears is the first
bacteriologic clue of TB. Obtain first morning sputum on 3 consecutive days.
Sputum culture – a positive culture for M. tuberculosis confirms a diagnosis of
TB.
Chest X-ray – to determine presence and extent of disease.
Tuberculin skin test (purified protein derivative or Mantoux test)
– inoculation of tubercle bacillus extract (tuberculin) into the intradermal layer of the
inner aspect of the forearm.
Nonspecific screening test – such as multiple puncture tests (tine test), should
not be used to determine if a person is infected.
MEDICATION
♦A combination of drugs to which the organisms are susceptible is given to
destroy viable bacilli as rapidly as possible and to protect against the
emergence of drug resistant organism.
♦Current recommended regimen of uncomplicated, previously untreated
pulmonary tuberculosis is an initial phase of 2 months of bacterial drugs,
including isoniazid (INH), rifampin ( Rifadin), pyrazinamide (PZA), and
ethambutol (EMB). This regimen should be followed until the results of
drug susceptibility studies are available, unless there is little possibilityn of
drug resistance.
a. If drug susceptibility results are known and organism is fully susceptible,
ethambutol does not need to be included.
b. For children whose visual acuity cannot be monitored, ethambutol is not
normally recommended except with increased likelihood of isoniazid
resistance or if the child has upper lobe infiltration and or cavity
formation of TB.
c. Due to increasing frequency of global streptomycin reistance,
streptomycin is not considered interchangeable with ethambutol unless
organism is known to be susceptible to streptomycin.