Difference between revisions of "Tuberculosis"

(Reactivation Tuberculosis)
(40 intermediate revisions by 9 users not shown)
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==Background==
 
==Background==
*>1/3 of world's population is infected
+
[[File:MiliaryTB.png|thumb|Miliary TB neonate born to mother with active TB]]
*Infection Types
+
*Over 1/3 of world's population is infected[[File:Tuberculosis-x-ray-1.jpg|thumbnail|Bilateral pulmonary tuberculosis]]
**Primary Infection
 
***Usually contained by body via formation of tubercles
 
***Hematogenous spread limited to areas w/ high O2 or blood flow (apical lung, vertebrae)
 
****PPD positive
 
**Reactivation Infection
 
***More common in immunocompromised pts (AIDS, malignancy, DM, CRF)
 
**Check HIV in pts suspected of TB
 
*Special Populations
 
**AIDS
 
***TB is 200-500x more common in AIDS population than general population
 
***CD4 count
 
****Increased risk when <500
 
****Determines the clinical and radiographic presentations of TB
 
**Peds
 
***More likely to progress early to active disease
 
****Presentation more commonly that of primary TB
 
***>5yr - classic symptoms
 
***<5yr - miliary TB, meningitis, cervical lymphadenitis, PNA that doesn't respond to abx
 
***Children are usually not infectious due to their weak cough
 
  
==Diagnosis==
+
===Infection Types===
===Clinical Features===
+
*Primary Infection
====Primary Tuberculosis====
+
**Usually contained by body via formation of tubercles
*Usually asymptomatic (only identified by positive PPD)
+
**Hematogenous spread limited to areas with high O2 or blood flow (apical lung, vertebrae)
*May be rapidly progressive and fatal in immunocompromised pts
+
***PPD positive
**Fever, malaise, wt loss, chest pain
+
*Reactivation Infection
 +
**More common in immunocompromised patients (AIDS, malignancy, DM, immunosupressive medications)
 +
*Miliary Tuberculosis
 +
**Disseminated tuberculosis
 +
**Looks like millet seeds
 +
**Seen in patients with comorbid AIDS
 +
***Check [[HIV]] in patients suspected of TB
 +
**PPD is positive in only 50% of cases
 +
 
 +
===Special Populations===
 +
*[[AIDS]]
 +
**TB is 200-500x more common in AIDS population than general population
 +
**CD4 count
 +
***Increased risk when <500
 +
***Determines the clinical and radiographic presentations of TB
 +
*Pediatric
 +
**More likely to progress early to active disease
 +
***Presentation more commonly that of primary TB
 +
**>5yr - classic symptoms
 +
**<5yr - milliary TB, meningitis, cervical lymphadenitis, pneumonia that does not respond to usual antibiotics
 +
**Children are usually not infectious due to their weak cough
 +
 
 +
===Tuberculin Skin Test===
 +
;Used for population screening, but not for rule-out in patients with concern for active disease
 +
''Reaction considered positive in following situations:''
 +
*>5 mm
 +
**[[HIV]] positive
 +
**Close contact with active TB patient
 +
**Nodular or fibrotic changes on CXR
 +
**Immunosuppressed (TNF-alpha inhibitor, chemo, organ transplant)
 +
*>10 mm
 +
**Children < 4 yrs old
 +
**Healthcare/lab/prison employees and residents
 +
**Co-morbid conditions (dialysis, DM, blood/head/neck/lung malignancy, IV drug users)
 +
**People from high prevalence areas
 +
*>15 mm
 +
**Persons with no known risk factors for TB
 +
 
 +
==Clinical Features==
 +
===Primary Tuberculosis===
 +
*Usually asymptomatic (only identified by positive PPD/quantiferon gold)[[File:Screen Shot 2015-09-11 at 9.27.22 AM.png|thumbnail|Tuberculous lymphadenopathy]][[File:Screen Shot 2015-09-11 at 9.21.17 AM.png|thumbnail|Tuberculous vertebral osteomyelitis (Pott's Disease)]]
 +
*May be rapidly progressive and fatal in immunocompromised patients
 +
**Fever, malaise, weight loss, chest pain
 
*Tuberculous pleural effusion may occur if subpleural node ruptures into the pleura
 
*Tuberculous pleural effusion may occur if subpleural node ruptures into the pleura
 
**Pleuritic chest pain
 
**Pleuritic chest pain
 
**Exudative fluid
 
**Exudative fluid
 
***Organisms may not be visible on acid-fast staining (need pleural biopsy)
 
***Organisms may not be visible on acid-fast staining (need pleural biopsy)
====Reactivation Tuberculosis====
+
 
**Pulmonary: Productive cough, hemoptysis, dyspnea, pleuritic chest pain
+
===Reactivation Tuberculosis===
**Systemic: Fever, night sweats, malaise, fatigue, wt loss
+
*Pulmonary: Productive cough, hemoptysis, dyspnea, pleuritic chest pain
**Extrapulmonary
+
*Systemic: Fever, night sweats, malaise, fatigue, wt loss
***Lymphadenopathy (painless)
+
*Extrapulmonary  
***Pericarditis
+
**Painless lymphadenopathy/[[scrofula]] (most common extrapulmonary manifestation)
***Meningitis
+
**Pericarditis
***Adrenal insufficiency
+
**Peritonitis
***Arthritis
+
**Meningitis
***Osteomyelitis
+
**Adrenal insufficiency
 +
***If adrenals affected, TB typically spreads to bilateral adrenals rather than unilateral
 +
***Think about in the patient presenting in shock with TB risk factors
 +
**Arthritis
 +
**Osteomyelitis
 +
***Pott's disease, usually in thoracic spione
 +
 
 +
==Differential Diagnosis==
 +
{{HIV associated conditions}}
 +
 
 +
==Evaluation==
 
===CXR===
 
===CXR===
 +
[[File:Miliary.png|thumbnail|CXR of miliary TB]]
 
*Primary infection
 
*Primary infection
 
**Infiltrates in any area of the lung
 
**Infiltrates in any area of the lung
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**Upper lobe or hilar nodules and fibrotic lesions
 
**Upper lobe or hilar nodules and fibrotic lesions
 
**Ghon foci, areas of scarring, calcification
 
**Ghon foci, areas of scarring, calcification
*HIV pts less likely to have classic lesions and may have normal CXR
+
*Miliary TB
==Treatment==
+
**Looks like millet seeds on CXR
 +
*Immunocompromised patients less likely to have classic lesions and may have normal CXR
 +
 
 +
===PCR Sputum Assay===
 +
*Rapidly detects TB in sputum specimens (as well as [[rifampin]] resistance)
 +
*Use to rule-out patients for active TB
 +
*Need two sputum specimens (expectorated or induced) at least 8 hours apart (including at least one early morning specimen)
 +
 
 +
==Management==
 
===Active TB===
 
===Active TB===
*Isoniazid + rifampin + pyrazinamide + ethambutol x8wk followed by INH/RIF x18wk
+
*[[Isoniazid]] + [[rifampin]] + [[pyrazinamide]] + [[ethambutol]] x 8wk followed by INH/rifampin x18wk
**2 drug continuation tx x 18-31wk
+
**2 drug continuation treatment x 18-31wk
 
===Latent TB===
 
===Latent TB===
 +
*Isoniazid x 9 months
 
*Consider treatment for:
 
*Consider treatment for:
 
**Recent conversion to PPD-positive
 
**Recent conversion to PPD-positive
**Persons in close contact w/ individual w/ active TB
+
**close contact with active TB
**Isoniazid x9mo
+
**immunocompromised patients (or plan to start immunosupressive medications)
  
 
==Disposition==
 
==Disposition==
*Discharge
+
===Discharge===
**Otherwise healthy
+
*Otherwise healthy
***Contact public health services before discharge
+
**Contact public health services before discharge
****Instructions for home isolation and f/u at appropriate clinic to receive meds
+
***Instructions for home isolation and follow up at appropriate clinic to receive meds
***Do not start TB meds in ED unless specifically instructed by public health
+
**Do not start TB meds in ED unless specifically instructed by public health
*Admit
+
 
**Ill-appearing
+
===Admit===
**Diagnosis is uncertain
+
*Ill-appearing
**Pt is noncompliant
+
*Diagnosis is uncertain
 +
*Patient is treatment non-adherent
  
 +
==References==
 +
<references/>
 
[[Category:ID]]
 
[[Category:ID]]
[[Category:Pulm]]
+
[[Category:Pulmonary]]

Revision as of 19:53, 30 September 2018

Background

Miliary TB neonate born to mother with active TB
  • Over 1/3 of world's population is infected
    Bilateral pulmonary tuberculosis

Infection Types

  • Primary Infection
    • Usually contained by body via formation of tubercles
    • Hematogenous spread limited to areas with high O2 or blood flow (apical lung, vertebrae)
      • PPD positive
  • Reactivation Infection
    • More common in immunocompromised patients (AIDS, malignancy, DM, immunosupressive medications)
  • Miliary Tuberculosis
    • Disseminated tuberculosis
    • Looks like millet seeds
    • Seen in patients with comorbid AIDS
      • Check HIV in patients suspected of TB
    • PPD is positive in only 50% of cases

Special Populations

  • AIDS
    • TB is 200-500x more common in AIDS population than general population
    • CD4 count
      • Increased risk when <500
      • Determines the clinical and radiographic presentations of TB
  • Pediatric
    • More likely to progress early to active disease
      • Presentation more commonly that of primary TB
    • >5yr - classic symptoms
    • <5yr - milliary TB, meningitis, cervical lymphadenitis, pneumonia that does not respond to usual antibiotics
    • Children are usually not infectious due to their weak cough

Tuberculin Skin Test

Used for population screening, but not for rule-out in patients with concern for active disease

Reaction considered positive in following situations:

  • >5 mm
    • HIV positive
    • Close contact with active TB patient
    • Nodular or fibrotic changes on CXR
    • Immunosuppressed (TNF-alpha inhibitor, chemo, organ transplant)
  • >10 mm
    • Children < 4 yrs old
    • Healthcare/lab/prison employees and residents
    • Co-morbid conditions (dialysis, DM, blood/head/neck/lung malignancy, IV drug users)
    • People from high prevalence areas
  • >15 mm
    • Persons with no known risk factors for TB

Clinical Features

Primary Tuberculosis

  • Usually asymptomatic (only identified by positive PPD/quantiferon gold)
    Tuberculous lymphadenopathy
    Tuberculous vertebral osteomyelitis (Pott's Disease)
  • May be rapidly progressive and fatal in immunocompromised patients
    • Fever, malaise, weight loss, chest pain
  • Tuberculous pleural effusion may occur if subpleural node ruptures into the pleura
    • Pleuritic chest pain
    • Exudative fluid
      • Organisms may not be visible on acid-fast staining (need pleural biopsy)

Reactivation Tuberculosis

  • Pulmonary: Productive cough, hemoptysis, dyspnea, pleuritic chest pain
  • Systemic: Fever, night sweats, malaise, fatigue, wt loss
  • Extrapulmonary
    • Painless lymphadenopathy/scrofula (most common extrapulmonary manifestation)
    • Pericarditis
    • Peritonitis
    • Meningitis
    • Adrenal insufficiency
      • If adrenals affected, TB typically spreads to bilateral adrenals rather than unilateral
      • Think about in the patient presenting in shock with TB risk factors
    • Arthritis
    • Osteomyelitis
      • Pott's disease, usually in thoracic spione

Differential Diagnosis

HIV associated conditions

Evaluation

CXR

CXR of miliary TB
  • Primary infection
    • Infiltrates in any area of the lung
    • Isolated hilar or mediastinal adenopathy may be only finding
  • Reactivation infection
    • cavitary/noncavitary lesions in upper lobe or superior segment of lower lobe
  • Latent infection
    • Upper lobe or hilar nodules and fibrotic lesions
    • Ghon foci, areas of scarring, calcification
  • Miliary TB
    • Looks like millet seeds on CXR
  • Immunocompromised patients less likely to have classic lesions and may have normal CXR

PCR Sputum Assay

  • Rapidly detects TB in sputum specimens (as well as rifampin resistance)
  • Use to rule-out patients for active TB
  • Need two sputum specimens (expectorated or induced) at least 8 hours apart (including at least one early morning specimen)

Management

Active TB

Latent TB

  • Isoniazid x 9 months
  • Consider treatment for:
    • Recent conversion to PPD-positive
    • close contact with active TB
    • immunocompromised patients (or plan to start immunosupressive medications)

Disposition

Discharge

  • Otherwise healthy
    • Contact public health services before discharge
      • Instructions for home isolation and follow up at appropriate clinic to receive meds
    • Do not start TB meds in ED unless specifically instructed by public health

Admit

  • Ill-appearing
  • Diagnosis is uncertain
  • Patient is treatment non-adherent

References

  1. Gutteridge, David L MD, MPH, Egan, Daniel J. MD. The HIV-Infected Adult Patient in The Emergency Department: The Changing Landscape of the Disease. Emergency Medicine Practice: An Evidence-Based Approach to Emergency Medicine. Vol 18, Num 2. Feb 2016.