Introduction to TBCP

A primary care guide project

by Dr Gerard Loh

MO

KK Bandar Miri

Acknowledgements:

Dr Wong Yong Kai, MO, TBCP KK Miri

TBCP Staff, KK MIRI

Note: These guides serve as introductory notes to the new MO in TBCP setting, always refer to CPG for more precise

guidelines.

The Primary Care Guide Project 2013

www.myhow.wordpress.com

TUBERCULOSIS

Cases:

1) New cases PTB Never treated for TB

2) Follow up Intensive phase / Maintenance / Surveillance

3) Relapse

- D/S +ve relapse : after cured, came back with smear +ve

- D/S ve relapse : after cured, came back with symptoms or CXR features

4) Chronic case remain smear +ve despite re-treatment

5) Treament failure after 5/12 treatment remain smear +ve

6) Treatment after interruption defaulter > 2/12 with smear +ve

7) Contact Tracing

Tuberculosis

- Pulmonary - Extra-pulmonary

Clinical:

Cough > 2/52, with sputum +/- blood stained

LOW/ LOA

Fever with chills, night sweats

TB Lympadenitis

Ix: FNAC / excisional biopsy

TB Pleura

Ix: thoracocentesis/pleural tapping for AFB

Radiological:

- Lesions or hazinesss in upper lobe, +/- cavities

TB Genitourinary

Ix: Urine AFB

Bacteriological

Sputum AFB +ve or C&S MTB +ve

TB Meningitis

Ix: CSF AFB

Immunological:

Mantoux > 10mm

ESR up to 100+

TB bone/joints

Miliary TB

Radiological Features

Image source : Institue of Tropical Medicine, Antwerp

I. Minimal slight lesions without cavitations

II. Moderately advanced disemminated lesions, not exceeding total volume of 1 lung, cavitations < 4mm

III. Far Advanced extensive changes

Management of confirmed TB

PLAN:

- Notify

- Contact Tracing

- Home Isolation 2/52

- Check Visual Acuity

- MC 2/52

- TCA 2/52 to review investigations , rpt SAFB, LFT

- DOTS

Ix:

FBC/ESR

FBS/FLP/BUSE/CREAT/LFT

HIV/Hep B-C / VDRL

SAFB x 3 / Sputum TB C&S

Monthly SAFB

2 Monthly CXR + ESR * monthly SAFB only in Sarawak due to high rate of false negative results

* CPG recommends SAFB and CXR at 2 months and 6 months, 4 months if no clinical improvement

Treatment of TB

1. Intensive Phase - 2 months of EHRZ / SHRZ

* may extend 1 month if 1st / 2

nd month SAFB remain +ve

2. Maintenance Phase 4-10 months of HR

Anti TB drugs

First Line Drugs: Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), Ethambutol (E), Streptomycin (S)

Recommended Tx : 2EHRZ + 4HR + Pyridoxine

- For improved compliance, FORECOX a fixed dose combination anti TB is recommended

TB Recommended Regimes

Pulmonary TB 2EHRZ / 4 HR

TB Lymph Node

TB Pleural effusion and/or Pericarditis

2EHRZ / 4HR

Bone / Joint 2EHRZ / 7HR

TB Meningitis 2SHRZ / 10HR

FORECOX

WEIGHT (KG)

(Adult Dose)

INTENSIVE PHASE

Duration : 2 MONTHS

30-39 2 tab

40-54 3 tab

55-70 4 tab

> 70 5 tab

Weight INH RIF ETH PZA

Till 20 kg 100mg 300mg 400mg 500mg

25 125 625

30 150 500 750

35 200

450 600 1000

40

45 225 800 1250

50 250 600

55 300 900 1500

60 1000

65

70 1200

>70

TB in Children

Peds dosage ( recommended regime 2 HRZ / 4HR )

* For prophylaxis INH 10mg/kg (6H or 3 HR)

Dose (mg/kg) Maximum

Isoniazid 10 ( 10 15) 300mg

Rifampicin 15 (10 20) 600mg

Ethambutol 20 (15 25) 1g

Pyrazinamide 35 (30 40) 2g

+ Pyridoxine 5-10mg

Adverse Drug Reactions

Signs and symptoms Organs affected

Isoniazid Paraesthesia hands or feet Liver, peripheral nerves

Rifampicin Orange-reddish urine, easy bruising Blood (Plt ), GIT, Kidney

Ethambutol loss of colour vision, arthralgia Eyes, Liver

Pyrazinamide Dyspepsia, gout, arthralgia GIT, Liver, Joint

Streptomycin Ringing in the ears, ataxia, vertigo and deafness CN8 neuritis, Kidney

Adverse Reactions

Minor No need to interrupt treatment Severe stop immediately Sx: Nausea, lethargy, pruritus

Tx: Symptomatic relief

Stevenson-Johnson Syndrome (SJS)

Toxic Epidermal Necrolysis (TEN)

Drug rash+eosinophilia+systemic syndrome (DRESS)

Drug Induced Hepatitis (DIH)

SJS / TEN immune-complex hypersensitivity involving skin and mucous membranes

Sx: necrolysis of skin, eyelid, tongue

DIH When serum transaminase level >3 fold upper limit , symptomatic

*If baseline LFTs are abnormal, do investigate the underlying cause (U/S Abdo, Hep B/C)

do not start antiTB first, refer to specialist

Drug Desensitisation / rechallenge

Drug rechallenge Done by re-starting drugs once symptoms abated, gradually increasing dose and adding drugs

1. Determine maximum dose

2. Begin day 1 with Isoniazid, low dose

3. Gradually increase till maximum

4. Move on to the next anti TB, until adverse reaction to drug and dose is determined

eg:

Challenge Dose (mg)

Adverse Reactions Drug Day 1 Day 2 Day 3 Day 4

Isoniazid

(INH)

Dose 50 100 300 NIL

Date 1/3/14 2/3/14 3/4/14

Rifampicin

(RIF)

Dose 75 300 450 NIL

Date 5/3/14 6/3/14 7/3/14

Pyrazinamide

(PZA)

Dose 250 500 1000 1500 Joint pain + rashes

Date 8/3/14 9/3/14

Ethambutol

(ETM)

Dose 200 400 800 1200

Date

Streptomycin

(SM)

Dose 250 500 1000

Date

Contact Tracing

Latent TB (LTBI) infected by MTB, but bacteria in dormancy, not causing any active symptoms

Diagnosis:

Close contact with Mantoux test > 10mm

- no active symptoms

- normal CXR

- SAFB negative

Mx:

- allow home with advise and surveillance for 6mo, 12mo, 18mo

Criteria for Tx:

- HIV / immunocompromised

- Child < 5 years with close PTB contact prophylaxis INH 10mg/kg for 6/12 (6H or 3 HR)

* before starting prophylaxis , rule out active TB ( FBC/ESR/CXR)

* if in doubt refer to paediatrician (for admission and gastric lavage for AFB)

AntiTB regime for LTBI in Children

6 H Isoniazid 10mg/kg

3 HR Isoniazid 10mg/kg + Rifampicin 15mg/kg

+ Pyridoxine 5 10mg OD

Weight INH RIF ETH PZA

Till 20 kg 100mg 300mg 400mg 500mg

25 125 625

30 150 500 750

35 200

450 600 1000

40

45 225 800 1250

50 250 600

55 300 900 1500

60 1000

65

70 1200

>70

AntiTB regime for LTBI in Children

6 H Isoniazid 10mg/kg

3 HR Isoniazid 10mg/kg + Rifampicin 15mg/kg

+ Pyridoxine 5 10mg OD

Timeline of TB management and follow up

Timeline

Day 0 Start Anti TB : INTENSIVE PHASE : 2 EHRZ Notify, Home isolation, MC 2/52

Check Visual Acuity

Ix: HIV/Hep B/c / VDRL + FBC/ESR + FBS/FLP/BUSE/Creat/LFT

Sputum MTB C&S

Monthly SAFB, 2 monthly CXR/ESR

Day 14 Review Ix taken earlier and reponse to tx (ADR), rpt LFT and SAFB

1/12 INTENSIVE PHASE 1/12

SAFB x 3

2/12 INTENSIVE PHASE 2/12

CXR / ESR

SAFB x 3 : positive extend Intensive phase 1/12 + Ix: LPA, C&S MTB (* if after 3/12 still +ve refer Physician for MDR TB)

negative proceed to MAINTENANCE PHASE : 4 HR 3/12 MAINTENANCE PHASE 1/12

SAFB

4/12 MAINTENANCE PHASE 2/12

CXR/ESR

SAFB

5/12 MAINTENANCE PHASE 3/12

SAFB

6/12 MAINTENANCE PHASE 4/12

CXR/ESR

SAFB

COMPLETE TREATMENT

If SAFB ve , CXR no changes, cough reduced, good weight gain and appetite FOLLOW UP TB SURVEILANCE

+6/12 Surveilance 6 months

CXR / SAFB

< DISCHARGE > With advise

FORECOX (FDC)

WEIGHT (KG) INTENSIVE PHASE

30-39 2 tab

40-54 3 tab

55-70 4 tab

> 70 5 tab

Adverse Drug Reactions

Signs and symptoms Organs affected

Isoniazid Paraesthesia hands or feet Liver, peripheral nerves

Rifampicin Orange-reddish urine, easy bruising Blood (Plt ), GIT, Kidney

Ethambutol loss of colour vision, arthralgia Eyes, Liver

Pyrazinamide Dyspepsia, gout, arthralgia GIT, Liver, Joint

Streptomycin Ringing in the ears, ataxia, vertigo and deafness CN8 neuritis, Kidney

Adverse Reactions

Minor No need to interrupt treatment Severe stop immediately Sx: Nausea, lethargy, pruritus

Tx: Symptomatic relief

Stevenson-Johnson Syndrome (SJS)

Toxic Epidermal Necrolysis (TEN)

Drug rash+eosinophilia+systemic syndrome (DRESS)

Drug Induced Hepatitis (DIH)

TB Recommended Regimes

Pulmonary TB 2EHRZ / 4 HR

TB Lymph Node

TB Pleural effusion and/or Pericarditis

2EHRZ / 4HR

Bone / Joint 2EHRZ / 7HR

TB Meningitis 2SHRZ / 10HR

Introduction to LEPROSY

By Dr Gerard Loh

Leprosy Chronic granulomatous infection, primarily affects skin and peripheral nerves

Three cardinal signs:

1. Hypopigmented / erythematous skin lesions with sensory impairment

2. Enlarged peripheral nerves with signs of nerve damage e.g. pain, tenderness, sensory/motor deficit

3. Presence of acid-fast bacilli in skin smear or biopsy

Leprosy patches

- skin patch with definite loss of sensation (heat/touch/pain)

- flat/raised

- reddish/copper coloured

- non- pruritic

- non tender

Ripley-Jopling Classification

WHO Classification

Paucibacillary (I, TT, BT) Multibacillary: BB, BL, LL

< 5 skin lesions > 5 skin lesions

No bacilli on skin smear Skin Smear Positive

Investigations:

- Slit Skin Smear (SSS)

- Skin Biopsy

- PCR

SSS

- Done every 6/12

- 6 sites : 2 earlobes + 4 active lesions

* if less than 4 sites, 2 earlobes + all active lesions

Bacteriologic Index (BI) Morphological Index (MI) BI = Sum of all index

no of sites taken

MI = Total no of solid bacilli X 100%

Total no of bacilli (solid + fragmented)

Density of leprosy bacilli

Include both living (solid) and dead (fragmented) Percentage of living bacilli

Valuable indicator of response to treatment BI < 4 : 1 year Tx ( within 1 year 6 months) BI > 4 : 2 years Tx (within 2years 6months)

MI reduced from +6 +2 if compliant

Management:

Notify, contact tracing

start MDT regimen

6 monthly SSS (for MBL)

Ix: G6PD, FBC/BUSE/Creat/LFT/UFEME/RBS

3 monthly BUSE/CREAT/LFT

Paucibacillary

Monthly treatment Rifampicin 600 mg

Daily treatment Dapsone 100 mg

Duration

6 months

Surveillance: 5 years

Completion 6 doses within 9 months

Multibacillary

Monthly treatment Rifampicin 600 mg

Clofazimine 300 mg

Daily treatment

Dapsone 100 mg

Clofazimine 50 mg

Duration

1 year (BI < 4)

2 years (BI 4)

Surveillance: 15 years

Completion 12 doses within 18 months (BI < 4)

24 doses within 36 months (BI 4)

Leprosy Rx in Children

Paucibacillary

10 14 yo Rifampicin 450 mg daily Dapsone 50mg daily

< 10 yo

Rifampicin 10 mg/kg

Dapsone 2 mg/kg

Duration

6 months

Surveillance 5 years

Multibacillary

10 14 yo Rifampicin 450 mg monthly Dapsone 50 mg daily

Clofazimine 150 mg monthly

50 mg EOD

< 10 yo

Rifampicin 10 mg/kg

Dapsone 2 mg/kg

Clofazimine 6 mg/kg monthly

1 mg/kg EOD

Duration

1 year (BI < 4)

2 years (BI 4)

Surveillance 15 ears

* G6PD deff Replace dapsone with orfloxacin/minocycline

Once completed treatment SSS both ears + maximum 6 other sites

Follow up:

- PBL = 3 years; no need SSS / MBL = 15 years;

- First 5 years = SSS yearly

- MBL contacts = examine yearly for 3 years

Adverse Drug Reactions

Dapsone Hemolysis, hepatitis, photosensitive dermatitis, pruritus, Dapsone Hypersensitivity Syndrome,

methaemoglobinaemia

Clofazimine Darkening of skin, GI complaints, dryness of the skin and eyes, pruritus

Rifampicin Reddish discoloration of urine, urticaria, GI complaints, leucopenia, eosinophilia, thrombocytopenia, liver

& renal dysfunction, flu-like syndrome, pruritus, Stevens Johnson Syndrome

Type 1 Lepra Reaction (Reversal Reaction)

- mostly in BB, BT and BL (may occur in LL, TT on Rx)

- Type IV hypersensitivity reaction, alteration in cell mediated immunity

- Upgrading reaction : erythematous and swelling over existing lesions

- Downgrading reaction : new lesions, progress to LL

Type II Lepra Reaction ( Erythema Nodosum Leprosum)

- Mostly occur in LL

- Type III hypersensitivity reaction

- precipitation of immune complexes in tissues and blood vessels

- Sudden appearance of erythematous tender subcutaneous nodules

- may become vesicular, pustular, bullous, and may ulcerate

a/w

- Fever, malaise, may be toxic. Oedema of hands, feet, face.

- Acute neuritis, iritis, arthritis, dactylitis, lymphadenitis, orchitis, nephritis

* may be life-threatening if untreated

Treatment of adverse reactions

- Rest + MC

- Symptomatic relief analgesia

- Suggested course of Prednisolone:

40 mg (8 tablets) every morning for 14 days

30 mg (6 tablets) every morning for 14 days

20 mg (4 tablets) every morning for 14 days

15 mg (3 tablets) every morning for 14 days

10 mg (2 tablets) every morning for 14 days

5 mg (1 tablets) every morning for 14 days

* Follow up every 14 days before reducing dose

* if not clinical improvement refer hospital

References

Guide to Eliminate Leprosy as a Public Health Problem, WHO, 2000

Leprosy 2013, by Dr Maurice Steve Utap, Family Medicine Specialist, KK Tudan

Institute of Tropical Medicine, Antwerp

http://itg.content-e.eu/Generated/pubx/173/tuberculosis/clinical_aspects.htm

Tables, algoritms and management recommendations from

CPG Malaysia, Managment of TB (3rd

edition)

Acknowledgements:

Dr Maurice Steve Utap, FMS, KK Tudan

Dr Wong Yong Kai, Medical Officer, TBCP, KK Miri

TBCP staff KK Miri