Tuberkulose ikke bare et importproblem. Mogens Jensenius Infeksjonsmedisinsk avdeling Oslo universitetssykehus, Ullevål

Transkript

1 Tuberkulose ikke bare et importproblem Mogens Jensenius Infeksjonsmedisinsk avdeling Oslo universitetssykehus, Ullevål

2 TB history Has existed since the Stone Age Upsurge during the Industrial Revolution in Europe and North America Caused 25% of all deaths Modern-time Caucasians are more resistant to TB than people from Africa and elsewhere

3 How TB is spread Spread only by smear-positive pulmonary cases Transmission occurs virtually only in closed and crowded environments

4 Exposure to smear-positive patient 10-30% are infected Primary TB Small children

5 Exposure to smear-positive patient 10-30% are infected Latent TB Primary TB Small children BCG vaccine

6 Exposure to smear-positive patient 10-30% are infected Latent TB 90% remain healthy 10 % develop Secondary TB during their life-time 50% within first 2 years

7 Exposure to smear-positive patient 10-30% are infected Latent TB 90% remain healthy 10 % develop Secondary TB during their life-time 50% within first 2 years

8 Exposure to smear-positive patient 10-30% are infected Latent TB In severe immunosuppresion, 10 % develop Secondary TB every year

9 Symptomer på sekundær TB Langvarige (>3 uker) Hoste Feber eller feberfølelse Nattesvette Vekttap

10 Severe pulmonary TB with cavities (smear-positive)

11 Mild pulmonary TB with tree-inbud nodules (smear-negative)

12 TB pleurisy

13 TB lymphadenitis

14 Intra-abdominal TB

15 TB osteomyelitis

16 CNS tuberculosis Meningitis Tuberculomas

17 Alle standard TB-medisiner er gamle Isoniazid 1952 Pyrazinamid 1954 Etambutol 1962 Rifampicin 1969

18 Routine treatment for uncomplicated and susceptible TB Isoniazid Rifampicin Pyrazinamid Ethambutol + pyridoxin Intensive phase 2 months Isoniazid Rifampicin + pyridoxin Continuation phase 4 months

19 Combination tablets Isoniazid Rifampicin Pyrazinamid Ethambutol Intensive phase 2 months Isoniazid Rifampicin Continuation phase 4 months

20 Treatment for complicated and susceptible TB Isoniazid Rifampicin Pyrazinamid Ethambutol + pyridoxin Intensive phase 3 months Isoniazid Rifampicin + pyridoxin Continuation phase 6-9 months

21 Mer enn 90% av alle tuberkulosepasienter som behandles i Norge blir friske

22 TB worldwide in 2015 Still an enormous problem ~1/3 of world s population is infected ~9.6 million new cases in % HIV co-infected 480,000 (5%) cases had MDR-TB 16% (1.5 million) died

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24 Nye TB tilfeller i Norge, 2014 Total insidens-rate: 7/ innbyggere Norskfødte: 0,5/ Asiatere: 51/ Afrikanere: 219/ Somalier: 386/

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27 Smitteoppsporing rundt tilfeller med smittsom TB

28 Forebyggende behandling Rifampicin + isoniazid i 3 mndr Gis som regel til ALLE smittede barn og ungdommer, og til mange voksne <35 år

29 Microscopy of sputum smears Inexpensive and rapid Positive when >5,000 bacteria/ml Indicates infectiousness Sensitivity 60% compared to cultures Cannot differentiate between dead and living bacteria

30 Culture Growth on Löwenstein-Jensen solid media takes 3-8 weeks Growth in Bactec radiometric liquid culture system takes 9-16 days

31 Xpert MTB/RIF Real time PCR Detects M. tuberculosis and rifampicin resistance genes Processing time 1.5h Positive when >10 bacteria/ml

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33 Sykdommer og aktuelle Reumatologiske Reumatoid artritt Bechterews sykdom Psoriasisartritt Dermatologiske Plaque-psoriasis Gastrointestinale Mb. Crohn Ulcerøs kolitt DMARDs

34 DMARDs og latent TB TNF-alfa blokkere T-celle eller B-celle hemmere IL1- hemmere Pasienter med latent TB som behandles med TNF-alfa blokker har 5x større risiko for å utvikle aktiv TB

35 Undersøkelser før evt DMARDs Sykehistorie Eksponert for TB? Bodd i høyendemisk land? Tidligere TB? Rtg thorax IGRA-test Henvis til spesialist ved positive funn

36 Forebyggende behandling Rifampicin + isoniazid i 3 mndr Starte med DMARDs når behandlingen er ferdig

37 Globally ~300,000 pulmonary MDR-TB cases

38 Previously untreated cases Average global MDR-TB prevalence 3.3%

39 Retreatment cases Average global MDR-TB prevalence prevalence 20% 20%

40 Definisjon på MDR-TB Resistens mot rifampicin og isoniazid

41 MDR-TB must be treated for a long time Intensive phase: 5-8 months With a 2nd-line injectable per oral drugs Continuation phase: for at least 12 months With 3 per oral drugs

42 Side effects are common Tinnitus, hearing impairment, renal insufficiency Headache, nausea, tendinitis Nausea, diarrhea, neuropathy, hypothyreosis Headache, anxiety, psychosis Hepatitis, nausea arthralgia

43 Treatment succes rates of MDR- TB are appalling Globally only 49% are successfully treated Many pts are lost to follow-up, die or become chronic cases