Tuberculosis Management and Symptoms

Study Notes

TB is a disease that requires primary care management, but primary care providers should be aware of diagnosis and treatment
NICE guidance is summarized for primary care but does not cover all types of TB (e.g., meningeal, pericardial, bone TB)
Worldwide, TB affects 10 million people
In the UK, incidence was 9.6/100,000 in 2015 (just over 6,000 cases). Variations exist across the country
75% of UK TB cases are reported in people born outside the UK; only 15% of cases in recent immigrants(diagnosed within 2 years of entry)
Strong correlation between deprivation and TB risk in the UK
Article reviewed in February 2024

Pulmonary TB: Cough lasting over 3 weeks, potential for sputum, shortness of breath, or coughing up blood
Extrapulmonary TB: Symptoms may include swollen lymph nodes in neck, pain in bones, joints, and back; abdominal pain; confusion, visual issues, or persistent headaches; skin lesions (e.g., erythema nodosum, lupus vulgaris); breathlessness, chest pain or ankle swelling.
People from ethnic minorities and those with HIV are more likely to present with extrapulmonary TB

Mantoux test (intradermal skin test): Used to detect TB infection; interpretation based on induration (not redness).
Interferon gamma test: A blood test, decision on which to use is a specialist-driven decision based on further details like glandular fever
A 3-year follow-up trial conducted in sub-Saharan Africa showed a vaccine on trial reduced the chance of active TB by 50% , confidence interval of 2.1-74%

Neonates:
- NICE recommends neonatal BCG immunizations to all areas of high incidence (≥40/100,000 in the Green Book). Low-incidence areas consider high risk
- A neonate with one or more parents or grandparents born in high-incidence area or born in such area and moved to a low-incidence area within the neonatal period, is classified as a high risk neonate.
Childhood and Adolescence: Routine BCG immunisation between 10-14 years is no longer recommended, but those aged 4-16 at risk should be offered
Healthcare workers: BCG should be offered to all healthcare workers who haven't been immunized previously (and are Mantoux-negative)
Immigrants from high-incidence countries: Offer BCG for unvaccinated (no scar, no documentation) immigrants aged under 16 or age 16-35 from sub-Saharan Africa or a country with high incidence of TB (500/100,000).

Diagnosis of active respiratory TB: Posterior anterior CXR, multiple sputum samples (at least three, including one early morning sample)
Diagnosis of active non-respiratory TB: Often biopsy or needle aspiration
Management of respiratory TB: Six months of 4-drug initial regimen (2 months of isoniazid, rifampicin, pyrazinamide, and ethambutol followed by 4 months of isoniazid & rifampicin). Consider twice-weekly dosing for directly observed therapy (DOT)patients.

Risk factors include a history of prior treatment and treatment failure, contact with a known case of multidrug-resistant TB, birth in a high TB incidence country, residence in London, age between 25 and 44
Management must be adjusted

Diagnosis: Immunocompromised individuals use Mantoux skin tests, Household contacts aged 5+ of those with active TB, NON-household close contacts; offer IFN-gamma testing if Mantoux is positive or if Mantoux is less reliable (e.g., those who have had BCG).
Management: specialists need to assess the treatment need after ruling out active TB, treatment durations and regimens depend on multiple factors.

Rifampicin, isoniazid, and pyrazinamide (common TB drugs) can cause liver damage (up to 25% of people treated). Symptoms include nausea, fatigue, jaundice, abdominal pain, vomiting, confusion, and occur within the first 1-2 months of treatment.
Management involves stopping medication for 1-2 weeks until liver function normalises and then gradually reintroducing (80-90% of patients respond)