Tubercolosi, sintomi, mortalità, come si cura e relazione con HIV

La tubercolosi è una malattia che molti associano al passato, ma ancora oggi provoca milioni di vittime in tutto il mondo. Si tratta di una patologia che ha causato il più alto numero di vittime nella storia dell’umanità e che si attesta ancora oggi come una delle principali cause di morte al mondo, nonostante esista una cura.

Può sembrare assurdo che, nel 2024, ci siano ancora così tante persone che muoiono per una malattia curabile, ma è così. Scopriamo insieme cosa la causa, come si trasmette e come si cura. E, alla fine, esploreremo anche il legame tra tubercolosi e HIV, una delle principali co-infezioni nel mondo.

Che cos’è la tubercolosi?

La tubercolosi è un’infezione batterica che colpisce prevalentemente i polmoni, ma può interessare anche altre parti del corpo come ossa, reni e cervello nel caso della tubercolosi extrapolmonare. Il batterio responsabile, il Mycobacterium tuberculosis, si è evoluto con l’uomo per millenni, rendendo questa malattia diffusa in tutto il mondo, inclusa l’Italia. Forse sorprende, ma anche nel nostro paese si registrano numerosi casi ogni anno.

Quali sono le forme in cui si presenta la tubercolosi

La tubercolosi si manifesta in due forme:

• Latente: il batterio è presente nell’organismo ma non provoca sintomi. Tuttavia, in condizioni di immunodepressione, può “risvegliarsi” e diventare attivo.
• Attiva: in questa forma, la malattia si manifesta con sintomi e diventa contagiosa, specialmente tramite le goccioline respiratorie emesse durante la tosse.

Le forme più comuni colpiscono i polmoni, ma esiste anche la tubercolosi extrapolmonare, che può coinvolgere altre parti del corpo. Ci concentreremo principalmente sulla forma polmonare, che rappresenta il maggior rischio di trasmissione per una mera questione di semplicità divulgativa.

Sintomi e manifestazioni cliniche della tubercolosi

La tubercolosi polmonare presenta sintomi piuttosto comuni, che possono essere facilmente sottovalutati:

• Tosse persistente per oltre tre settimane, spesso con presenza di sangue nell’espettorato
• Febbre
• Perdita di peso inspiegabile
• Sudorazioni notturne

Sintomi che inizialmente possono sembrare banali, ma proprio per questa ragione spesso vengono ignorati o trattati con leggerezza. Nel caso della tubercolosi extrapolmonare, i sintomi variano in base agli organi colpiti: per esempio, infezioni ai reni possono causare problemi urinari, mentre l’infezione alle ossa provoca dolori articolari.

Trasmissione, fattori di rischio e come ci si contagia con la tubercolosi

La tubercolosi si trasmette principalmente per via aerea, attraverso le goccioline di saliva (droplet) emesse da una persona infetta durante la tosse, lo starnuto o semplicemente parlando. Il rischio di contrarre la malattia aumenta quando si trascorre molto tempo in un ambiente chiuso con una persona affetta.

Perché si verifichi un contagio, sono necessarie circa 8 ore di esposizione in una stanza non ventilata.

Chi è più a rischio?

Alcuni gruppi di persone sono maggiormente a rischio di contrarre la tubercolosi, come:

• Persone che vivono in spazi sovraffollati, ad esempio in ospedali, carceri o centri di accoglienza
• Individui con sistema immunitario indebolito, come chi convive con l’HIV o malattie croniche
• Persone malnutrite o che vivono in condizioni di vita precarie

Identificare precocemente le persone infette è fondamentale per interrompere la catena di trasmissione e limitare il rischio di diffusione.

Come si fa la diagnosi della tubercolosi

Diagnosticare la tubercolosi può essere complesso, ma oggi disponiamo di strumenti affidabili per individuare la presenza del batterio:

• Test cutaneo alla tubercolina (Mantoux): è il test più famoso e messo in pratica, in sostanza una piccola quantità di sostanza viene iniettata sotto la pelle e la reazione viene valutata. Ma attenzione: il test di Mantoux può essere positivo anche se non si è malati, invece un risultato negativo garantisce che non c’è infezione. Serve per vedere se si è entrati in contatto con la tubercolosi, non se si è malati!
• Test IGRA con QuantiFERON: misura la risposta del sistema immunitario al batterio tramite un prelievo di sangue, è molto affidabile.
• Test rapido GeneXpert MTB/RIF: usato per rilevare anche antibiotico-resistenze. Abbastanza recente, è molto affidabile nella positività. Si tratta di un test “rapido” che da esito in un paio d’ore.
• Coltura dell’espettorato: richiede diverse settimane per i risultati, ma è essenziale per confermare la diagnosi e determinare a quali antibiotici è resistente il batterio.
• Radiografia del torace: utile per individuare cavitazioni o opacità polmonari, spesso tipiche della tubercolosi attiva, ma ovviamente non da un esito certamente positivo in caso di positività e non da informazioni sulle resistenze

Solitamente, in base al caso, vengono fatti più test.

Come si cura e come si fa il trattamento della tubercolosi

Il trattamento della tubercolosi è lungo e impegnativo. Richiede l’assunzione di 4 o 5 antibiotici per un periodo che varia dai 6 ai 9 mesi. È cruciale seguire il trattamento con precisione, senza interromperlo, per evitare l’insorgenza di antibiotico-resistenze.

Un infettivologo, specializzato in tubercolosi, seguirà il paziente durante il trattamento, adattando la terapia in base alla risposta individuale e alle eventuali resistenze del batterio. Il successo della cura dipende dalla costanza del paziente nell’assumere i farmaci prescritti.

La terapia va sviluppata in base al ceppo batterico, quindi è il tisiologo a gestire quali farmaci e in che dosi. Solitamente la terapia è una combinazione tra isoniazide, rifampicina, etambutolo, rifabutina e pirazinamide.

Come si fa la prevenzione della Tubercolosi: il ruolo del vaccino BCG

Esiste un vaccino contro la tubercolosi, il BCG, che viene somministrato prevalentemente nei paesi con alta incidenza di tubercolosi per prevenire le forme gravi nei bambini. Purtroppo, questo vaccino non garantisce una protezione completa contro la malattia negli adulti, ma è molto efficace nei bambini.

Il vaccino BCG ha oltre 100 anni e, sebbene non sia il più efficace tra i vaccini moderni, continua ad essere l’unico disponibile per prevenire la tubercolosi. Purtroppo, l’interesse a sviluppare un nuovo vaccino più sicuro ed efficace è limitato, soprattutto nei paesi in cui la malattia è curabile.

La relazione tra tubercolosi e HIV

Una delle co-infezioni più pericolose al mondo è quella tra HIV e tubercolosi. L’HIV indebolisce il sistema immunitario, rendendo le persone più suscettibili alla tubercolosi attiva. Le persone affette da HIV hanno una probabilità 30 volte maggiore di sviluppare la tubercolosi rispetto a chi non è infetto dal virus dell’HIV.

Nei paesi con un’alta prevalenza di HIV, la coinfezione TB-HIV è un problema sanitario enorme. In questi casi, è fondamentale diagnosticare e trattare entrambe le malattie simultaneamente e con molta attenzione, poiché le interazioni tra i farmaci antitubercolari e antiretrovirali possono complicare il trattamento.

Risulta ovvio che l’assunzione delle terapie da parte del paziente deve essere certosina.

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