Tuberculosis: Difference between revisions
User238345 (talk | contribs) No edit summary |
User238345 (talk | contribs) No edit summary |
||
| Line 27: | Line 27: | ||
==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 | ||
| Line 38: | Line 38: | ||
*Systemic: Fever, night sweats, malaise, fatigue, wt loss | *Systemic: Fever, night sweats, malaise, fatigue, wt loss | ||
*Extrapulmonary | *Extrapulmonary | ||
**Painless lymphadenopathy (most common extrapulmonary manifestation) | **Painless lymphadenopathy (most common extrapulmonary manifestation) | ||
**Pericarditis | **Pericarditis | ||
**Peritonitis | **Peritonitis | ||
**Meningitis | **Meningitis | ||
**Adrenal insufficiency | **Adrenal insufficiency | ||
**Arthritis | **Arthritis | ||
**Osteomyelitis | **Osteomyelitis | ||
Revision as of 13:30, 11 September 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
- Painless lymphadenopathy (most common extrapulmonary manifestation)
- Pericarditis
- Peritonitis
- 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
Admit
- Ill-appearing
- Diagnosis is uncertain
- Pt is noncompliant
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.