MANAEMENT OF ACTIVE PULMONARY TUBERCULOSIS IN GENERAL PRACTICE
DR.S.ABBAS ALI
MD DNB MNAMS
Fellowship in clinical cardiology
PGDHSC (Ultrasonography)
PGDHSc (Echocardiogram)
FCGP., MCCP (cardiology)
230/12 Chandralok colony
NH-2 Goverdhan chauraha
Mathura – 281004
Uttar Pradesh

Pulmonary tuberculosis is a sub acute respiratory infection with acid fast bacilli Mycobacterium tuberculosis. The most frequent symptoms are cough, fever, night sweats and malaise. Cough in pulmonary tuberculosis is initially non-productive, but often progress to sputum production and in some cases Haemoptysis. The sputum is generally yellow and is neither malodorous nor thick. Extremely advanced cases may also present with bloody sputum. Rarely, the bleeding is massive leading to shock, asphyxia and death.
Tuberculosis (TB) is one of the top 10 causes of death worldwide. In 2016, 10.4 million people fell ill with TB, and 1.7 million died from the disease (including 0.4 million among people with HIV). Over 95% of TB deaths occur in low- and middle-income countries. Seven countries account for 64% of the total, with India leading the count, followed by Indonesia, China, Philippines, Pakistan, Nigeria, and South Africa. In 2016, an estimated 1 million children became ill with TB and 250 000 children died of TB (including children with HIV associated TB).

The management of active pulmonary tuberculosis starts with proper classification, such as drug susceptible tuberculosis, Drug resistant tuberculosis and HIV-PTB by advising following investigations
• Sputum smear (AFB) examination: • atlest two samples of sputum should be examined. Early morning sputum specimens tend to have a higher yield than specimens collected at either times and overnight sputum collection have provided even greater sensitivity. Presence of AFB confirms the diagnosis that the patient is suffering from active pulmonary tuberculosis. This investigation does not confirm that this active PTB is whether DSPTB or DRPTB or HIV-PTB
• X-ray chest PA view: this is not a confirmatory investigation unless confirmed by sputum microscopy. X-ray chest will be helpful in knowing the extent of damage of lung.
• CB NAAT or Gene xpert of sputum AFB: this is latest weapon which delivers very fast results within 2 hours. This rule out drug susceptibility PTB from Drug resistance PTB. It also rules out Rifampicin Resistance.
• Card test for HIV: It is essential to rule out HIV-PTB. Many TB patients were being treated without knowledge of the presence or absence of concurrent HIV infection. Detection of HIV antibodies among TB patients is crucial to the holistic management.
• The other tests Interferon gamma release essay (TB Gold, TB spot), ADA, PCR Blood and Mantoux test were not helpful in diagnosis of Active Pulmonary Tuberculosis and should not be prescribed.
Classification
DST TB: it is assumed 85% of pulmonary TB cases were drug susceptible and curable. They include new cases, Retreatment and default cases.
DIAGNOSIS: Diagnosis of Drug susceptible tuberculosis requires clinical history plus three investigations such as
• LED microscopy AFB Sputum smear examination
• X-ray chest PA view
• CB NAAT or Gene xpert sputum of AFB: this test is strongly recommended is retreatment and default cases
Management and treatment:
Two months RHEZ and four months RHE if your area is high risk
Rule and treat other comorbidities such diabetes, COPD, anaemia, immunodeficiency etc.
Monitor the therapy using AFB sputum smear examination and X-ray chest every 2 months
Case cured: previous sputum positive TB becomes sputum negative on two occasions of 2 months gap.
Drug Resistant TB: An estimated prevalence of 3% in new cases and 12-15% in retreatment cases. Multidrug-resistant TB (MDR-TB) remains a public health crisis and a health security threat. WHO estimates that there were 600 000 new cases with resistance to rifampicin – the most effective first-line drug, of which 490 000 had MDR-TB. Drug resistance tuberculosis is divided in to two categories; primary resistance, which is the presence of drug resistance in someone who has never had treatment from tuberculosis and secondary resistance, which is the presence of resistance in a patient who has previously been treated for tuberculosis. Primary resistance results from acquiring an infection that is already drug resistance, while secondary resistance is the result of inappropriate therapy which may be either due to patient attitude towards treatment or empirical prescription of drugs by physicians without following fixed guidelines of WHO or serial DST reports. MDRPTB is defined as resistance to at least rifampicin and isoniazid. The treatment of MDRPTB is extremely difficult, since the drugs used are less effective, more costly and poorly tolerated due to drug related side effects. Failure to control drug resistance tuberculosis has led to outbreak of PRE XDRPTB, XDRPTB and XXDRPTB.
PRE XDR-PTB: defined as resistance to Rifampicin, isoniazid plus resistance to fluoroquinolones or second line injectable (3 drugs).
XDR-PTB: defined as resistance to rifampicin, isoniazid plus resistance fluoroquinolones and at least one second line injectables (capreomycin, amikacin, or kanamycin) (four drugs)
XXDR-PTB: resistance to more than four drugs.
DIAGNOSIS: initial diagnosis of drug resistance PTB requires clinical history (such as previous prescriptions) and 3 investigations such as
• LED microscopy AFB sputum smear examination
• X-ray chest PA view
• CB NAAT (Cartridge Based Nucleic acid amplification test) or Gene Xpert: this is initial test in treatment failures.
For Management we require one more test such
• Serial Liquid cultures: liquid culture gives fast results with in three weeks in comparison of solid cultures. The management and treatment of MDRPTB is complex and if family physician has expertise in managing MDRPTB cases, then manage the cases according to serial DST reports. Management of XDRPTB cases were definitely beyond the reach of family physicians and should be referred to specialized Government sectors where such services available.
HIV-PTB: Tuberculosis is a major opportunistic infection of HIV patients’ worldwide and is a leading killer of HIV-positive people: in 2016, 40% of HIV deaths were due to TB. The management again starts with identification and proper classification of TB such as Drug sensitive and Drug resistance, as drug resistance TB has been responsible for high rates of mortality in HIV infected individuals.
DIAGNSOSIS: investigations required for drug susceptible HIV-PTB
• Sputum for AFB
• X-ray chest PA view
• Gene Xpert of sputum
• Rapid card test for HIV : Out of three cards at least two cards of different companies and confirmed by ELISA
For drug resistance HIV-PTB
• Liquid cultures for AFB sputum
Investigations for Management and follow-up:
• CD4 cell count:
• Viral load
• Haemogram
• Liver profile
• Identification and management of Comorbities eg. Diabetes, malnutrition
The investigations and treatment of HIV-TB is expensive and this services were available to patients at free of cost nearest Government ART centre. Beside ATT it requires lifelong ART (antiretroviral therapy) which should be initiated within 2 weeks of starting ATT.