Diagnosis and Management of TB John Yates Consultant Infectious Diseases.
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Diagnosis and Management of TB
John YatesConsultant Infectious Diseases
Diagnosis
• Generally sub-acute illness• Any persistent symptom may indicate active
tuberculosis• May be relatively mild• Any systemic symptoms – fever, weight loss,
night sweats, malaise, anorexia – increase suspicion
• Exposure history usually irrelevant if high risk ethnic background
Sites of infection• About 50/50 pulmonary/non-pulmonary• 24% extra-pulmonary LNs• 10% intra-throracic LNs• 10% pleural• 6% bone/joint ( 3% spine)• 5% GI• 3% CNS• 2% miliary• 1% GU• Others – skin, eye, breast,
Diagnosis- pulmonary
• Persistent cough +/- haemoptysis• Fever, weight loss, night sweats• Symptoms may be very mild• Usually stethoscope not useful• Breathlessness uncommon unless severe,
disseminated disease• May be asymptomatic• Main initial investigation – CXR• Referral to TB clinic
Diagnosis - pulmonary
• CXR• Sputum, if productive, x3 for smear and culture• Basic blood tests • HIV test• Mantoux/IGRA• CT to guide bronchoscopy/biopsy if unproductive• Broncho-alveolar lavage/induced sputum for
smear and culture• PCR for smear positive cases/difficult diagnoses
Early pulmonary disease
Patch of nodules
Early pulmonary disease
Late pulmonary disease
cavity
Lymphadenopathy
Asymmetrical hilar enlargement
Extra-pulmonary
• Cervical lymph nodes – mantoux +/- IGRA, biopsy for histology/culture
• Other sites imaging/biopsy• Multifarious presentations
• Main aid to diagnosis is suspicion• Don’t be put off by normal plain films of
chest/abdo/spine/bone
Extra-pulmonary
• Persistent symptoms > 2 weeks• +/- night sweats/weight loss/malaise• High risk ethnic backgrounds• Elevated ESR/CRP, normocytic anaemia, low
albumin
• Back pain, abdo pain, headache etc• Please refer to TB clinic
Diagnosis –extra pulmonary
• Immunological tests – negative in 10% active disease for mantoux
• Targeted imaging – but disease often multi-focal e.g. peritoneum, lymph nodes, spine, chest simultaneously
• Biopsy for histology, smear and culture
Abdominal TB
Ascites
Lymph node mass
Spinal TB
Increased soft tissue around L4/5
Management• Risk assessment for Multi-Drug Resistant -MDR TB – 1.5%
cases resistant to rifampicin and isoniazid• Smear positive cases sent for PCR for drug resistance • Isolation of smear positive cases for 2 weeks– usually at
home but in hospital if ill or unable due to shared accommodation/homelessness
• Initiate treatment – quadruple therapy –rifampicin/isoniazid/pyrazinamide, ethambutol or moxifloxacin
• Monitored treatment – TB nurses, clinic• Review with culture results• MDR cases referred to St George’s
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