Difference between revisions of "Tuberculosis"

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==Clinical Features==
 
==Clinical Features==
 
===Primary Tuberculosis===
 
===Primary Tuberculosis===
*Usually asymptomatic (only identified by positive PPD)
+
*Usually asymptomatic (only identified by positive PPD)[[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 pts
 
*May be rapidly progressive and fatal in immunocompromised pts
 
**Fever, malaise, wt loss, chest pain
 
**Fever, malaise, wt loss, chest pain
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*Systemic: Fever, night sweats, malaise, fatigue, wt loss
 
*Systemic: Fever, night sweats, malaise, fatigue, wt loss
 
*Extrapulmonary  
 
*Extrapulmonary  
**Painless lymphadenopathy (most common extrapulmonary manifestation)[[File:Screen Shot 2015-09-11 at 9.27.22 AM.png|thumbnail|Tuberculous lymphadenopathy]]
+
**Painless lymphadenopathy (most common extrapulmonary manifestation)
 
**Pericarditis
 
**Pericarditis
 
**Peritonitis  
 
**Peritonitis  
 
**Meningitis
 
**Meningitis
 
**Adrenal insufficiency
 
**Adrenal insufficiency
**Arthritis [[File:Screen Shot 2015-09-11 at 9.21.17 AM.png|thumbnail|Tuberculous vertebral osteomyelitis (Pott's Disease)]]
+
**Arthritis
 
**Osteomyelitis
 
**Osteomyelitis
  

Revision as of 13:30, 11 September 2015

Background

Miliary TB neonate born to mother with active TB
  • >1/3 of world's population is infected

Infection Types

  • 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

Clinical Features

Primary Tuberculosis

  • Usually asymptomatic (only identified by positive PPD)
    Tuberculous lymphadenopathy
    Tuberculous vertebral osteomyelitis (Pott's Disease)
  • May be rapidly progressive and fatal in immunocompromised pts
    • Fever, malaise, wt 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 (most common extrapulmonary manifestation)
    • Pericarditis
    • Peritonitis
    • Meningitis
    • Adrenal insufficiency
    • Arthritis
    • Osteomyelitis

Differential Diagnosis

HIV associated conditions

Diagnosis

CXR

  • 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
  • HIV pts less likely to have classic lesions and may have normal CXR

Treatment

Active TB

  • Isoniazid + rifampin + pyrazinamide + ethambutol x8wk followed by INH/RIF x18wk
    • 2 drug continuation tx x 18-31wk

Latent TB

  • Consider treatment for:
    • Recent conversion to PPD-positive
    • Persons in close contact w/ individual w/ active TB
    • Isoniazid x9mo

Disposition

Discharge

  • Otherwise healthy
    • Contact public health services before discharge
      • Instructions for home isolation and f/u 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
  • Pt is noncompliant

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.