Transmission and Pathophysiology of TB
M. tuberculosis bacilli initially cause a primary infection, a small percentage of which eventually progress to clinical diseases of varying severity. However, the majority (about 95%) of primary infections are asymptomatic (Suárez et al., 2019). An unknown percentage of primary infections resolve spontaneously, but in most cases, there is a latent (inactive) phase. Infection is usually not transmitted initially and is never contagious in the latent period.
Infection occurs when inhaled particles are small enough to overcome the protective barriers of the upper airway and settle deep in the lungs, usually in the subpleural air space of the middle or lower lobes (Suárez et al., 2019). Larger droplets tend to settle in the upper airways and do not lead to disease. Infection usually begins with a single droplet nucleus, which carries several pathogens. Theoretically, only one organism is enough to cause infection in susceptible people, but less susceptible people may need repeated contact to develop an infection.
M. alveolar macrophages must take up tuberculosis bacilli to develop an infection. Tubercle bacilli that are not neutralized by macrophages reproduce in them, eventually killing the host macrophage (via CD8 lymphocytes) (Suárez et al., 2019). The cells causing inflammation are attracted to such an area, causing focal pneumonitis to merge into a characteristic tuberculous granuloma, which is determined by histological methods. During the first weeks of infection, some infected macrophages migrate to nearby lymph nodes (portal, mediastinal), where they gain access to the bloodstream.
In most cases, latent tuberculous infection develops after primary infection. In about 95% of cases, after about three weeks of active growth of mycobacteria, the immune system begins to suppress the multiplication of the bacilli before clinical symptoms and signs appear (Suárez et al., 2019). Bacilli foci in the lungs or other organs transform into epithelioid cell granulomas with caseous and necrotic centers. Conditions that disrupt cellular immunity (which is very important for protection against tuberculosis) greatly facilitate reactivation.
Clinical Manifestations
In its early stages, tuberculosis is almost asymptomatic. The patient’s condition worsens, but no specific symptoms are observed. Clinical signs are increased fatigue, weakness, sudden weight loss for no apparent reason, a temperature of 37-38 °C, which does not subside for a long time, and night sweats (CDC, 2022). The face becomes pale, and the cheeks are flushed.
The pulmonary form of TB is accompanied by a cough that is mild at first but increases in intensity over time. Later, yellow-green sputum becomes secreted, and in the cavernous stage, hemoptysis occurs. With tuberculosis of the cerebral membranes and the brain, symptoms of general intoxication are joined by sleep disorders and headaches, the intensity of which gradually increases. Then, stiffness of occipital muscles, symptoms of Kernig and Brudzinski, and neurological disorders appear.
Main Medical Problems of the Patient
The patient presented to the hospital with multiple complaints. It is essential to consider that a close relative of the patient was a potential carrier of the disease. Physical examination revealed abnormal lung sounds in the upper lobes on both sides. Furthermore, problems included cervical and axial lymphadenopathy, and sputum culture was positive for M. tuberculosis (Suárez et al., 2019). However, even before the study, the patient already had significant symptomatology through lung disease.
Primary Psychosocial Concerns
Tuberculosis is not only a medical problem but also a psychosocial problem. The social problem is more significant and has more consequences than the medical problem. It consists of the fact that people with TB sometimes deliberately infect people around them and their family members. Considering that one person sick with pulmonary tuberculosis may infect about 100 people annually, the importance of the problem for society becomes apparent (Suárez et al., 2019).
Some patients have become drug-resistant to TB drugs, and the people infected by them also have this resistance from the beginning. The patient with pulmonary tuberculosis is bothered for months by intoxication, subfebrile body temperature, weakness, sweating, and sleep disturbances. One needs emotional support from loved ones and relatives. Thus, tuberculosis is a highly complex disease that causes medical and mental consequences and problems.
Compliance and Outcomes
On average, treatment of newly diagnosed forms takes a year and a half, and treatment of chronic forms lasts for years. During this time, drug resistance of the pathogen to major antituberculosis drugs can develop. It is estimated that about 20% of TB cases worldwide are resistant to at least one of the first- or second-line anti-TB drugs and 5% are resistant to isoniazid and rifampicin, the most powerful and commonly used first-line antibiotics (Furin et al., 2019).
In this case, it is necessary to use reserve drugs, which patients worse tolerate, have more side effects, and the course of treatment is longer. If a patient with drug-resistant strains of mycobacteria infects others, he transmits the disease and drug resistance. It causes frequent treatment abandonment and, hence, decreased efficacy. Among patients in 2020 who were alive at the time of diagnosis, 82.2% completed TB treatment (Suárez et al., 2019). At the same time, both drug-resistant TB and its treatment have less success rate.
Community Clinics and Resources
The Patient Protection and Affordable Care Act may strengthen current efforts to control tuberculosis (TB) in the United States by strengthening the role of the community health center. However, essential healthcare functions related to TB will remain necessary and the responsibility of federal, state, and local health departments. Testing and treating latent TB infection is not explicitly covered as a recommended preventive service without cost participation or co-payment. Thus, the law does not cover the treatment of undocumented patients and does not include funding for treatment.
Resources such as isoniazid INH and three other drugs – rifampin, pyrazinamide, and ethambutol – are common throughout the country. Moreover, patients are offered psychological support, and there are specialized treatment centers and testing centers. In 2020, the CDC used average estimates of hospitalization costs, which are $34,520 per patient in 2020, which is less expensive than unsubsidized treatment (CDC, 2022). There is no direct data concerning non-community facilities. However, it can be stated that treatment in community facilities is mostly covered.
TB Implications
Nurses play a vital role in the treatment of tuberculosis (TB): For the duration of therapy, which can last up to two years, they are the ones who give patients their prescribed medications every day, monitor how they take all the pills and watch closely for side effects (Furin et al., 2019). However, advanced practice and ICU nurses are at risk for infection and must undergo preventive examinations at regular, specified intervals before entering the workplace. Patients with smear bacilli should be kept in an isolation room to prevent the spread of infection.
Moreover, immunosuppressed patients should not be allowed to contact patients with any form of pulmonary tuberculosis. When working in the isolation ward, especially with patients with multidrug-resistant tuberculosis, the nurse should use a respirator to prevent infection. It should also be remembered that such patients are no more infectious than patients with susceptible TB, but they keep their bacilli for much longer – even with proper treatment, up to six months (Suárez et al., 2019). Furthermore, nurses are subject to psychological risks since the behavior of patients often leads to a tense work atmosphere and depression.
Reference
CDC. (2022). Interim Guidance: 4-Month rifapentine-moxifloxacin regimen for the treatment of drug-susceptible pulmonary tuberculosis. MMWR Morb Mortal Wkly Rep, 285–289. Web.
Furin, J., Cox, H., & Pai, M. (2019). Tuberculosis. The Lancet, 393(10181), 1642-1656.
Suárez, I., Fünger, S. M., Kröger, S., Rademacher, J., Fätkenheuer, G., & Rybniker, J. (2019). The diagnosis and treatment of tuberculosis. Deutsches Aerzteblatt International, 116(43).
