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Tuberculosis
Melissa Belair
Danielle Florio
Laurie Kaldma
Emily Lento
Angela Johnson
Pathophysiology
Tuberculosis infection occurs in three stages:
- Primary infection
- Latent infection
- Active infection
PATHO
Primary
Tiny particles are inhaled and deposit deep into the lungs. The body's natural defenses, also known as macrophages, eat the TB bacterium but are unable to destroy all the bacteria. The bacteria reproduces within the macrophage and eventually kill their host. This leads to the initial lung inflammation found with TB infection
Primary
(Tierney & Nardell, 2018).
Latent
In 95% of cases, after 3 weeks of bacteria growth the immune system is successful in controlling the infection. During this time there are no symptoms of the infection and the patient is not contagious, however there is still a risk for TB to be reactivated into an active infection
Latent
(WHO, 2019).
Active
If the body’s defense system fails to eliminate the infection, the bacteria rapidly grows and multiplies in the macrophages. These macrophages eventually form nodular granulomatous structure called tubercles causing the infection.
Active
(Tierney & Nardell, 2018).
10 million people developed active TB infections in 2018 leading to 1.5 million deaths. TB is one of the top ten causes of death worldwide
INCIDENCES
(World Health Organization, 2019).
Canadian
Prevalence
Canada has the lowest TB rates in the world, with only 1796 cases in 2017.
- 71.8% of cases were foreign born individuals.
- 17.4% were Canadian-born, Indigenous cases
- Only 7.0% were Canadian-born, non-Indigenous.
(LaFreniere, et al., 2017).
DIAGNOSTICS
How TB is diagnosed
DIAGNOSTICS
TB can be diagnosed through diagnostic imagine, laboratory studies (specimens), and to obtain difficult specimens, a bronchoscopy procedure can be done.
Chest X-Ray
Diagnostic Imaging
Chest X-Ray
Small or large air spaces, fine granular or seed-like appearances in the lungs, bronchiectasis are all manifestations that could lead to the diagnosis of TB (Jaeger, et at., 2013).
The issue with x-ray and other diagnostic imaging of the lungs is that manifestations of TB can be mistaken for other diseases (Jaeger, et al., 2013).
According to the World Health Organization, chest x-rays are used to “identify participants eligible for bacteriological exam” (Jaeger, et al., 2013, pp. 1).
Lab
Laboratory Tests
Sputum Smears & Blood Work
The most effective way to diagnose TB is through bacteriology (Katiyar & Katiyar, 2019).
Samples are obtains from expectorated sputum which is then analyzed (Jaeger, et al., 2013).
So, what happens if you get a negative result or cannot obtain a sputum sample?...
Bronchoscopy
Bronchoscopy
To obtain adequate sputum samples for diagnosis
A bronchoscopy procedure involves using a small fiber-optic scope which is passed down the patient’s airway in order to collect specimens (Le Palud, et al., 2014).
It is a procedure done under sedation, and can only take a few minutes. Risk and benefits are explained to the patient like any other procedure.
SIGNS & SYMPTOMS
Signs and Symptoms
TB bacteria most commonly grow in the lungs, and can cause symptoms such as:
A bad cough that lasts 3 weeks or longer
Pain in the chest
Coughing up blood or sputum (mucus from deep inside the lungs)
Other symptoms of TB disease may include:
Weakness or fatigue
Weight loss
No appetite
Chills
Fever
Sweating at night
Center for Disease Control and Prevention. (2019).
Complications
COMPLICATIONS
Despite effective treatment, TB disease can lead to significant short-and long-term health consequences such as:
- malnutrition
- paradoxical reactions to medications
- multi-drug resistance
- TB related sepsis
- developing mycetomas
- impaired pulmonary functions
- focal neurological deficits
- bronchiectasis
- chronic pulmonary aspergillosis
Shah, & Reed, (2014)
Risk Factors
RISK FACTORS
Tuberculosis is spread by airborne droplets, through coughing, sneezing, laughing, and even talking. These droplets are then inhaled by the susceptible person. We have broken down the risk factors into two categories; clinical/behavioral, and environmental/ socio-economical
Rachow et al., 2019
Clinical/ behavioral risk factors:
clinical/ behavioral
- immunocompromised status (such as HIV, cancer, infection, transplanted organs)
- pre-existing medical conditions (diabetes, COPD, asthma, chronic renal failure, malnourishment, hemodialysis, selected malignancies)
- taking medications that weaken the immune system
- abuse of smoking, drug use, and/or alcohol
Rachow et al., 2019
Environmental/ socio-economical risk factors:
enviro/ socio-economical
- close contact to someone with active TB
- people without adequate health care (minorities, homeless, living in poverty)
- immigration from countries with high prevalence of TB (southeast Asia, Africa, Latin America, Carribean)
- living in over-crowded substandard housing arrangements or being in jail/ prison
- being a health care worker preforming high risk activities
Ross, 2016
Client and family teaching and education
TEACHING
Health care professionals have a critical role in educating patients diagnosed with TB and their families. Along with educating about the general pathophysiology of the infection and how it is spread from person to person, the important points for discussion can be separated into pre- treatment counseling and pre-discharge assessment and education.
Pre- treatment counseling
Pre- treatment
It is important that a prior counseling of the patient and near relatives is done before start of therapy to achieve better outcomes. Subjects to discuss include the following:
- Educating the patient about tuberculosis and its prolonged treatment, emphasizing on the possible adverse effects of drugs
- Discussing about the need for proper compliance to treatment and its expected outcomes, including the chances of obtaining cure in these patients.
- Plans for periodic assessment of response to therapy; and how to prevent drug resistance occurring or amplification of resistance taking place during therapy
- Discussing infectiousness and infection control measures to prevent transmission of the disease
- Need for nutritional supplement
Katiyar & Katiyer, 2019
Pre- discharge assessment and education
Pre- discharge
It is essential that nurses properly assess and educate their patients before being discharged back to the community. This includes;
- assessing the patient's ability to continue therapy at home
- instructing the patient and family about infection control procedures (proper tissue disposal, hand hygiene, coughing)
- assessing patient's adherence to their medication regimen
- assessing if a referral to an outpatient clinic for closer monitoring would be beneficial
Ross, 2016
Prevention
PREVENTION
In general, the best way to prevent TB is to avoid exposure to someone with active TB, and to keep your immune system healthy. Here are some other principles for preventing the spread of tuberculosis:
- identifying and treating people with latent TB before the disease becomes active
- routinely screening healthcare workers and individuals at high risk of infection
- maintaining proper ventilation in indoor spaces to decrease the amount of bacteria in the air
- Using germicidal ultraviolet lamps to kill airborne bacteria in buildings where people at high risk of tuberculosis live or congregate
- proper education for those with TB regarding medication adherence and ways to prevent passing it on to others (hand hygiene, cough etiquette)
Center for Disease Control and Prevention, 2016
Prevention in health care
Preventing the spread of TB in health care facilities
- early detection and treatment of people with active TB
- initiate isolation precautions with negative pressure rooms for those suspected or confirmed with active TB until chance of infection is reduced
- persons entering these isolation rooms should use disposable particulate respirators
- maintain initial and routine skin tests for TB amongst all health care workers
- promptly initiate contact investigation procedures among health care workers, patients and visitors exposed to an untreated or ineffectively treated infectious patient
- all health care workers should receive annual education about TB including; information on TB risk factors, the signs and symptoms of TB disease, and TB infection control policies and procedures.
Ross, 2016
Video
Here is a short video that our group found helpful to explain and visualize how tuberculosis is spread the pathophysiology of the disease once a person is infected.
Video
Center for Disease Control and Prevention, 2016
References
Center for Disease Control and Prevention. (2019). Tuberculosis disease: Symptoms and risk factors. Retrieved from: https://www.cdc.gov/features/tbsymptoms/index.html
Center for Disease Control and Prevention. (2016). Tuberculosis: How TB spreads. Retrieved from: https://www.cdc.gov/tb/topic/basics/howtbspreads.htm
Fogel, N. (2015). Tuberculosis: a disease without boundaries. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26198113
Jaeger, S., Karargyris, A., Candemir, S., Siegelman, J., Folio, L., Antani, S., & Thoma, G. (2013). Automatic screening for tuberculosis in chest radiographs: a survey. Quantitative imaging in medicine and surgery, 3(2), 89–99. doi:10.3978/j.issn.2223-4292.2013.04.03
Katiyar, S.K. & Katiyar, S. (2019). Protocol for the management of newly diagnosed cases of tuberculosis. Indian Journal of Tuberculosis, 66, 507-515. doi: 10.1016/j.ijtb.2019.11.003
LaFreniere, M., Hussain, H., He, N., McGuire. M. (2017). Tuberculosis in Canada: 2017. https://doi.org/10.14745/ccdr.v45i23a04
Le Palud, P., Cattoir, V., Malbruny, B., Magnier, R., Campbell, K., Oulkhouir, Y., Zalcman, G., & Bergot, E. (2014). Retrospective observational study of diagnostic accuracy of the Xpert® MTB/RIF assay on fiberoptic bronchoscopy sampling for early diagnosis of smear-negative or sputum-scarce patients with suspected tuberculosis. BMC pulmonary medicine, 14, 137. doi:10.1186/1471-2466-14-137
Rachow, A., Ivanova, O., Wallis, R., Charalambous, S., Jani, J., Bhatt, N., … Churchyard, G. (2019). TB sequel: Incidence, pathogenesis and risk factors of long-term medical and social sequelae of pulmonary TB- a study protocol. BMC Pulmonary Medicine, 19(4). doi: 10.1186/s12890-018-0777-3
Ross, C.J.M. (2016). Management of patients with chest and lower respiratory tract disorders. In P. Paul, R. Day, & B. Williams (Eds.), Brunner and Suddarth’s Canadian Textbook of Medical-Surgical Nursing. (pp.575-630). Philadelphia, PA: Wolters-Kluwer
Shah, M. & Reed, C. (2014). Complications of tuberculosis. Current Opinion in Infection Diseases, 27(5), 403-410. doi: 10.1097/QC0.000000000000090
Tierney, D., & Nardell, E. A. (2018, April). Tuberculosis (TB) - infectious diseases. Retrieved from https://www.merckmanuals.com/en-ca/professional/infectious-diseases/mycobacteria/tuberculosis-tb
World Health Organization. (2019). Global Tuberculosis Report 2019. Who.int. Retrieved 28 February 2020, from https://www.who.int/tb/global-report-2019.