Tuberculosis (TB) is one of the top 10 causes of death in Nepal. It is estimated that about 17,000 people die due to TB every year in Nepal. Tuberculosis is caused by a bacterium called Mycobacterium Tuberculosis. Tuberculosis is an infectious disease that primarily affects the respiratory system, but it can also affect other systems, such as the gastrointestinal system, musculoskeletal system, nervous system, etc. It may be present as a latent or an active infection. Active cases can be presented with symptoms like cough, hemoptysis (blood in the sputum), fever, weight loss, etc.

Usually seen in: All age groups

Gender affected: Both men and women but more common in men

Body part(s) involved: Lungs, Intestine, Bones, Brain, Blood

Prevalence Rate: Worldwide: 10 million (2019). In Nepal: According to National Tuberculosis Prevalence Survey (2018-19), estimates 69,000 new TB cases annually. Previously, it was estimated to be 44,000 per year. However, around 27,000 people affected with TB are diagnosed and enrolled in the treatment every year.

Mimicking Conditions: Pneumonia, Lung cancer, Fungal infection of the lung, Sarcoidosis

SYMPTOMS OF TUBERCULOSIS

Pulmonary tuberculosis or TB of the lungs is the most common type of TB. Other types such as the TB of the bones, lymph nodes, brain, kidneys, intestine, and genitals are also seen.

Symptoms of Pulmonary TB

Tuberculosis most commonly affects the lungs and can cause the following symptoms:

Coughing that lasts for more than 2 weeks with or without fever

Fever, especially an evening rise in body temperature

Presence of blood in the sputum

Chest pain

Loss of appetite

Loss of weight

Chronic fatigue

Night sweats and chills

Symptoms of Systemic TB (other than pulmonary TB)

Occasionally, tuberculosis may also affect other organs, such as bones, stomach, etc., and presents with common symptoms like fever, weight and appetite loss and some specific symptoms related to organ system involved like

Bone TB involving the spine can cause back pain and neurological complications like paraplegia where the lower limbs become paralyzed.

Gastrointestinal system disease can cause nausea, vomiting, diarrhea, malabsorption etc.

Tuberculosis of the kidneys can cause blood in the urine.

Infection involving the brain and its covering membrane can cause seizures, headaches, neurological abnormalities, etc.

CAUSES OF TUBERCULOSIS

Tuberculosis is caused by a bacterium called Mycobacterium tuberculosis. TB usually spreads from one person to the other through the air. When a person suffering from TB sneezes, coughs or spits, the bacteria get into the air. Hence, when a person inhales even a few of these bacteria from the air, he/she becomes infected. Although it is contagious, the bacteria grow at a slow rate and requires you to spend considerable time around the person who is sick. This means, it requires close and prolonged contact with a person who has active tuberculosis.

Note: Remember! Tuberculosis cannot spread through a simple handshake or sharing utensils as the bacteria cannot survive for long outside of the human body.

TYPES OF TUBERCULOSIS

There are 5 different types of tuberculosis based on the type of infection. These include:

Latent tuberculosis

Latent tuberculosis does not cause any symptoms as the body’s immune system keeps the infection at bay. In latent tuberculosis, the person carries the bacteria but does not develop any symptom However, there is a possibility that the latent infection may reactivate at a later stage in life when the body’s immune defenses go down and may lead to active disease.

Active tuberculosis

Active tuberculosis refers to a condition where the bacteria are in an active stage and cause symptoms, further classified into pulmonary and systemic tuberculosis.

Pulmonary tuberculosis is primarily a disease of the lungs (pulmonary TB).

Systemic tuberculosis, active tuberculosis is present in other parts of the body, such as bones, lymph nodes, brain, kidneys, intestine, and reproductive system.

Disseminated tuberculosis

Miliary tuberculosis, this is a severe type of infection where the tuberculosis bacteria spread to the entire body through the bloodstream.

Multidrug resistant tuberculosis (MDR TB)

MDR TB is caused by a bacterium which is resistant to at least two most common and potent drugs used to treat TB namely isoniazid and rifampin.

Extensively drug resistant tuberculosis (XDR TB)

This is a rare type of tuberculosis in which the bacteria are resistant to more than two drugs used to treat TB. In addition to isoniazid and rifampin, people suffering from XDR TB are resistant to fluoroquinolones (an antibacterial medicine) and at least one of three injectable second-line drugs used to treat bacteria.

RISK FACTORS OF TUBERCULOSIS

Although all age groups are at risk of TB, the risk is higher in people who:

• Live in or travel to a country with a higher prevalence of tuberculosis such as tropical and developing countries.
•  Work in places constantly exposed to crowds, such as hospitals, community centers, prisons, etc.
• Suffer from malnourishment. It is seen that undernourished people are 3 times more at risk of TB as compared to healthy people.
• Suffer from diabetes or are on medicines such as steroids or anti-cancer drug therapy.
• Suffer from weakened immunity or are recovering from an illness.
• Are infected with HIV/AIDS as the risk of getting tuberculosis is 18 times higher for patients with HIV.
• Consume excess alcohol and smoke tobacco products.

DIAGNOSIS OF TUBERCULOSIS

Along with a detailed history and physical examination, the doctor also orders laboratory tests and imaging studies to confirm a suspected case of tuberculosis.

Following tests are used to confirm a diagnosis:

Blood Tests

• Cartridge based nucleic acid amplification test (CB-NAAT)
• TB Platinum Interferon Gamma Release Assay
• Complete Blood Count, Erythrocyte Sedimentation Rate
• Sputum AFB (ZN Stain)
• Mycobacterium tuberculosis DNA PCR - Qualitative
• Skin prick test (Mantoux test)

Imaging studies

• In pulmonary tuberculosis cases, imaging studies like X-Ray chest PA View, HRCT chest - plain are required to evaluate the extent of the disease in the lungs.
• In extrapulmonary tuberculosis cases, other imaging studies, such as X-Ray dorsal spine AP & lateral view, MRI brain, etc., may be done as appropriate.

TREATMENT OF TUBERCULOSIS

The treatment for tuberculosis depends on the type of infection.

Latent tuberculosis

if you have tested positive for tuberculosis in a screening test and high-risk category, treatment may be recommended in Nepal. The medicines for latent tuberculosis must be taken for a duration of 6 to 9 months as prescribed by a doctor.

Active tuberculosis

Antibiotics are the main treatment options for people suffering from TB. The treatment approach usually involves taking these drugs for a span of several months. These medicines are usually given in combination as part of a regimen to effectively treat tuberculosis. These medicines kill the bacteria causing tuberculosis or prevent its growth.

The first line of treatment for active tuberculosis consists of combination therapy with five antitubercular drugs. Of these, streptomycin is given in the form of an injection, whereas a single tablet consisting of all the four medicines (isoniazid, rifampicin, pyrazinamide and ethambutol) is available. The dose of this combination medicine is based on the weight of the patient.

Easy-to-use combination kits, containing a combination of the first-line antitubercular drugs are also readily available. The treatment continues for 6-8 months even if the symptoms get better, as it ensures complete recovery and prevents the development of drug resistance.

The DOTS (Directly Observed Therapy - Short Term), where the patient has to take the medicine in front of a DOTS agent. This is to ensure adherence to the treatment.

MDR TB and XDR TB

The tuberculosis bacteria are prone to develop drug resistance. Some patients do not respond to the first line of treatment and develop multi-drug resistant tuberculosis or MDR-TB. There are strains of bacteria resistant to most forms of available drugs and cause a severe form of the disease known as extensively drug-resistant tuberculosis or XDR-TB.

Treatment options for MDR and XDR tuberculosis consist of higher dosing of the first line of drugs and a combination of other oral medicines and injections. The course of the treatment is usually 18 months for MDR-TB and 224 months for XDR-TB.

Some of the common examples include:

Amikacin injections

Streptomycin injections

Levofloxacin preparations

Moxifloxacin preparations

Para-amino salicylic acid

Clofazimine preparations

Imipenem injections

Clarithromycin preparations

Bedaquiline

SUPPORTIVE CARE

This involves use of medications aimed to improve the symptoms such as fever, cough, and pain. Some of the common class of drugs used for supportive care of TB are:

• Anti-fever and analgesic medicines to provide relief from fever and pain.
• Antitussive medications to help reduce cough.
•  Vitamin B supplements given along with antitubercular medicines to help combat neurological side effects like nerve pain and neuropathies caused by antitubercular medicines.
• Antacids to prevent gastro-intestinal symptoms
• Medicines to reduce uric acid level (hyperuricemia is known to be a side-effect of TB medicines) such as allopurinol and febuxostat are recommended.
• In some cases, an herbal medicine/tonic for the liver is recommended as antitubercular medicines can impact the liver.

CARE FOR TUBERCULOSIS

With active tuberculosis, you can do the following things to care for yourself at home:

• Always use a handkerchief to cover your mouth and nose while sneezing or coughing.
• Wash your hands frequently with soap and water or use hand sanitizers.
• Take a balanced diet rich in vitamins and minerals.
• Drink plenty of fluids throughout the day.
• Take plenty of rest. Do not engage in any strenuous activities.
• Take the entire course of medicines prescribed by the doctor, even if your symptoms reduce or you start feeling better.

LIVING WITH TUBERCULOSIS

Tuberculosis is a disease that is often associated with a stigma as there are many misconceptions surrounding it. However, with recent improvements in available treatments and public awareness campaigns, the stigma of the disease is declining, and more and more people are recovering completely from the disease. In the active phase of the disease, it is advisable to refrain from interacting with many people and avoid crowded places to prevent transmission. Here are a few tips you need to keep in mind if you are on medications for tuberculosis:

• Maintain a routine if you are taking medications by yourself like taking medicines at the same time every day, marking off the date on a calendar or using a weekly pill dispenser.
• Inform your doctor if you experience any unusual symptoms or side effects of the medications. Your doctor might consider changing the drugs.
• Make sure you complete your course of medications. Not finishing the course or stopping the medications mid-way can not only increase the risk of getting sick and spreading the infection again but can also make the bacteria resistant to the drugs.
• Do not forget to follow cough etiquettes like covering your mouth when sneezing or coughing and throwing a used tissue in the trash can.
• Ask your doctor about the improvement in your condition, the change in medications, lab tests to be taken, and any questions you have related to the condition. This will help you understand the condition & take care of your health
• Caregivers should ensure to avoid close contact with the patient, If possible, let the patient share a single room with proper ventilation.
• Eat a diet rich in nutrients like vitamins, minerals, and antioxidants. Avoid eating oily, salty and spicy food. home cooked foods to boost your immunity and stay healthy.

PREVENT THE SPREAD OF TUBERCULOSIS

As tuberculosis spreads through infected droplets, it is important for a patient with active tuberculosis to follow certain hygiene measures to prevent the transmission of the infection.

Always cover your mouth with a handkerchief when coughing or sneezing to prevent the spread of droplets.

Patients with active tuberculosis must wear a surgical mask in the presence of others to prevent the transmission of droplets.

Wash your hands with soap and water or use hand sanitizers frequently to keep your hands clean.

The room where a patient with active tuberculosis lives must be well ventilated and should be cleaned with a disinfectant every day.

The pasteurization of milk also helps to prevent humans from getting bovine TB.

The last but the most important point is to complete your course of TB treatment because by doing so you not only lower your risk of recurrence/remission but also prevent community transmission of the disease.

The specialist doctors who diagnose and treat tuberculosis are:

General physician

Chest physician

Infectious disease specialist

Respiratory specialist or pulmonologist

Related Government Center & NGOs

National Tuberculosis Control Centre (NTCC)

SAARC Tuberculosis Centre (STC)

DOTS Centers

Nepal Anti-Tuberculosis Association (NATA) - Stop TB

TB Nepal, NAPID Nepal, HERD and BNMT

By

Ramendra Kumar Raman, PhD, Clinical Research

References

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