Tuberculosis Treatment Quiz

Extrapulmonary Tuberculosis

• Extrapulmonary TB is tuberculosis that occurs outside the lungs.
• Dissemination of the infection can be hematogenous or from adjacent organs.
• Symptoms vary based on affected site. Common symptoms include fever, malaise, and weight loss.
• Diagnosis involves culture, serology tests.
• Treatment typically includes multiple drugs for more than 6 months.

Intended Learning Outcomes

• Students will be able to identify different sites of extrapulmonary TB.
• Students will understand the clinical presentation of extrapulmonary TB.
• Students will know different diagnostic tests for extrapulmonary TB.
• Students will define latent TB and different treatment options for latent and extrapulmonary TB.

Case Study

• A 36-year-old woman with diabetes was admitted with abdominal tenderness and ascites.
• No other notable symptoms were present in the patient.
• Vital signs were within normal range (temperature 36.3°C, blood pressure 120/70mmHg, and heart rate 82/min)).
• Physical examination revealed ascites.

Laboratory Results

• No anemia, white blood cell elevation, or thrombocyte abnormalities were present.
• Peripheral blood smear was normal.
• Renal, hepatic, and electrolyte function were normal.
• C-reactive protein (CRP) was 39 mg/L (normal range 0-5 mg/L).
• Erythrocyte sedimentation rate (ESR) was 42 mm/h (normal range 0-20 mm/h).

Chest X-Ray and Abdominal Ultrasonography

• Chest X-ray was normal.
• Abdominal ultrasound showed abdominal free fluid, septations in fluid accumulation, and multiple implants in the peritoneal surfaces of the hepatic diaphragm and right paracolic area, with the largest implant measuring 16mm.

Paracentesis Results

• Paracentesis fluid was sent for pathology testing.
• Inflammatory cells were present, mostly lymphocytes.
• No malignant cells were found.
• Serum albumin gradient was <1.1, indicating the fluid was exudative.
• Brucella and viral markers were negative.

Tuberculin Testing and Microscopic Examination

• Tuberculin skin test was positive.
• Tuberculosis quantiferon PCR in blood was positive.
• Ascitic fluid direct microscopic examination showed no tuberculosis bacilli and acid-fast stain was negative.

Abdominal CT and MRI

• Abdominal CT scan showed fluid accumulation, hepatic peritoneal surface nodular lesions, increased reticular density in the omental area, and mesentery lymph nodes.
• Adenosine deaminase (ADA) level was 62 units/L.
• Abdominal MRI showed nodular opacities in the peritoneal area and ascites.

Trucut Biopsy

• Trucut biopsy of peritoneal surface nodules revealed granulomas with histiocytic cells.

Treatment

• Six months of multi-drug therapy for tuberculosis was initiated.
• The patient responded well, and the ascites resolved.

Sites of Extrapulmonary Tuberculosis

• Gastrointestinal TB
• Liver TB
• TB peritonitis
• CNS tuberculosis
• Genitourinary TB
• TB pericarditis
• TB lymphadenitis
• Cutaneous TB
• TB of bone and joints
• Miliary TB

TB Peritonitis

• Peritoneal infection from abdominal lymph nodes or salpingo-oophoritis.
• Common in alcoholics with cirrhosis.

Gastrointestinal Tuberculosis

• Caused by Mycobacterium bovis or Mycobacterium tuberculosis.
• Common sites are the jejuno-ileal and ileocecal regions.
• Symptoms may include inflammation, pain, diarrhea, obstruction, and bleeding, and may mimic appendicitis.

Tuberculosis of the Liver

• Result of direct spread or miliary tuberculosis.
• Obstructive jaundice can occur if the gall bladder is involved.

Tuberculous Meningitis

• Chronic, potentially life-threatening form of tuberculosis.
• Very common in children under five years old in areas with high TB prevalence.
• Symptoms include low-grade fever, headache, nausea and drowsiness which can progress to stupor or coma; with positive Kernig and Brudzinski signs.

Complications of Meningitis

• Basal meningeal adhesions
• Blood vessel thrombosis (leading to stroke and hemiparesis).
• Obstruction of cerebrospinal fluid (CSF) flow, leading to increased intracranial pressure, hydrocephalus, and potentially seizures
• Tuberculoma (brain lesion) development

Tuberculoma

• Focal neurological signs, seizures and risk of rupture with secondary meningitis.

Genitourinary Tuberculosis

• Renal manifestations can resemble pyelonephritis; pyuria without typical urinary pathogens (sterile pyuria).
• Affects the bladder, prostate, seminal vesicles, or epididymis in men.
• Inflammation can extend to the perinephric space and cause a cold abscess on the thigh.
• Salpingo-oophoritis (infection of the fallopian tubes and ovaries) can lead to pelvic pain, scarring, infertility, or ectopic pregnancy.

TB Pericarditis

• Rare, typically occurs in the third to fifth decades of life..
• It can develop from mediastinal lymph node foci or pleural tuberculosis.
• Symptoms may include pericardial friction rub, chest pain, or fever. Pericardial tamponade can also occur.

TB Pericarditis Types

• Effusion: compressive symptoms of tamponade (dyspnea, neck vein distention, paradoxical pulse, muffled heart sounds, potential hypotension)
• Effusion/constriction: combination of infusion and restrictive types
• Constriction: high jugular venous pressure (JVP), hepatomegaly (HM), ascites, and edema (associated with restrictive symptoms)

TB Lymphadenitis (Scrofula)

• Usually involves posterior cervical and supraclavicular lymph nodes.
• Likely due to contagious spread from intrathoracic lymphatics or infection of tonsils/adenoids.
• Mediastinal lymph nodes frequently enlarge as part of primary pulmonary TB.
• Characterized by painless, unilateral lymph node enlargement (1+ lymph nodes, often matted).
• Untreated cases can develop necrosis, liquefaction, cold abscesses, and potential sinus formation.

Cutaneous Tuberculosis (Scrofuloderma)

• Direct extension from an underlying TB focus on lymph node, bone or joint.
• May appear as ulcers, and sinus tracts on the overlying skin
• Can also be as a result of immune reaction to the infection.

Tuberculosis of Bone and Joints

• Common in areas with high TB prevalence
• Typically occurs in older individuals
• Axial skeletal involvement is frequently observed more than peripheral joint involvement • Pott's disease: spinal TB, vertebrae collapse with risk of spinal cord compression and paraplegia • Arthritis is usually monoarticular
• LL> UL involvement

Miliary Tuberculosis

• Usually found in children <4 years old, immunocompromised, and elderly patients.

Diagnosis

• Complete Blood Count (CBC): lymphocytosis, anemia of chronic illness
• Erythrocyte Sedimentation Rate (ESR): high
• Imaging: based on the site involved
• Fluid sampling and cytology or tissue biopsy when indicated

Tuberculosis Testing

• Chemical analysis and cytology (fluids): low glucose, high protein and lymphocytosis
• Acid-fast staining, microscopic analysis, mycobacterial culture, fluid and tissue samples
• Nucleic acid-based testing
• Chest X-Ray: for the exclusion or confirmation of pulmonary TB
• Tuberculin skin testing (TST)
• Interferon-gamma release assay (IGRA)

Tuberculin Test

• False-positive reactions:
  • BCG vaccination history
  • Infection with non-tuberculous mycobacteria
  • Reactions exceeding 15mm are less likely due to vaccination or environmental mycobacterium exposure
• False-negative reactions:
• Cutaneous anergy
• Recent TB infection (<8-10 weeks)
• Very old TB infection (years)
• Very young age (<6 months)
• Recent live-virus vaccination (like measles, smallpox)
• Overwhelming TB disease

Treatment

• Antituberculous drugs
• Surgery (drain abscesses, correct obstruction)
• Nutrition

Multi-drug Resistant Tuberculosis (MDR-TB)

• INH-resistant or rifampicin-resistant TB
• Requires different protocols with 2nd, 3rd (or 4th) line drugs instead of 1st line drugs.