Difference between revisions of "Tuberculosis"

(Reactivation Tuberculosis)
 
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***Presentation more commonly that of primary TB
 
***Presentation more commonly that of primary TB
 
**>5yr - classic symptoms
 
**>5yr - classic symptoms
**<5yr - milliary TB, meningitis, cervical lymphadenitis, pneumonia that does not respond to usual antibiotics
+
**<5yr - miliary TB, [[meningitis]], [[scrofula|cervical lymphadenitis]], [[pneumonia]] that does not respond to usual antibiotics
 
**Children are usually not infectious due to their weak cough
 
**Children are usually not infectious due to their weak cough
  
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*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)]]
 
*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
 
*May be rapidly progressive and fatal in immunocompromised patients
**Fever, malaise, weight loss, chest pain
+
**[[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===
 
===Reactivation Tuberculosis===
*Pulmonary: Productive cough, hemoptysis, dyspnea, pleuritic chest pain
+
*Pulmonary: Productive [[cough]], [[hemoptysis]], [[dyspnea]], pleuritic [[chest pain]]
*Systemic: Fever, night sweats, malaise, fatigue, wt loss
+
*Systemic: [[Fever]], night sweats, malaise, fatigue, weight loss
 
*Extrapulmonary  
 
*Extrapulmonary  
 
**Painless lymphadenopathy/[[scrofula]] (most common extrapulmonary manifestation)
 
**Painless lymphadenopathy/[[scrofula]] (most common extrapulmonary manifestation)
**Pericarditis
+
**[[Pericarditis]]
**Peritonitis  
+
**[[Peritonitis]]
**Meningitis
+
**[[Meningitis]]
**Adrenal insufficiency
+
**[[Adrenal insufficiency]]
 
***If adrenals affected, TB typically spreads to bilateral adrenals rather than unilateral
 
***If adrenals affected, TB typically spreads to bilateral adrenals rather than unilateral
 
***Think about in the patient presenting in shock with TB risk factors
 
***Think about in the patient presenting in shock with TB risk factors
**Arthritis
+
**[[Arthritis]]
**Osteomyelitis
+
**[[Osteomyelitis]]
***Pott's disease, usually in thoracic spione
+
***Pott's disease, usually in thoracic spine
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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==Evaluation==
 
==Evaluation==
===CXR===
+
===[[CXR]]===
 
[[File:Miliary.png|thumbnail|CXR of miliary TB]]
 
[[File:Miliary.png|thumbnail|CXR of miliary TB]]
 
*Primary infection
 
*Primary infection
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**Recent conversion to PPD-positive
 
**Recent conversion to PPD-positive
 
**close contact with active TB
 
**close contact with active TB
**immunocompromised patients (or plan to start immunosupressive medications)
+
**immunocompromised patients (or plan to start immunosuppressive medications)
  
 
==Disposition==
 
==Disposition==

Latest revision as of 21:50, 13 October 2019

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 - miliary 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
  • 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

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 immunosuppressive 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.