Minggu, 07 September 2008

Tuberculosis in Adulthood

Tuberculosis can affect all age groups from all socio-economic level, including pregnant women. The disease still become health problems in developing countries but tuberculosis has reemerged as an important public health problems in developed countries ever since the increment of HIV infection or AIDS worldwide. In Indonesia, around 627,000 new cases were reported annually and it is estimated that nearly 143,000 deaths from tuberculosis occurred every year.

Tuberculosis is caused by bacteria Mycobacterium tuberculosis and transmissions usually take place through the airborne spread of droplet nuclei produced by patients with infectious pulmonary tuberculosis, which are aerosolized by coughing, sneezing, or speaking. The disease usually affects lung, but in up to one-third of cases other organs are involved to include pleural, meningeal, brain, intestine, kidney, joint, bone, lymph-node, skin, and many other organs.

The risk of developing disease after being infected depends on individual’s innate susceptibility to disease and level of function of cell-mediated immunity. Most adult with tuberculosis are infected during childhood. The infection had spontaneous remission, but dormant bacteria may persist for years before being reactivated to produce post primary tuberculosis during adulthood if they are in an immunocompromised state.

Early in the course of disease, symptoms and signs are often nonspecific and insidious, consisting mainly of low-grade fever and night sweats, weight loss, anorexia, general malaise, and weakness. Cough eventually develops in pulmonary tuberculosis, and may be with blood streaking sputum. The clinical manifestations of extrapulmonary tuberculosis depend on the organs that being involved.

If properly treated, tuberculosis caused by drug-susceptible strains is curable in virtually all cases. Multiple drug regiments are given for 6 months or longer. Five major drugs are considered the first-line agents for the treatment of tuberculosis: isoniazid (INH), rifampicin, pyrazinamide, ethambutol, and streptomycin. Short-course regimens are divided into an initial or bactericidal phase (during which the majority of the bacteria are killed, symptoms resolve, and the patient becomes noninfectious) and a continuation or sterilizing phase (to eliminate semidormant persisters). The treatment regimen of choice consists of a 2-month initial phase of isoniazid, rifampicin, and pyrazinamide (in particular cases this regimen is added with ethambutol either with or without streptomycin) followed by a 4-month continuation phase of isoniazid and rifampicin.

In the next 3-4 months of treatment, usually the symptoms are improved and adherence to treatment regiment can be compromised because the patients think that they have already recovered from tuberculosis. This non-compliance attitude should be strongly avoided whenever possible, since infected patients who do not adhere to the prescribed regimen are especially likely to develop acquired drug resistance. The treatment ought to be start all over again with more drug combination and more difficult to be cured due to the development of multi drug resistance bacteria strains.

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