Tuberculosis: Difference between revisions
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==Background== | ==Background== | ||
*Over 1/3 of world's population is infected | |||
*Over 1/3 of world's population is infected | |||
===Infection Types=== | ===Infection Types=== | ||
*Primary Infection | *Primary Infection | ||
**Usually contained by body via formation of tubercles | **Usually contained by body via formation of tubercles | ||
**Hematogenous spread limited to areas | **Hematogenous spread limited to areas with high O2 or blood flow (apical lung, vertebrae) | ||
***PPD positive | ***PPD positive | ||
*Reactivation Infection | *Reactivation Infection | ||
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**Looks like millet seeds | **Looks like millet seeds | ||
**Seen in patients with comorbid AIDS | **Seen in patients with comorbid AIDS | ||
***Check HIV in patients suspected of TB | ***Check [[HIV]] in patients suspected of TB | ||
**PPD is positive in only 50% of cases | **PPD is positive in only 50% of cases | ||
Line 27: | Line 26: | ||
***Presentation more commonly that of primary TB | ***Presentation more commonly that of primary TB | ||
**>5yr - classic symptoms | **>5yr - classic symptoms | ||
**<5yr - | **<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 | ||
===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== | ==Clinical Features== | ||
[[File:Screen Shot 2015-09-11 at 9.27.22 AM.png|thumbnail|Tuberculous lymphadenopathy]] | |||
===Primary Tuberculosis=== | ===Primary Tuberculosis=== | ||
*Usually asymptomatic (only identified by positive PPD/quantiferon gold) | *Usually asymptomatic (only identified by positive PPD/quantiferon gold) | ||
*May be rapidly progressive and fatal in immunocompromised | *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, | *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 | |||
***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 | ***Pott's disease, usually in thoracic spine | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{HIV associated conditions}} | {{HIV associated conditions}} | ||
== | ==Evaluation== | ||
===CXR=== | [[File:Miliary.png|thumbnail|CXR of miliary TB]] | ||
[[File:MiliaryTB.png|thumb|Miliary TB neonate born to mother with active TB]] | |||
[[File:Tuberculosis-x-ray-1.jpg|thumbnail|Bilateral pulmonary tuberculosis]] | |||
[[File:Screen Shot 2015-09-11 at 9.21.17 AM.png|thumbnail|Tuberculous vertebral osteomyelitis (Pott's Disease)]] | |||
===[[CXR]]=== | |||
*Primary infection | *Primary infection | ||
**Infiltrates in any area of the lung | **Infiltrates in any area of the lung | ||
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*Miliary TB | *Miliary TB | ||
**Looks like millet seeds on CXR | **Looks like millet seeds on CXR | ||
*Immunocompromised patients less likely to have classic lesions and may have normal 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== | ==Management== | ||
===Active TB=== | ===Active TB=== | ||
*[[Isoniazid]] + [[rifampin]] + pyrazinamide + ethambutol x 8wk followed by INH/rifampin x18wk | *[[Isoniazid]] + [[rifampin]] + [[pyrazinamide]] + [[ethambutol]] x 8wk followed by INH/rifampin x18wk | ||
**2 drug continuation treatment x 18-31wk | **2 drug continuation treatment x 18-31wk | ||
**Use of [[pyrazinamide]] in pregnancy is controversial and typically reserved for women with MDR TB<ref>Sokolove PE, Derlet RW: Tuberculosis, in Walls RM, Hockberger RS, Gausche-Hill M, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 9. Philadelphia, Elsevier 2018, (Ch) 127:p 1682-1692.</ref> | |||
===Latent TB=== | ===Latent TB=== | ||
*Isoniazid x 9 months | *Isoniazid x 9 months | ||
Line 95: | Line 108: | ||
**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 | **immunocompromised patients (or plan to start immunosuppressive medications) | ||
*New vaccine has demonstrated effectiveness (50%) in preventing progression to active TB<ref>Final analysis of a trial of M72/AS01E vaccine to prevent tuberculosis Tait DR, Hatherill M, Van Der Meeren O, et al. N Engl J Med. 2019;381(25):2429-2439.</ref>. However, this is not yet widely available and further research is needed. | |||
==Disposition== | ==Disposition== | ||
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*Otherwise healthy | *Otherwise healthy | ||
**Contact public health services before discharge | **Contact public health services before discharge | ||
***Instructions for home isolation and | ***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 | ||
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*Ill-appearing | *Ill-appearing | ||
*Diagnosis is uncertain | *Diagnosis is uncertain | ||
*Patient is | *Patient is treatment non-adherent | ||
==External Links== | |||
*https://www.cdc.gov/tb/default.htm | |||
==References== | ==References== |
Latest revision as of 18:45, 14 December 2022
Background
- Over 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 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
- More likely to progress early to active disease
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)
- 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, weight 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 spine
Differential Diagnosis
HIV associated conditions
- HIV neurologic complications
- HIV pulmonary complications
- Ophthalmologic complications
- Other
- HAART medication side effects[1]
- HAART-induced lactic acidosis
- Neuropyschiatric effects
- Hepatic toxicity
- Renal toxicity
- Steven-Johnson's
- Cytopenias
- GI symptoms
- Endocrine abnormalities
Evaluation
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
- 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
- Isoniazid + rifampin + pyrazinamide + ethambutol x 8wk followed by INH/rifampin x18wk
- 2 drug continuation treatment x 18-31wk
- Use of pyrazinamide in pregnancy is controversial and typically reserved for women with MDR TB[2]
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)
- New vaccine has demonstrated effectiveness (50%) in preventing progression to active TB[3]. However, this is not yet widely available and further research is needed.
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
- Contact public health services before discharge
Admit
- Ill-appearing
- Diagnosis is uncertain
- Patient is treatment non-adherent
External Links
References
- ↑ 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.
- ↑ Sokolove PE, Derlet RW: Tuberculosis, in Walls RM, Hockberger RS, Gausche-Hill M, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 9. Philadelphia, Elsevier 2018, (Ch) 127:p 1682-1692.
- ↑ Final analysis of a trial of M72/AS01E vaccine to prevent tuberculosis Tait DR, Hatherill M, Van Der Meeren O, et al. N Engl J Med. 2019;381(25):2429-2439.