Tuberculosis: Difference between revisions
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[[File:MiliaryTB.png|thumb|Miliary TB neonate born to mother with active TB]] | [[File:MiliaryTB.png|thumb|Miliary TB neonate born to mother with active TB]] | ||
*>1/3 of world's population is infected | *>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=== | ===Clinical Features=== |
Revision as of 10:38, 1 August 2015
Background
- >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
- More likely to progress early to active disease
Clinical Features
Primary Tuberculosis
- Usually asymptomatic (only identified by positive PPD)
- 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
- Lymphadenopathy (painless)
- Pericarditis
- Meningitis
- Adrenal insufficiency
- Arthritis
- Osteomyelitis
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
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
- Contact public health services before discharge
- Otherwise healthy
- Admit
- Ill-appearing
- Diagnosis is uncertain
- Pt is noncompliant
- ↑ 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.