A chronic infection caused by Mycobacteria

For more information on the management of TB see:

TB Control & Community-based DOTS as an Essential Component of District Health Services; Guidelines, MoH National TB & Leprosy Programme 2001

Manual of the National TB/Leprosy Programme in Uganda!st Edition, MoH National TB & Leprosy Programme 1992 (currently being revised)

For spinal TB, see p327

Causes

• Mycobacterium tuberculosis
• Mycobacterium bovis
• Transmitted by droplet infection and through drinking of unpasteurised milk

Clinical features

• Chronic cough of >3 weeks
• Chest pain
• Purulent sputum occasionally blood-stained
• Fevers with night sweats
• Weight loss
• Loss of appetite
• Generalized enlargement of lymph nodes

Complications include

• Massive haemoptysis

- coughing up >250mL blood per episode

• Spontaneous pneumothorax

• Pleural effusion

• Gastrointestinal TB (TB peritonitis)

• Tuberculous meningitis

• TB pericarditis

• Bone TB (TB spine, TB joints with deformity)

Differential diagnosis

• Histoplasma pneumonia
• Trypanosomiasis
• HIV/AIDS
• Malignancy
• Brucellosis

Investigations

X-Ray: chest - especially children
Sputum: for AAFBs (ZN stain), culture
Blood: full haemogram especially ESR, lymphocytes

Management

The country has adopted community-based TB care with DOTS (Directly Observed Therapy Short-Course)

All cases of TB are treated with short course regimens as shown in the table below. Fixed dose combinations are encouraged as they may improve compliance

a) Pulmonary TB
HC3

Treatment is divided into:

- an Initial (Intensive) Phase of 2-3 months and

- a second Continuation Phase of 4-6 months,

depending on the drug combinations used.

Various regimens are available but the following are recommended for use in Uganda.

TB treatment regimens are expressed in a standard format, eg. 2 EHRZ/6 EH where:

- letters represent abbreviated drug names
- numbers show the duration in months
-/shows the division between treatment phases

Drugs used:

Table 1: Short-course TB Treatment Regimes

Table 2: Daily drug doses (in mg) by body weight

Notes

♦ Streptomycin: patients >40yrs and <50kg should be given 750 mg (instead of 1g)

Ethambutol: not recommended for children <6yrs

Re-treatment Regime

Recommended for patients in category 4 in Table 1, ie:

• failure to respond to the recommended regime

• relapse after treatment

• defaulters - return after interruption of treatment

2 SEHRZ/1 EHRZ/5 EHR

ie. 2 months of daily streptomycin + ethambutol + isoniazid + rifampicin + pyrazinamide

followed by one month of daily ethambutol + isoniazid + rifampicin + pyrazinamide

followed by 5 months of daily ethambutol + isoniazid + rifampicin

Notes on drug reactions

• All anti-TB drugs are likely to cause minor or major reactions. For guidelines on how to handle such drug intolerance, including identification of the offending drug and desensitisation of the patient, see Appendix 1, p426

b) TB Arthritis
H

All patients:

2 HRZ/7 HR
ie. 2 months intensive phase of daily isoniazid + rifampicin + pyrazinamide
followed by 7 months continuation phase of daily isoniazid + rifampicin

c) TB Meningitis
H

See section on Meningitis, p9

d) Miliary TB, TB Pericarditis, TB Peritonitis,
H

All patients:

2 SHRZ/6 HR or alternative regime 2 EHRZ/6 HR

Prevention

• Early detection of cases, tracing of contacts
• Treatment till cure
• Isolation of sputum-positive cases
• Avoidance of overcrowding
• Drinking pasteurised milk products only
• BCG immunization
• Good nutrition