Tuberculosis Diagnosis & Therapy Lecture (UM2010)

Dr Jorge Garcia-Lara MICROBIOLOGY Unit: ISCM Module: UM2010 Yr. 2024-2025 u l o rc b e u T DIAGNO si s SIS by...

Dr Jorge Garcia-Lara MICROBIOLOGY Unit: ISCM Module: UM2010 Yr. 2024-2025 u l o rc b e u T DIAGNO si s SIS by LECTURE CORE : Dr. GARCIA- 1 LARA Bitesize SLIDES 4 School of Medicine Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) Physician Associate Studies (MPAS) 1  Dr Jorge Garcia-Lara The discoverer of M.tb, tuberculin, … (& much more) Robert Koch Nobel Prize in Medicine 1905 School of Medicine Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) Koch R. Die Atiologic der Tuberkulose. Berliner Klinische Physician Associate Studies (MPAS) 2 Wochenschrift 1882;  Dr Jorge Garcia-Lara M.tb Mycobacterium tuberculosis "gram +ve" rod bacterium acid fast stain positive slow growth - external envelopes impermeability complex cell wall (mycolic acids, glycolipids, free lipids, sulfolipids) School of Medicine Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) Physician Associate Studies (MPAS) 3  Dr Jorge Garcia-Lara M.tb external envelope s 4 Brown et al. 2015. Through the wall: extracellular vesicles in Gram-positive bacteria, mycobacteria and fungi. Nature Reviews Microbiology 13, 620–630  Dr Jorge Garcia-Lara What would you see in simple Gram-stain of M.tb ? School of Medicine Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) Physician Associate Studies (MPAS) 5  Dr Jorge Garcia-Lara And the other great guys  Ehrlich, 1882 – acid-fast stain School of Medicine INDEPENDENT STUDY Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) 6 Physician Associate Studies (MPAS)  Dr Jorge Garcia-Lara Diagnosis 1 Tuberculosis: acid fast stain Ehrlich, Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) M.tb is in School of Medicine Physician Associate Studies (MPAS) 7 red/pink  Dr Jorge Garcia-Lara Tuberculosis: Ziehl-Neelsen stain (or Acid-Fast Stain) INTERACTIVE LIVE SESSION School of Medicine SLIDE INDEPENDENT STUDY Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) 8 Physician Associate Studies (MPAS)  Dr Jorge Garcia-Lara And the other great guys  Ehrlich, 1882 – acid-fast stain  Nocard, 1885 - the avian bacillus, M. avium  Koch, 1890 – developed the ‘old tuberculin’ (OT)  Roentgen, 1895 - X-rays discovery  Theobald Smith, 1898 – the bovine bacillus M. bovis (see Vaccine)  Von Piquet & Mantoux, 1908 – TST development  Siebert 1934 – development of PPD 1940’s - Siebert's Mantoux test and chest X-ray examinations (US Public Health Service) to study the epidemiology of tuberculosis and discriminated the difference between overt School andof Medicine INDEPENDENT STUDY Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) latent Physician Associate infection Studies (MPAS) 9  Dr Jorge Garcia-Lara Diagnosis 2 The Tuberculin reaction Characterized by delayed hypersensitivity (i.e., Type IV hypersensitivity – 2-3 days for max. development): the early predominance of mononuclear cells (lymphocytes and monocytes/macrophages; a small proportion are tuberculin sensitized) most cells are recruited through the release of biologically active substances by sensitized lymphocytes increase in vascular permeability leading to erythema and edema (NOT IMPORTANT TO THE TEST) School of Medicine Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) Physician Associate Studies (MPAS) 10  Dr Jorge Garcia-Lara Tuberculin Skin Test (TST): overall principle School of Medicine Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) Physician Associate Studies (MPAS) 11  Dr Jorge Garcia-Lara School of Medicine Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) Physician Associate Studies (MPAS) 12  Dr Jorge Garcia-Lara PPD (Purified Protein Derivative) (TUBERSOL, Sanofi Pasteur) Purified protein derivative (PPD) of M. tuberculosis M. tuberculosis grown in protein-free medium Polysorbate 80 (Tween 80) - stabilizer Phenol - preservative in sterile isotonic phosphate buffered saline. School of Medicine Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) Physician Associate Studies (MPAS) 13  Dr Jorge Garcia-Lara School of Medicine Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) Physician Associate Studies (MPAS) 14  Dr Jorge Garcia-Lara RISK FACTOR NHS refers you to the CDC guidelines School of Medicine Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) Physician Associate Studies (MPAS) 15  Dr Jorge Garcia-Lara Diagnosis 3 Diagnostic NICE, 2016 Disseminat. investigations Joint/Bone Pericard Mening. Pleural Lymph Lung Skin CNS GU GI possibl possibl possibl X-Ray e e e possibl possibl e possibl possibl e possibl CT (thorax e e (thorax routine routine e ) / head) possibl possibl routine routine possibl MRI e e e Bronchosco possibl p. e possibl possibl possibl e possibl Ultrasound e e (abdo e m.) Echocardiog possibl. e iv possibl urography e Laparoscop possibl possibl y e e Microscop routin routine routine routine routine routine routine routine routine routine School of Medicine y Medicinae Baccalaureus e Baccalaureaus Chirurgiae (MBBS) routinStudies Physician Associate (MPAS) routine routine routine routine routine 16 routine routine routine Activity Dr Jorge Garcia-Lara Name 3 common routine diagnostic approaches used for the identification of tuberculosis in most body systems Submission : in class Contributors : individual undertaking Output : directed study proposal activity School of Medicine Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) Physician Associate Studies (MPAS) 17  Dr Jorge Garcia-Lara What happens the next time that you run a Tuberculin (Mantoux) assay? Will you have a memory immune response ? School of Medicine Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) Physician Associate Studies (MPAS) 18  Dr Jorge Garcia-Lara MIF INFECTIO N granuloma PROCESS CD4+ Th (e.g., IL-2 M.tb APC IL-12 macrophages) IFNg proliferation Th1 reactivation IFNg memory TUBERCULIN cells proliferation TNF REACTION Langerhans cells skin activation resident resident PPD macrophages macrophages Injection site /neutrophils /neutrophils 1ary erythema inflammation delayed hypersensitiv. 2ndary type IV induration 19 inflammation  Dr Jorge Garcia-Lara LIVE SESSION SLIDE INDEPENDENT STUDY no memory not developed immune system depleted/ overstimul. imm. syst. not enough antigen, wrong location. … 20 Activity Dr Jorge Garcia-Lara Immunodiagnosis of latent M. tuberculosis infection – Interferon-g Release Assays (IGRA) Antigen-specific T-cells (in patient IFN-g release upon blood after M.tb activation with ESAT- Antigens infection) 6, CFP-10, and/or TB7.7) ESAT-6 CFP-10 TB7.7 M. tuberculosis + + + M. bovis - - - School of Medicine Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) Physician Associate Studies (MPAS) 21  Dr Jorge Garcia-Lara INTERACTIVE LIVE SESSION School of Medicine SLIDE INDEPENDENT STUDY Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) 22 Physician Associate Studies (MPAS)  Dr Jorge Garcia-Lara MICROBIOLOGY Unit: ISCM Module: UM2010 Yr. 2024-2025 Tuberculo sis therapy by LECTURE CORE : Dr. GARCIA- 1 LARA Bitesize SLIDES 5 School of Medicine Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) Physician Associate Studies (MPAS) 23  Dr Jorge Garcia-Lara 1940’ s Tuberculosis therapy bed rest, special diets and fresh air, pneumothorax and other lung-collapse procedures, and surgical resection 24  Dr Jorge Garcia-Lara Professor Dame Margaret Turner- OBITUARY A pioneer of modern respiratory medicine 2017 Warwick Pioneering physician who advanced the understanding of lung function form physiology to immunology First female president of the Royal College of Physicians Diagnosed with tuberculosis in her last year of medical studies at Oxford, she was treated for a year in a sanatorium. SUPPLEMENTARY 25  Dr Jorge Garcia-Lara Tuberculosis treatment after the 1940’s  1882 – streptomycin  1921 – BCG vaccine  1949 – para-aminosalycilic acid  1952 – isoniazid (including administration to subclinical cases)  recent years - rifampicin REFERENCE 26  Dr Jorge Garcia-Lara neona laten Therapy t. t adult EDR Activ Active + e CNS 2 6 mo. 3 mo. 4-10 mo. mo. Isoniazid (w/ + + + + pyrixodine) rifampicin + + + pyrazinamide + ethambutol + adjunctive corticosteroid + s capreomycin, kanamycin + and/or amikacin 27  Dr Jorge Garcia-Lara neona laten Therapy t. t adult EDR* Activ Active + e CNS 2 6 mo. 3 mo. 4-10 mo. mo. Isoniazid (w/ + + + + pyrixodine) rifampicin + + + pyrazinamide + ethambutol + adjunctive corticosteroid + s capreomycin, kanamycin + and/or amikacin 28 * EDR, Extensively Drug Resistant  Dr Jorge Garcia-Lara Therapy in case of 1 antibiotic resistance / allergy : always triple therapy 7.5% of TB cases in the UK are isoniazid resistant !!! pyrazinami ethambuto Allergy Isoniazid rifampicin de l Isoniazid + + + pyrazinamid + + + e ethambutol + + + rifampicin as in EDR SUPPLEMENTARY School of Medicine SLIDE Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) 29 Physician Associate Studies (MPAS)  Dr Jorge Garcia-Lara Latent tuberculosis Mtb adapts to infection environmental (e.g., hypoxia, nutrient starvation and reduced pH encountered) Alters metabolism & arrests replication It includes transient transcriptional activation of approximately 50 genes under the control of the DosR ‘dormancy’ regulator And there are additional genes appropriate depending on the specific environmental cue The products of these induced genes are currently being explored 30  Dr Jorge Garcia-Lara Latent tuberculosis If the Mantoux is positive & if an IGRA is also positive offer treatment for latent TB School of Medicine Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) Physician Associate Studies (MPAS) 31  Dr Jorge Garcia-Lara MICROBIOLOGY Unit: ISCM Module: UM2010 Yr. 2024-2025 Tuberculo sis vaccine by LECTURE CORE : Dr. GARCIA- 1 LARA Bitesize SLIDES 6 Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) 32 Physician Associate Studies (MPAS)  Dr Jorge Garcia-Lara The Bacillus Calmette-Guerin vaccine (BCG) It contains live attenuated Mycobacterium bovis, which causes TB in cows & badgers … AND HUMANS 1900’s Albert Calmette & Camille Guérin M. tuberculosis in glycerin, potato and ox bile Replaced M. tuberculosis by M. bovis https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3749764/pdf/maed-08-53.pdf 33  Dr Jorge Garcia-Lara BCG vaccine eligibility groups 1. new registrations in: primary care antenatal services points of contact with secondary or tertiary care 2. people entering education, including university 3. links with statutory and voluntary groups working with new entrants and looked-after children and young people 4. unvaccinated or TST negative travelers to endemic countries 5. occupational risks Tuberculosis pathway 34  Dr Jorge Garcia-Lara Details on occupational risk eligibility groups during contact investigations & occupational risk o healthcare personnel in contact with patients or clinical specimens o TB lead physician and nurse o case manager o pharmacist o infectious disease doctor/consultant in communicable disease control or health protection o staff in care homes o veterinary & staff handling animals (e.g., abattoir) o social worker o staff of hostels for the homeless o staff accommodating refugees and asylum seekers o voluntary sector & local housing representatives SUPPLEMENTARY 35  Dr Jorge Garcia-Lara Vaccination for NHS staff Therapy Previously Tuberculin Active TB unvaccinated (or Mantoux) test potential clinical negative clinical symptoms symptoms & & history history DIAGNOSIS Treatment Tuberculosis pathway 36  Dr Jorge Garcia-Lara Are we ok because we have a vaccine ? variable protection 70-80% effective against the most severe forms of TB (e.g., meningitis) even less effective against lung tuberculosis recommend: babies, children & adults 35, no evidence of efficacy not in pregnancy or immunocompromised it DOES NOT work well in adults Electron micrograph of an effectiveness varies with region alveolar macrophage protection wanes and varies (may last isolated by broncholavage from a tuberculosis for 10-15 yrs) patient in Malawi. no evidence of efficacy of repeated vaccination School of Medicine Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) Physician Associate Studies (MPAS) 37  Dr Jorge Garcia-Lara Are we ok because we have a vaccine In the UK is?NOT part of the children vaccination schedule unless: born in an area with high TB incidence (40 / 100,000) parent/grandparent from endemic country living for 3 mo. in endemic country close prolonged contact with someone with pulmonary TB occupational risk individuals 38  Dr Jorge Garcia-Lara How good is the BCG vaccine ? 117,139 new TB cases 1913 2004 REFERENCE 39  Dr Jorge Garcia-Lara School of Medicine Questions ? [email protected] @GarciaLaraClan #UCLanMicrobiology School of Medicine Medicinae Baccalaureus Baccalaureaus Chirurgiae (MBBS) Physician Associate Studies (MPAS) 40