Pulmonary Tuberculosis

Infectious diseases

Clinicals - History

Fact Explanation
Persistent, chronic cough with sputum production Most patients with pulmonary tuberculosis present with a productive cough. In the initial stages it may be non productive, but later with inflammation and tissue necrosis, sputum production will be prominent. Persistent, chronic cough with sputum production
Most patients with pulmonary tuberculosis present with a productive cough. In the initial stages it may be non productive, but later with inflammation and tissue necrosis, sputum production will be prominent.
Hemoptysis Some patients rarely present with the complain of coughing of blood. May result from post tuberculous bronchiectasis, rupture of a dilated vessel, bacterial/fungal infection in a cavitatory lesion, or from rupture of calcified lesions into the lumen of an airway. Hemoptysis
Some patients rarely present with the complain of coughing of blood. May result from post tuberculous bronchiectasis, rupture of a dilated vessel, bacterial/fungal infection in a cavitatory lesion, or from rupture of calcified lesions into the lumen of an airway.
Fever, night sweats, loss of apetite, loss of weight, malaise and general ill health Because of the ongoing inflammation and tissue necrosis, tuberculosis known to associated with lot of systemic symptoms which affect patients' day to day life. Fever, night sweats, loss of apetite, loss of weight, malaise and general ill health
Because of the ongoing inflammation and tissue necrosis, tuberculosis known to associated with lot of systemic symptoms which affect patients' day to day life.
Pleuritic chest pain Some patients develop inflammation of the lung parenchyma adjacent to a pleural surface causing pleuritic type chest pain. Pleuritic chest pain
Some patients develop inflammation of the lung parenchyma adjacent to a pleural surface causing pleuritic type chest pain.
Difficulty in breathing Difficulty in breathing is unusual symptom unless there is extensive disease or a large pleural effusion compromising lung expansion. Difficulty in breathing
Difficulty in breathing is unusual symptom unless there is extensive disease or a large pleural effusion compromising lung expansion.
Neurological symptoms - Headache, decreased level of consciousness Manifest in tuberculous involving the nervous system, such as tuberculous meningitis. Neurological symptoms - Headache, decreased level of consciousness
Manifest in tuberculous involving the nervous system, such as tuberculous meningitis.
Back pain, joint pain, joint swelling, limited joint movements Pain in the affected region is the usual presenting symptom of skeletal tuberculosis. Swelling of the involved joint, limitation of movements and back pain with the involvement of the vertebral column also may be noted. Back pain, joint pain, joint swelling, limited joint movements
Pain in the affected region is the usual presenting symptom of skeletal tuberculosis. Swelling of the involved joint, limitation of movements and back pain with the involvement of the vertebral column also may be noted.
Urinary symptoms - Hematuria, dysuria, increased frequency of urination, flank pain Predominantly found in patients with genitourinary tuberculosis. Urinary symptoms - Hematuria, dysuria, increased frequency of urination, flank pain
Predominantly found in patients with genitourinary tuberculosis.
Abdominal distension Tuberculosis can involve the peritoneum, giving rise to accumulation of exudate in the peritoneal cavity causing abdominal distension. Abdominal distension
Tuberculosis can involve the peritoneum, giving rise to accumulation of exudate in the peritoneal cavity causing abdominal distension.
Past personal or contact/travel history of tuberculosis Presence of positive past personal history of tuberculosis aid in diagnosis as it increases the likelihood of reactivation of dormant bacilli. Also as it is transmitted mainly via respiratory droplets, positive contact history raise the suspicion of tuberculosis. Past personal or contact/travel history of tuberculosis
Presence of positive past personal history of tuberculosis aid in diagnosis as it increases the likelihood of reactivation of dormant bacilli. Also as it is transmitted mainly via respiratory droplets, positive contact history raise the suspicion of tuberculosis.
History of immunocompromised state - eg:- HIV infection, diabetes mellitus Body defense against tuberculous bacilli is mainly done via cell mediated immunity and in certain situations (such as diabetes mellitus, HIV infection, corticosteroid therapy, other immunosuppressive drug treatment) the ability of the host to respond to the organism may be reduced increasing the likelihood of developing tuberculosis. History of immunocompromised state - eg:- HIV infection, diabetes mellitus
Body defense against tuberculous bacilli is mainly done via cell mediated immunity and in certain situations (such as diabetes mellitus, HIV infection, corticosteroid therapy, other immunosuppressive drug treatment) the ability of the host to respond to the organism may be reduced increasing the likelihood of developing tuberculosis.
Symptoms related to genital organs - pelvic pain, menstrual irregularities and infertility in women, - painless or only slightly painful scrotal mass in men Tuberculous bacilli known to infect genital organs in both men and women. So patients can present with symptoms related to the genital tract. Symptoms related to genital organs - pelvic pain, menstrual irregularities and infertility in women, - painless or only slightly painful scrotal mass in men
Tuberculous bacilli known to infect genital organs in both men and women. So patients can present with symptoms related to the genital tract.

Clinicals - Examination

Fact Explanation
Body mass index (BMI) Usually patients with tuberculosis are underweight, malnourished patients. So it is good if you can measure their weight, height and calculate the BMI. Body mass index (BMI)
Usually patients with tuberculosis are underweight, malnourished patients. So it is good if you can measure their weight, height and calculate the BMI.
Pallor Patients may have anemia, which is clinically detectable by looking at the conjunctiva. Pallor
Patients may have anemia, which is clinically detectable by looking at the conjunctiva.
Lymphadenopathy Commonly involved nodes are cervical nodes and supraclavicular nodes. Usually these enlarged nodes are painless and early in the disease process they are discrete. Later stages nodes become matted and the overlying skin will show signs of inflammation. Lymphadenopathy
Commonly involved nodes are cervical nodes and supraclavicular nodes. Usually these enlarged nodes are painless and early in the disease process they are discrete. Later stages nodes become matted and the overlying skin will show signs of inflammation.
Respiratory system - increased respiratory rate, tracheal deviation, reduced chest expansion, stony dull/impaired percussion note, reduced air entry, broncheal breathing, coarse crepitations, increased vocal resonance These signs are present commonly in patients with secondary pulmonary tuberculosis. Areas of consolidation of the lung, give rise to bronchial breathing and crepitations with increased vocal resonance on auscultation. If there is associated pleural effusion, breath sounds will be absent with a stony dull percussion note. Respiratory system - increased respiratory rate, tracheal deviation, reduced chest expansion, stony dull/impaired percussion note, reduced air entry, broncheal breathing, coarse crepitations, increased vocal resonance
These signs are present commonly in patients with secondary pulmonary tuberculosis. Areas of consolidation of the lung, give rise to bronchial breathing and crepitations with increased vocal resonance on auscultation. If there is associated pleural effusion, breath sounds will be absent with a stony dull percussion note.
Ascites In peritoneal tuberculosis, there is accumulation of excessive fluid in the peritoneal cavity. Ascites
In peritoneal tuberculosis, there is accumulation of excessive fluid in the peritoneal cavity.
Hepato-splenomegaly Some patients may have enlarged liver and/or spleen. Hepato-splenomegaly
Some patients may have enlarged liver and/or spleen.
Precordial rub Involvement of the pericardium causing pericardial inflammation will give rise to characteristic pericardial friction rub on precordial auscultation. Precordial rub
Involvement of the pericardium causing pericardial inflammation will give rise to characteristic pericardial friction rub on precordial auscultation.
Palpable mass in the right iliac fosssa In intestinal tuberculosis, mass can be felt in the abdomen. Since the most common involved sites are the terminal ileum and cecum, which usually present in the right iliac fossa of the abdomen the palpable mass may found in right iliac fossa in most patients. Palpable mass in the right iliac fosssa
In intestinal tuberculosis, mass can be felt in the abdomen. Since the most common involved sites are the terminal ileum and cecum, which usually present in the right iliac fossa of the abdomen the palpable mass may found in right iliac fossa in most patients.

Investigations - Diagnosis

Fact Explanation
Tubercullin/Mantoux test This simple, cost effective test demonstrates how well cell mediated immunity has been developed in the patient's immune system. T lymphocytes sensitized by prior infection are recruited to the skin site and release lymphokines, which induce local vasodilatation causing erythema, edema and accumulation of other inflammatory cells to the area causing induration. Tubercullin/Mantoux test
This simple, cost effective test demonstrates how well cell mediated immunity has been developed in the patient's immune system. T lymphocytes sensitized by prior infection are recruited to the skin site and release lymphokines, which induce local vasodilatation causing erythema, edema and accumulation of other inflammatory cells to the area causing induration.
Full blood count Most commonly found abnormalities in tuberculosis are anemia and slight leukocytosis. Leukopenia, increased levels of monocytes and eosinophils have also been documented. Sometimes patient may develop pacytopenia as a result of direct involvement of the bone marrow. Full blood count
Most commonly found abnormalities in tuberculosis are anemia and slight leukocytosis. Leukopenia, increased levels of monocytes and eosinophils have also been documented. Sometimes patient may develop pacytopenia as a result of direct involvement of the bone marrow.
Erythrocyte sedimentation rate (ESR) Usually due to ongoing inflammation, ESR result is high compared to the normal range. Erythrocyte sedimentation rate (ESR)
Usually due to ongoing inflammation, ESR result is high compared to the normal range.
Microbiological tests - blood culture, sputum culture, culture of the gastric contents in children, bone marrow culture, cerebrospinal fluid culture, pleural fluid culture, bronchial washings culture Culture posititivity is the gold standard diagnostic tool in tuberculosis. At least 3 single specimens should be collected initially, preferably on different days from sputum-producing patients. Microbiological tests - blood culture, sputum culture, culture of the gastric contents in children, bone marrow culture, cerebrospinal fluid culture, pleural fluid culture, bronchial washings culture
Culture posititivity is the gold standard diagnostic tool in tuberculosis. At least 3 single specimens should be collected initially, preferably on different days from sputum-producing patients.
Ziehl–Neelsen stain of the sputum Special staining should be done in order to demonstrate tuberculous bacilli as they are acid fast organisms. Ziehl–Neelsen stain of the sputum
Special staining should be done in order to demonstrate tuberculous bacilli as they are acid fast organisms.
If present, pleural/pericardial/ascitic fluid analysis A high protein (> 50% of the serum protein) concentration, increased lymphocyte count and a low glucose level in accumulated fluid suggest tuberculous infections. If present, pleural/pericardial/ascitic fluid analysis
A high protein (> 50% of the serum protein) concentration, increased lymphocyte count and a low glucose level in accumulated fluid suggest tuberculous infections.
PCR (polymerase chain reaction) for tuberculous bacilli In this rapid diagnostic test to detect Mycobacterial tuberculosis ribosomal RNA or DNA. PCR (polymerase chain reaction) for tuberculous bacilli
In this rapid diagnostic test to detect Mycobacterial tuberculosis ribosomal RNA or DNA.
Adenosine deaminase test Adenosine deaminase, an enzyme whicht is essential for the maturation and differentiation of lymphoid cells, found to be elevated in pleural, pericardial and peritoneal fluids when tuberculosis involves those sites. Adenosine deaminase test
Adenosine deaminase, an enzyme whicht is essential for the maturation and differentiation of lymphoid cells, found to be elevated in pleural, pericardial and peritoneal fluids when tuberculosis involves those sites.
Chest X-ray In most patients with pulmonary tuberculosis chest X-ray is abnormal. But an endobronchial lesion may not give rise to a radiographic finding. Also a normal chest X-ray is a common finding in patients with pulmonary tuberculosis disease and HIV infection.
Secondary pulmonary tuberculosis usually causes upper lobe apical cavitation in one or both lungs. In primary tuberculosis, hilarlymphadenopathy may found commonly in children.
Chest X-ray
In most patients with pulmonary tuberculosis chest X-ray is abnormal. But an endobronchial lesion may not give rise to a radiographic finding. Also a normal chest X-ray is a common finding in patients with pulmonary tuberculosis disease and HIV infection.
Secondary pulmonary tuberculosis usually causes upper lobe apical cavitation in one or both lungs. In primary tuberculosis, hilarlymphadenopathy may found commonly in children.
Lumbar puncture and cerebrospinal fluid (CSF) analysis, if suspecting tuberculous meningitis In the presence of meningeal signs on examination, lumbar puncture should be done. A high protein (> 50% of the serum protein concentration), elevated lymphocyte count and low glucose are found in tuberculous meningitis. The Acid fast bacilli smear of cerebrospinal fluid is usually negative; however, the culture may be positive. Lumbar puncture and cerebrospinal fluid (CSF) analysis, if suspecting tuberculous meningitis
In the presence of meningeal signs on examination, lumbar puncture should be done. A high protein (> 50% of the serum protein concentration), elevated lymphocyte count and low glucose are found in tuberculous meningitis. The Acid fast bacilli smear of cerebrospinal fluid is usually negative; however, the culture may be positive.
Urine analysis The first morning-voided midstream specimen is the best. Multiple specimens should be taken to demonstrate the presence of mycobacteria.
Pyuria in an acid urine with negative urine culture favours the diagnosis of tuberculosis and culturing the urine should be done to detect mycobacteria.
Urine analysis
The first morning-voided midstream specimen is the best. Multiple specimens should be taken to demonstrate the presence of mycobacteria.
Pyuria in an acid urine with negative urine culture favours the diagnosis of tuberculosis and culturing the urine should be done to detect mycobacteria.
Computed Tomography (CT) brain, spine, Magnetic resonance imaging (MRI) or spine If there are focal neurological findings on examination or if there are suggestions of increased intra cranial pressure, a CT scan of the brain, should be done before the lumbar puncture. In meningitis, the scan may be normal but can also show diffuse edema or obstructive hydrocephalus. Tuberculomas are generally seen as ring-enhancing mass lesions.
CT /MRI scan of the spine are considered to be more sensitive than X-rays to detect the early changes of spinal tuberculosis.
Computed Tomography (CT) brain, spine, Magnetic resonance imaging (MRI) or spine
If there are focal neurological findings on examination or if there are suggestions of increased intra cranial pressure, a CT scan of the brain, should be done before the lumbar puncture. In meningitis, the scan may be normal but can also show diffuse edema or obstructive hydrocephalus. Tuberculomas are generally seen as ring-enhancing mass lesions.
CT /MRI scan of the spine are considered to be more sensitive than X-rays to detect the early changes of spinal tuberculosis.
Fiberoptic bronchoscopy - bronchoalveolar lavage, and/or transbronchial biopsy Should be carried out in patients with diagnostic uncertainty. Fiberoptic bronchoscopy - bronchoalveolar lavage, and/or transbronchial biopsy
Should be carried out in patients with diagnostic uncertainty.
Tissue biopsy Tissue biopsies from the lung, pericardium, lymph nodes, bones and joints, bowel, salpinges, and epididymis should be considered when there is diagnostic uncertainty. Tissue biopsy
Tissue biopsies from the lung, pericardium, lymph nodes, bones and joints, bowel, salpinges, and epididymis should be considered when there is diagnostic uncertainty.
HIV screening Should be done if the clinical findings and other investigation results point towards HIV infection as the underlying cause. HIV screening
Should be done if the clinical findings and other investigation results point towards HIV infection as the underlying cause.
Fasting blood glucose Should be done to find out undiagnosed diabetic patients, as diabetes is a known predisposing factor for the development of tuberculosis. Fasting blood glucose
Should be done to find out undiagnosed diabetic patients, as diabetes is a known predisposing factor for the development of tuberculosis.

Investigations - Management

Fact Explanation
Sputum culture and Ziehl–Neelsen stain To assess the response to treatment and to identify drug resistant category patients. Sputum culture and Ziehl–Neelsen stain
To assess the response to treatment and to identify drug resistant category patients.
Liver function tests Anti tuberculosis drugs such as isoniazid, rifampin, pyrazinamide known to cause hepatotoxicity, which is a well documented adverse effect of above mentioned drugs. Therefore liver function tests should be monitored during follow up clinic visits. Liver function tests
Anti tuberculosis drugs such as isoniazid, rifampin, pyrazinamide known to cause hepatotoxicity, which is a well documented adverse effect of above mentioned drugs. Therefore liver function tests should be monitored during follow up clinic visits.
Ophthalmological assessment Ethambutol known to cause optic neuritis as an adverse effect. Therefore visual acuity and color discrimination should be checked prior to therapy as a baseline assessment and afterwards monthly to detect the adverse effect early. Ophthalmological assessment
Ethambutol known to cause optic neuritis as an adverse effect. Therefore visual acuity and color discrimination should be checked prior to therapy as a baseline assessment and afterwards monthly to detect the adverse effect early.
Liver function tests To assess the liver functions as the anti tuberculosis drugs known as hepatotoxic agents and can cause derangement in liver functions. Liver function tests
To assess the liver functions as the anti tuberculosis drugs known as hepatotoxic agents and can cause derangement in liver functions.
Renal function tests - serum creatinine Should be done to assess renal functions as some drugs excrete with urine and dose should be adjusted if the renal functions are impaired. Renal function tests - serum creatinine
Should be done to assess renal functions as some drugs excrete with urine and dose should be adjusted if the renal functions are impaired.
Antigen-specific interferon-gamma release assays Useful for screening for Mycobacterial tuberculosis infection, especially in persons with previous bacille Calmette-Guérin (BCG) vaccination or possible nontuberculosis mycobacteria. Antigen-specific interferon-gamma release assays
Useful for screening for Mycobacterial tuberculosis infection, especially in persons with previous bacille Calmette-Guérin (BCG) vaccination or possible nontuberculosis mycobacteria.

Management - Supportive

Fact Explanation
Patient and family education Patient and family members should be educated about the disease condition, nature of it, possible complications, way of transmission and importance of drug compliance. Latter has to be emphasized and highlighted as in tuberculosis patient need long term chemotherapy with proper clinic follow up, where patients usually tend to default treatment once they feel better clinically and develop resistant to available drugs. Patient and family education
Patient and family members should be educated about the disease condition, nature of it, possible complications, way of transmission and importance of drug compliance. Latter has to be emphasized and highlighted as in tuberculosis patient need long term chemotherapy with proper clinic follow up, where patients usually tend to default treatment once they feel better clinically and develop resistant to available drugs.

Management - Specific

Fact Explanation
Pharmacological management (pulmonary tuberculosis) - Anti tuberculosis drug therapy Active tuberculosis should be treated with combination drug therapy to ensure mycobacterial killing and tissue sterilization.
Two stages of treatment are recommended.
Four-drug regimen (isoniazid, rifampin, pyrazinamide, ethambutol) in the initial intensive phase for 2 months via directly observed therapy, followed by 2 drug regimen (isoniazid, rifampin)in the continuation phase, administered daily or intermittently for 4-7 months.
Isoniazid monotherapy is preferred for latent tuberculosis infection, except those suspected to have primary drug-resistant tuberculosis.
Pharmacological management (pulmonary tuberculosis) - Anti tuberculosis drug therapy
Active tuberculosis should be treated with combination drug therapy to ensure mycobacterial killing and tissue sterilization.
Two stages of treatment are recommended.
Four-drug regimen (isoniazid, rifampin, pyrazinamide, ethambutol) in the initial intensive phase for 2 months via directly observed therapy, followed by 2 drug regimen (isoniazid, rifampin)in the continuation phase, administered daily or intermittently for 4-7 months.
Isoniazid monotherapy is preferred for latent tuberculosis infection, except those suspected to have primary drug-resistant tuberculosis.
Treatment of extra pulmonary tuberculosis Same principles should be applied as treatment of pulmonary tuberculosis. However, treatment durations are extended up to 9 months for skeletal tuberculosis and 9 to 12 months for nervous system tuberculosis. Adjunctive steroid therapy is recommended in patients with meningitis and pericarditis to decrease morbidity and mortality. Treatment of extra pulmonary tuberculosis
Same principles should be applied as treatment of pulmonary tuberculosis. However, treatment durations are extended up to 9 months for skeletal tuberculosis and 9 to 12 months for nervous system tuberculosis. Adjunctive steroid therapy is recommended in patients with meningitis and pericarditis to decrease morbidity and mortality.
Management of treatment resistant tuberculosis Treatment with 4-6 drugs to which the infection is susceptible is recommended.
Multidrug-resistant and extensively drug-resistant tuberculosis require at least 18 - 24 months of therapy, depending on the patient's response to treatment.
There is a newer drug called bedaquiline, but it should only be given in settings where patients can be closely monitored.
Thoracic surgery for resection of the lung lesion is often considered as an adjunctive therapy.
Management of treatment resistant tuberculosis
Treatment with 4-6 drugs to which the infection is susceptible is recommended.
Multidrug-resistant and extensively drug-resistant tuberculosis require at least 18 - 24 months of therapy, depending on the patient's response to treatment.
There is a newer drug called bedaquiline, but it should only be given in settings where patients can be closely monitored.
Thoracic surgery for resection of the lung lesion is often considered as an adjunctive therapy.
Prevention - Nosocomial transmission When active tuberculosis is suspected in patients, the patients should be evaluated rapidly, should placed in a separate isolation room, should advised to wear a mask and proper disposal of sputum should be advocated. Prevention - Nosocomial transmission
When active tuberculosis is suspected in patients, the patients should be evaluated rapidly, should placed in a separate isolation room, should advised to wear a mask and proper disposal of sputum should be advocated.
Prevention - Vaccination, chemoprophylaxis Primary preventive methods include administration of the bacille Calmette-Guérin (BCG) vaccine, to reduce the occurrence of severe and disseminated tuberculosis in young children and chemoprophylaxis for the close susceptible contacts of diagnosed patients.
Routine screening for tuberculosis in high-risk populations should be carried out to detect undiagnosed patients early.
Prevention - Vaccination, chemoprophylaxis
Primary preventive methods include administration of the bacille Calmette-Guérin (BCG) vaccine, to reduce the occurrence of severe and disseminated tuberculosis in young children and chemoprophylaxis for the close susceptible contacts of diagnosed patients.
Routine screening for tuberculosis in high-risk populations should be carried out to detect undiagnosed patients early.
Prevention - Notification, contact screening Every case must be notified and close contacts of the patient should be traced and chemoprophylaxis should be given where appropriately. Prevention - Notification, contact screening
Every case must be notified and close contacts of the patient should be traced and chemoprophylaxis should be given where appropriately.
Management of complications - anemia, pleural effusions, ascites, vertebral body destruction Complications should be anticipated, suspect, detect early and treat as soon as possible. Management of complications - anemia, pleural effusions, ascites, vertebral body destruction
Complications should be anticipated, suspect, detect early and treat as soon as possible.
Management of other co-morbid diseases - Diabetes Multidisciplinary team approach should be carried out to manage the patient properly. Management of other co-morbid diseases - Diabetes
Multidisciplinary team approach should be carried out to manage the patient properly.
Nutritional measures Malnourished patients should referred to a dietitian to manage nutritional issues appropriately. Nutritional measures
Malnourished patients should referred to a dietitian to manage nutritional issues appropriately.

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