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TB AND THE ELDERLYPATIENTdr SALIM S THALIB Sp.P2014

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Dr SALIM S THALIB Sp.P

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Caused by Mycobacterium tuberculosis

Spread by Airbone route

Droplet nuclei

Affected by Infectioussness of patient

Environmental condotions

Duration of exposure

Most persons exposed do not become infected

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1/3 of the world infected

2-3 million deaths/year Diagnosis is slow

Tx is long, complicated and toxic Resistance is rising

David Schlossberg, 2004

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7th

Stomach cancer

HIV

Suicide

1990

Murray & Lopez: Lancet 1997

2020

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Tuberculosiscomplex

M. Tuberculosis

M. BovisM. Africanum

M. microti

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Mycobacterium tuberculosis (MTB) is a

pathogenic bacterial species in the genus

Mycobacterium and the causative agent of

most cases of tuberculosis

The physiology of M. tuberculosis is

highly aerobic and requires highlevels of oxygen

M. tuberculosis requires oxygen to grow.

M. tuberculosis divides every 1520 hours

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Caused by Mycobacterium tuberculosis (M.

tuberculosis)

Spread person to person through airborne particles

that contain M. tuberculosis, called droplet nuclei Transmission occurs when an infectious person

coughs, sneezes, laughs, or sings

Prolonged contact needed for transmission 10% of infected persons will develop TB disease at

some point in their lives

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One cough produces 500 droplets nuclei

The average TB patient generates 75,000

dropletsper day before therapy

This drops to 25infectious droplets per

day within 2 weeks of effective therapy

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Number and Size of Organisms Liberated

Wells 1934, Duguid 1945, Wells/Riley 1953, et al.

Sejumlah organisme bertebaran:

Berbicara>o 200

Batuk.>0 3.500

Bersin>4.500 1. 000 000.

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FACTORS AFFECTING TB TRANSMISSION

Characteristics of the source case

Environment

Factor increasing risk for contacts

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The source

Cough,

Duration of symptoms

Cavitary disease

Sputum smear positive for AFB

RISK FACTORS FORTRANSMISSION TB

FAKTOR RESIKO DARI SUMBER PENULARAN

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The length of time you spend near the person

The distancebetween you and the person

The amount of clean airmoving through thespaces

Size and openness of space

Effectiveness of ventilation

RISK FACTORS FORTRANSMISSION TB

FROM A PERSON WITH INFECTIOUS TB DISEASE

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Disease in the lung, airway, or larynx

Presence of cough or other forceful expiratory

measures. Presence of acid-fast bacilli (AFB) in the sputum

Failure of patient to coverthe mouth and nose

when coughing or sneezing.

CHARACTERISTICS OF TB PATIENTS

THAT ENHANCE TRANSMISSION

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POTENSI PENULARAN PASIEN TB

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PRIMARY LESION

Uncontrolled spreadAbortive infection

Latency TB

Primary infectionMycobacteria- containing

droplets

PATHOGENESA TUBERCULOSIS

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LATENT ACTIVE

POST PRIMARY TB

Exogenous reinfection

Endogenous reactivation

PATHOGENESA TUBERCULOSIS

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Occurs whenperson breathes in bacteria

and it reaches the air sacs (alveoli) of lung

Immune system keeps bacilli containedand under control

Person is not infectious and has no

symptoms

LATENCY TB INFECTION (LTBI)

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Person:

Not ill

Not contagious

Normal chest x-ray

Germs:

Sleeping but still alive

Surrounded (walled off) by

bodys defense system Usually positive skin test

GRANULOMA

TB BACILLI

LATENCY TB INFECTION (LTBI)

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Wall breaks down due to aweakened immune system

WHAT CAUSES TB INFECTION TO

BECOME TB DISEASE ?

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RISK FACTOR RELATIVE RISK

HIV / AIDS 50-100

JEJUNOCAECAL SHUNT 27-63

SOLID TUMOURS 1-36

SILICOSIS 8-34

DIABETES MELITUS2-4

HEAD AND NECK NEOPLASMS 16

HEMODYALISIS 10-15

HAEMOTOLOGICAL NEOPLASMS 4-15

FIBROTIC LESIONS 2-15

IMUNOSUPPRESSIVE DRUGS

2-12

HEAVY SMOKING 5

LOW BODY WEIGHT 2-4

GASTRECTOMY 2-4

NORMAL POPULATION 1

RISK FACTORS ASSOCIATED WITH DEVELOPING TB DISEASE

RELATIVE RISK WITH RESPECT TO THE NORMAL POPULATION

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TB AND THE ELDERLYPATIENTdr SALIM S THALIB Sp.P

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TB AND THE ELDERLYPATIENT

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TBIN THE ELDERLY

The majority of TB in theelderly is secondary to

reactivation of latent TB

infection

With age, the T-cellmediated immune

response wanes allowing

for latent TB to become

active.

Kaufmann SHE. Nature Reviews Immunology 2001;1:20-30.

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TBIN THE ELDERLY

Other factors contributing to reactivation of TBinclude:

Age-associated diseases:

cardiovascular disease, COPD

Poor nutrition Chronic renal failure

Chronic institutionalization:

2-3 fold higher incidence of TB in nursinghome residents

Leung et al. J Am Geriatr Soc 2002;50:1219-26.

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PRESENTATIONOF TB IN OLDER ADULTS

May be difficult to diagnose TB in older adults

May not have classic presentation:

-less likely to have hemoptysis, fever, night sweats

than younger patients

Nonspecific symptoms are common including: Changes in activities of daily living

Chronic fatigue/weakness

Cognitive impairment

Anorexia/weight loss Persistent low-grade fever

Symptom duration may be greater in the elderly

Korzeniewska-Kosela M et al. Chest 1994;106:28-32.

Van Den Brande P et . Journal of Gerontology 1991;46:204-9.

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May be confused with age-related illnesses:

Malignancy

Diabetes mellitus

Malnutrition

Often only diagnosed postmortem

Lee et al.found that in their study of young and elderlypatients with pulmonary TB, initial diagnosis of TB wasmade correctly in 94.2% of younger patients, and only in

66.4% of elderly patients (p

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TYPICAL TB CHESTX-RAY

Liaw YS et al. J Am Geriatr Soc 1995;43:256-60

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TYPICAL TB CHESTX-RAY

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ELDERY TB CHESTX-RAY

TYPICAL TB CHESTX-RAY

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TYPICAL TB CHESTX-RAY

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TREATMENT

Since most cases result from reactivation, drugresistance is less of a concern in elderlypatients

Resistance should be considered if patient is:

1)From an area where there is a high

prevalence of multi-drug resistance (MDR)

2) A contact to a case with MDR

3) Had previous inadequate treatment for activetuberculosis

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DRUGTREATMENT

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DRUGTREATMENT

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ADVERSEDRUG EFFECTS

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ADVERSEDRUG EFFECTS

Yee D et al. Am J Resp Crit Care Med 2003;167:1472-77.

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Yee D et al. Am J Resp Crit Care Med 2003;167:1472-77

ADVERSEDRUG EFFECTS

17-34 years

35-59 years

60 years and older

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Hepatotoxicity:

incidence of INH-associated hepatotoxicity increases with age

risk of liver damage at age 50: 2.3%

severity of hepatitis also increases with age, with a higher

mortality in patients older than 50

ADVERSEDRUG EFFECTS

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DRUG INTERACTIONS

Many elderly patients have multiple medical problems

including:

Diabetes

Heart disease

Chronic lung disease

End-stage renal disease

High potential for interaction with Rifampicineand other

medications

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Finch et al. Intern Med.2002;162:985-992.

http://www.drugs.com/drug_interactions.html

DRUG INTERACTIONS

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Finch et al. Intern Med.2002;162:985-992.

http://www.drugs.com/drug_interactions.html

DRUG INTERACTIONS

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OUTCOMES

Increased mortality due to TB noted in older populations

Wang et al.reported a 26.5 % one-yearmortality in

patients >60 years old, versus 4.1% mortality in patient

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THANK