NTEP AND NACP😊

• TB Otorrhea

• Ocular TB
• M/c - Granulomatous panuveitis

• Acid-fast bacillus due to mycolic acid

• Virulence
• Cord factor
• Lipoarabinomannan (LAM)
• Inhibits phagolysosome formation
• Urine LAM test useful in HIV-positive TB patients

• Common organs affected
• Most common: Lung
• Second most common: Lymph nodes

Associated Lesions

• Sample
• Sputum

• Sputum Concentration methods
• Modified Petroff method (4% NaOH)
• N-acetyl-L-cysteine + 2% NaOH

• After getting 100/100 3 times in TB, then started to decrease

Histological features (Biopsy):

• Caseous necrosis: Central pink area.

• Langhan's giant cell:
• Horseshoe/necklace pattern of nuclei.

Diagnostic Modalities for TB

• CXR: Non-sensitive and non-specific

LJ Medium composition

• Coagulated hen's egg

• Mineral salt solution

• Asparagine

• Malachite green

• British cuisine - english breakfast

Xpert MTB/RIF Sensitivity & Specificity (by Sample)

• In pleural effusion diagnosis: 
• Gene X-pert is of lesser value; 
• Pleural biopsy and culture is required

TB Radiology

• Fibrocavitary TB:
• Generally unilateral or asymmetrical.
• Bulky right hilum due to enlarged hilar lymph nodes.

Miliary TB:

 

• Due to hematogenous spread of infection.

• Also seen in
• Histoplasmosis
• Healed varicella
• hemosiderosis
• silicosis
• small metastasis

• His (Histoplasmosis) chicken () iron () thinn → cancer () vann → He joined military (Miliary)

Tree in bud sign: (3a)

• Seen in TB.
• Due to endobronchial spread of infection.
• Centrilobular nodules

• CT scan showing Mediastinal Lymph nodes: (3b)
• They are necrotic lymph nodes,
• hence not enhancing.
• Only margins of lymph nodes will enhance
• Ring / Peripheral enhancing lymph nodes.

• Necrotic lymph nodes and pleural effusion - TB.

TB Meningitis

Conglomerate lesions

• with necrotic tuberculomas

Thick and enhanced meninges.

• Basal exudates.

On MR Spectroscopy

• Lipid peak is seen

Hydrocephalus

• Dilated ventricles

MR Spectroscopy

• Creates a graph of chemical metabolites.

Condition	Maximum Peak
Normal brain	NAA
Tumor	Choline
Tuberculosis	Single lipid peak + basal exudates
Neurocysticercosis	Multiple amino acid peaks.

Comparison Table

TREATMENT OF TUBERCULOSIS (NTEP)

• Drug Sensitive TB: 2 HRZE + 4 HRE.
• H: Isoniazid
• R: Rifampicin
• Z: Pyrazinamide
• E: Ethambutol

• Drug Resistant TB

Type	Resistance Pattern
Rifampicin resistance	• Resistant to R only; • sensitive to H
MDR	• Resistant to H + R • MD Likes HR girl
Pre-XDR	• Resistant to H + R + FQ • Pre → three → HR Fuck
XDR	• Resistant to H + R + FQ + • One of Bedaquiline or Linezolid • Any group A drugs ↳ (Levofloxacin, moxifloxacin, bedaquiline, linezolid) • H () R () Fuck (FQ) → Lie (Linezolid) Bed (Bedaquiline)
TDR	• Resistance to all 1st & 2nd line drugs

• High-priority TB-HIV district:
• Co prevalence > 10%

• For TB with HIV
• First start treatment of TB (ATT).
• After 2 weeks, start treatment of HIV (ART).
• D/t IRIS → Immune Reconstitution Inflammatory syndrome
• TB flare up
• Use Rifabutin instead of Rifampicin
• If TB meningitis
• After 4 weeks
• If Disseminated TB
• After 2 months

• Both → Butin

• Prophylaxis → Pentin

Newer regime:

• BPaLM regime x 6 months
• Approved for Longer MDR in Aug 2024
• B: Bedaquiline
• Pa: Pretomanid
• L: Linezolid
• M: Moxifloxacin

New drugs

• 1. Bedaquiline
• ATP synthase inhibitor
• QT prolongation
• Bedil () kidakkan with cutee () → Need ATP ()

• 2. Delamanid
• Group C drug

• 3. Pretomanid
• Free radical → mycolic cell wall injury
• QT prolongation
• Preman Free time () il → mathilu polichu () → with a cutee ()

• Bed () il Premam () → Cute → QT prolongation

MDR has 2 resistance

1. R Resistance

2. H resistance



• D/t
1. kat G gene mutation
2. INH a/b mutation
• Single gene mutation : Shorter/longer MDR.
• Double gene mutation : Longer MDR.

• Bedaquiline resistance
• atpE gene

Special Situations

• TB in pregnancy:
• 2HRE + 7 HR
• Pregnancy → 9 months (2 months HER, 7 months in HR)
• Avoid Streptomycin, Bedaquilin, Petromanid
• NO Preman () in My () Bed () during pregnancy

Prophylaxis/TB Preventive Therapy (TPT)

TPT Regimens

• Contact with Drug-Resistant TB (DR-TB):
• 4R 6O

• Both → Butin

• Prophylaxis → Pentin

Latent TB Diagnosis

TST/Mantoux test:

• Type IV hypersensitivity

• 0.1 mL of purified protein derivative

• Site: Forearm

• Reading: 48-96 hrs (72 hrs: Ideal)

• False positives: BCG vaccination

• False negatives: Immunodeficient states

• Positive In case of:

Induration Threshold	Associated Risk Factors
5 mm	HIV, immunosuppressed, close contacts of TB, history of prior TB
10 mm	Recent immigrants, age <4 years, high-risk occupation
15 mm	No risk factor

IGRA (Interferon-γ Release Assay)/ QuantiFERON GOLD

• Measures IFN-γ by ELISA

• BEST TEST TO CHECK EXPOSURE >> mantoux

• BLOOD ONLY TEST

• T-lymphocytes exposed to TB antigens:



• CFP-10
• TB7.7
• ESAT-6

 

• M/c HIV in India:
• HIV-1 group M subgroup C
• Mnemonic: M C → m/c

• HLA B27/57 → Good prognosis → Controller

• HLA B35 → Poor prognosis → Progressor

• Structural Genes (Mature Virion):
• Env (gp160 → gp120 + gp41)
• Gag → p17 (matrix), p24 (capsid), p7 (nucleocapsid), p6 (budding)
• Pol → p12 (protease), p66/p51 (RT), p32 (integrase)

• Attachment:
• gp120:
• bind CD4 T cells/macrophages
• gp41:
• Transmembrane anchoring protein
• Conformational change & Exposes fusion peptide
• aids cell penetration
• Co-receptors: CXCR4, CCR5
• CCR5 on macrophages (early infection)
• CXCR4 on T cells (late infection)
• CCR5 (delta 32) mutation = Immunity to HIV AIDS
• When the binding is complete the virus enters the cell.

• FRIEBERG CLASSIFICATION

• Disease Course:
• CD4 decreases during acute syndrome
• Clinical latency → 10 years (healthy, but no microbiological latency)
• Later: Opportunistic infections

 

WHO STAGING

• M/c Opportinistic infection:
• TB

• M/c Pneumonia
• Strep > TB

• M/c Ocular feature
• Microangiopathy

• M/c finding in HIV Retinopathy
• Cotton wool spots

• M/c ocular side effect in HAART
• Immune Recovery Uveitis
• Non granulomatous uveitis (anterior > Posterior)
• Usually in CMV Retinitis

Laboratory Diagnosis of HIV: NACO

• Screening in ICTC centers (Integrated Counselling & Testing Centres)
• Mobile ICTC:
• In rural area, ↓ prevalence
• Fixed ICTC:
• In ↑ high prevalence
• Facility integrated ICTC:
• In low burden area
• Standalone ICTC:
• In high burden area

• Method → Community-based screening

 

Screening:

• 4th gen assays → p24 Ag + HIV Ab

• According to NACO → ERS to be performed
• (All 3 to be performed)
1. ELISA: Most sensitive, 1st test
2. Rapid test
3. Dried blood Spot test

• Other screening tests:
• Immunoconcentration
• Particle agglutination

HIV probable +ve

Diagnostic/Conformational tests:

• Adults:
• Western blot >>> qPCR
• Most Diagnostic
• qPCR is only done in adults
• Western Blot (HIV-1) → qPCR
• WHO: 2 envelope proteins (+/- gag/pol)
• Envelope to who
• CDC: Any 2 bands (p24, gp160, gp120, gp41)

• Children:
• HIV TNA/ DNA RT-PCR (IOC)
• TNA: Total nucleic acid
• Also to assess response

• Serology (blood markers):
• Earliest: HIV RNA plasma (used for needle-stick injury)
• Next: HIV-1 p24 antigen

• Others:
• Viral isolation/Viral load estimation

Prognostic test:

• CD4 count (Response to Rx)

All in initiative → Adolescent HIV

Nirantar scheme → To ↑↑ awareness

SUNRISE project → ↑ incidence in North Eastern states

First line ART (FLART):

• HAART = Highly Active Anti Retro Viral Therapy

• Indicated for all HIV-positive patients, regardless of CD4 count

• Lifelong therapy

• Minimum 3 drugs from minimum 2 groups

• Viral load > CD4 count for monitoring treatment efficacy

• 2 NRTIs + 1 NNRTI / Integrase Inhibitor

• T + L + D

Prophylaxis

Post-exposure prophylaxis (PEP):

• In needle stick injury
• TLD:
• T300, L300, D50 x 28 days as 1 OD tablet
• Started within 2 hrs
• Maximum: <72 hr

Pre-exposure prophylaxis of HIV

• Beneficiaries:
• Spouses of HIV +ve patients
• Habitual sex worker clients

• Regimen:
• Tenofovir + Emtricitabine
• Mnemonic:
• Take a TEa (tenofovir, emtricitabiune)
• Before going to Lena every 6 months

• Lenacapavir
• Novel first in class PrEP
• MOA: HIV capsid inhibitor
• Inhibiting capsid assembly & nuclear import of viral DNA
• 900 mg S/c every 6 months
• t1/2 = 38 days

Prevention of opportunistic infection:

• Pneumocystis jirovecii pneumonia (PJP) infection
• Cotrimoxazole preventive therapy
• Dose:
• Double strength.
• 800 mg Sulfamethoxazole + 160 mg Trimethoprim

Started:

• At CD4 <350/mm3

• Given for minimum 6 months

• Stopped when CD4 >350/mm3
• On 2 occasions 6 months apart

Cotrimoxazole prophylaxis

Age group	Indication
HIV-exposed infants > 4–6 weeks	All infants
Children < 5 years	All children
Children > 5 years	CD4 < 350 and/or WHO stage 3 or 4
Adults and pregnant women	CD4 < 350 and/or WHO stage 3 or 4
HIV + TB coinfection	All patients
Malaria endemic area	Children and adults regardless of CD4 count or stage

Prevention of Mother to Child Transmission

• Mother on ART with Nevirapine:
• Zidovudine (AZT) for 6 weeks to prevent archived resistance

• Baby exposed to HIV +ve mothers:
1. Risk of transmission Low:
• <1000 copies/mL viral load,
• Nevirapine x 6 weeks
2. Risk of transmission High:
• Exclusive breastfeeding:
• Zidovudine + Nevirapine x 12 weeks
• Replacement feed:
• Zidovudine + Nevirapine x 6 weeks in child
1. 1000 copies/mL viral load
2. Mother not on ART
3. Unknown viral load
4. Newly Dx HIV +ve within 6 wks of delivery

• Cotrimoxazole prophylaxis from 6 weeks to 18 months

• Early infant diagnosis is done at 6 weeks by DNA-PCR
• If negative → screen every 6 months → till 2 years

• Confirmatory testing is done at 18 months by DNA-PCR

• Children with HIV
• Failure to thrive

UNAIDS

• Headquarters: Geneva.

• Has set policy to achieve: 95-95-95.
• By 2030

• Global action against the HIV/AIDS epidemic
• 95% of all people living with HIV
• Diagnosed
• 95% of diagnosed people
• Rx with ART
• 95% of people on ART
• Achieve viral suppression

• Logo: White colour plus with a red dot.

• Initiative of: National AIDS control programme

• Ensures: Sexual and reproductive health services

• Behavioural change therapy for clients of commercial sex workers & high risk population

• Manage STIs/RTIs

• Syndromic management with kits

Suraksha Clinic vs International Red Cross

• Provides for:
• war victims
• disasters

• Headquarters is in: Geneva.