Pulmonary and Extrapulmonary tuberculosis

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Pulmonary Tuberculosis

Signs and Symptoms

• Cough of more than two weeks which is usually productive (In HIV-positive adolescents and adults, a cough of any duration.)
• Hemoptysis (Sputum with blood stain)
• Fever
• Chest pain
• Excessive night sweats and
• Loss of weight

Extra-Pulmonary Tuberculosis

Extra- pulmonary tuberculosis may involve many sites of the body such as the pleura, pericardium, lymph nodes, meninges, bones, gastrointestinal tract, genitourinary system, epididymis, eyes and skin.

• Pleural tuberculosis:
  • Cough which may be non-productive
  • Pleuritic chest pain (Pain when breathing in)
  • Fever
  • Night sweats.
• Pericardial tuberculosis:
  • Chest pain
  • Low pulse volume
  • Cardiac tamponade (difficulties in breathing, tachycardia, hypotension, blood pressure decreasing with inhalation, and sudden collapse of the patient)
• Lymph node tuberculosis:
  • Lymph node tuberculosis may affect any site though it is more common in the cervical region.
  • Lymph nodes are usually painless.
  • Where caseation with liquefaction and sinus formation occurs, they may be painful.
• Meningeal tuberculosis:
  • Headache (insidious)
  • Neck stiffness,
  • Vomiting
  • Change in mentation (Confusion, drowsiness)
  • Convulsions
  • Paralysis
• Bone tuberculosis:
  • Bone deformity (Most common ones - gibbus formation due to vertebral collapse and may result in paraplegias)
  • Osteomyelitis
  • Arthritis (Swelling, Pain)
  • Cold abscess formation may also occur.
• Gastrointestinal tuberculosis:
  • Chronic diarrhea,
  • Malabsorption,
  • Intestinal obstruction.
  • Abdominal distention (Ascites, lymph adenopathy)
  • Pelvic abscesses.
• Genito-urinary tuberculosis:
• Renal tuberculosis may be asymptomatic, causing symptoms such as:
  • Hematuria (blood in urine)
  • Sterile pyuria with extensive renal involvement.
• Genital – Tuberculosis may cause symptoms such as:
  • Infertility
  • Salpingitis
  • Tubal abscess are presentations of infection of the fallopian tubes while epididymal tuberculosis may present as painless swellings.
• Ocular tuberculosis
  • Hylectenular conjunctivitis,
  • Iritis
  • Choroiditis.
• Dermal tuberculosis:
  • Dermal tuberculosis may include lupus vulgaris
  • Erythema nodusum (painful nodules under the skin).
• Adrenal tuberculosis:
  • Adrenal tuberculosis may cause adrenal insufficiency (Low BP, Weight loss, dizziness and palm sweeting and fainting).

Investigations

A diagnosis of TB can be made based on bacteriological confirmation and/or clinical evaluation (signs, symptoms and radiology). All presumptive TB patients should be subjected to laboratory investigations for TB and appropriate baseline investigations. If a negative result is obtained but a clinician suspects TB, radiological and clinical evaluation can be used to guide diagnosis.

• Laboratory Tuberculosis investigations
  • GeneXpert® MTB/RIF or Ultra (Cepheid)
  • Truenat™ (Molbio Diagnostics)
  • TB loop-mediated isothermal amplification (LAMP)
  • Smear microscopy
  • Lateral flow urine lipoarabinomannan assay (LF-LAM)
  • Line probe assay (LPA)
  • Solid and liquid culture
• Baseline Investigations
  • Full blood count
  • CRP/ESR
  • Urea and Creatinine
  • Liver Enzymes (AST and ALT)
  • Albumin
• Radiological Investigations
  • X – ray
  • CT Scan
  • MRI
  • Ultra Sound
• Other Investigations
  • Biopsy
  • Electrolytes
  • CSF analysis
  • Radiological changes that occur in Pulmonary Tuberculosis include:
  • Milliary
  • Cavitation
  • Lobar consolidation
  • Pleural effusion
  • Parenchymal infiltrates
  • Hilar lymphadenopathy
  • Sometimes Chest X-rays may not show any abnormality
  • Radiological findings in HIV-infected individuals depend on the degree of immunosuppression

Treatment

Treatment of tuberculosis is divided into two phases:

• Initial/Intensive Phase
• Continuation Phase

Treatment involves the use of combination of Tuberculosis Drugs.

NB: There is no place for the use of monotherapy in the treatment of tuberculosis nor for a trial of treatment

Adult Standard TB Regimens

TB Disease Category	Recommended regimen
Treatment phase	Intensive phase	Continuation Phase
All forms of TB (non-severe)	2RHZE	4RH
Miliary TB	2RHZE	4RH (when the meninges are affected then treatment should be for 12 months)
TB meningitis, tuberculosis osteoarticular, ocular and spinal TB	2RHZE	10RH

Abbreviations: RHZE (rifampicin/isoniazid/pyrazinamide/ethambutol), TB (tuberculosis).

The total duration of treatment is 12 months for TB meningitis and tuberculomas because of serious risk of disability and mortality; and for osteoarticular/spinal TB and ocular TB because of difficulties of assessing response to treatment.

Indications for steroids in the treatment of tuberculosis in adults:

• TB meningitis
• TB pericarditis
• TB Immune Reconstitution Inflammatory Syndrome
• Severe hypersensitivity reactions to anti-TB drugs
• Hypoadrenalism
• Renal tract TB (to prevent ureteric scarring)
• TB laryngitis with life-threatening airway obstruction

Note: Steroids doses must be tapered, and not be stopped abruptly.Recommended doses of adjuvant steroid therapy (drug of choice is prednisolone)

TB meningitis	1-2mg/kg (max 60mg) for 2 weeks, then taper off by 10mg every week over 6 weeks
TB pericarditis	1–2 mg (max 60 mg) for 4 weeks, then half for 4 weeks (max 30 mg/day), then taper off by 10mg every week over 6 weeks

Weight bands for dosing of anti-tuberculosis drugs (adults) 

Body weight (kg)	Intensive phase (RHZE 150/75/400/275mg)	Continuation phase (RH 150/75)
25-37	2	2
38-54	3	3
55-70	4	4
71 and above	5	5

 

Supportive

The following supportive strategies should be part of package of care

• Adherence,
• Nutritional support
• Tracing
• Home based care

Complications

• Pneumothorax
• Empyema or pyopneumothorax and laryngitis with advanced disease.
• Respiratory failure and right ventricular failure may develop as a late complication due to extensive pulmonary destruction and fibrosis.
• Colonization of cavities with Aspergillus fumigatus may occur resulting in haemoptysis.
• Post TB lung disease is common.
• Disability manifesting was exertional dyspnea is now becoming common.
• Constrictive pericarditis is a complication of TB pericarditis.
• Meningeal tuberculosis can result in hydrocephalus and focal deficits.
• TB of the spine may result in permanent neurological deficits.
• Gastrointestinal tuberculosis may lead to the development of ascites and malabsorption.

 

Referral Criteria

The patients with following features should be referred:

• Poor vitals such low oxygenation and Hypotension (Low blood pressure)
• Cardiac tamponade
• Drug induced liver injury (worsening liver enzymes)
• Difficulties in breathing
• Stroke and Paralysis
• Hydrocephalus