Summary

This document is a presentation on extrapulmonary tuberculosis (TB). It covers various aspects of the topic like case studies, diagnosis, and treatment. The document may also cover other diseases for differential diagnosis of extrapulomary TB. The document is from the Tropical Medicine Department, and was presented in 2024/2025.

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Tropical Medicine Department Extrapulmonary Tuberculosis 2024/2025 Extended Modular Program 1 1. Enumerate different sites of extrapulmonary TB. 2. discuss clinical picture of e...

Tropical Medicine Department Extrapulmonary Tuberculosis 2024/2025 Extended Modular Program 1 1. Enumerate different sites of extrapulmonary TB. 2. discuss clinical picture of extrapulmonary TB. 3.List different diagnostic tests of extrapulmonary TB. 4. know definition of latent TB. 5. define different treatment options for latent and extra pulmonary TB. Extended Modular Program 2 Extra-Pulmonary TB TB outside the lung. Dissemination: hematogenous, from adjacent organ S and S: vary according to site ( fever, malaise, loss of weight are common) Diagnosis: culture, serology TTT: multiple drugs for more than 6 months Extended Modular Program 3 Case Study A 36-year-old female known to have DM was admitted to the hospital with a 7-day history of tenderness in the abdomen who was referred from another center with reported ascites in ultrasonography. She denied any nausea, vomiting, abdominal pain, loss of appetite, weight loss, hematemesis, melena, or hematochezia. No chronic diseases, no alcohol use, no family history, no herbal agents, or no suspected drug use were reported. Extended Modular Program 4 Vital signs of the patients were in the normal ranges with 36.3 body temperature, 120/70 arterial blood pressure, and 82/min heart rate. Physical examination: ascites in the abdominal region, and there was no other abnormal finding. What is your differential diagnosis?? What do you recommend as further steps?? ???? Extended Modular Program 5 * Laboratory results reported no anemia, no white blood cell elevation, and no thrombocyte abnormality. Her peripheral smear was normal with no atypical cells. No renal function or hepatic function abnormality and no electrolyte abnormality were also reported. CRP was 39 (normal range: 0–5 mg/L) and erythrocyte sedimentation level was 42 (normal range: 0– 20 mm/h). Extended Modular Program 6 Chest X-ray was completely normal with no infiltrations or effusions. Abdominal ultrasonography reported abdominal free liquid deposition, septations in the fluid accumulation, and multiple implants in peritoneal surfaces in hepatic diaphragmatic region and right paracolic area, in which the biggest one was 16 millimetres. What do you recommend as further steps?? Extended Modular Program 7 We performed paracentesis and sent this fluid to pathology laboratory. Pathology reported inflammatory cells which are rich in lymphocytes. There were no malignant cells. According to the laboratory results, serum albumin ascites gradient was adult dt hydrocephalus, stroke, tuberculoma, oedema. Extended Modular Program 19 Tuberculoma S/S: Seizures, focal neurological signs. complications: rupture----subarachnoid space----TB meningitis. Extended Modular Program 20 Genito-Urinary TB Renal affection: S &S as pyelonephritis (eg, fever, back pain, pyuria) without the usual urinary pathogens on routine culture (sterile pyuria). Infection commonly spreads to the bladder and, in men, to the prostate, seminal vesicles, or epididymis (commonest) Extended Modular Program 21 Genito-Urinary TB Infection may spread to the perinephric space and down the psoas muscle, sometimes causing an abscess on the anterior thigh (cold abscess). Salpingo-oophoritis in adult females. Symptoms include chronic pelvic pain and sterility or ectopic pregnancy due to tubal scarring. Extended Modular Program 22 TB pericarditis Rare Common in 3rd to 5th decade of life. Pericardial infection may develop from foci in mediastinal lymph nodes or from pleural TB. Patients may have a pericardial friction rub, pleuritic and positional chest pain, or fever. Pericardial tamponade may occur. Extended Modular Program 23 TB Pericarditis Types Effusion: tamponade (dyspnea, neck vein distention, paradoxical pulse, muffled heart sounds, and possibly hypotension). Effusion/ constriction: Constriction: high JVP + HM, ascites, oedema. Extended Modular Program 24 TB lymphadenitis (scrofula) Typically involves posterior cervical and supraclavicular chains. Thought to be due to contiguous spread from intrathoracic lymphatics or from infection in the tonsils and adenoids. Extended Modular Program 25 TB lymphadenitis Mediastinal lymph nodes are also commonly enlarged as a part of primary pulmonary disease. usually indolent, unilat., painless, > 1 LN , matted ---if no ttt--- necrosis liquefaction, cold abscess ---rupture----sinus. Extended Modular Program 26 Cutaneous TB (scrofuloderma) Direct extension of an underlying TB focus (eg, a regional lymph node, an infected bone or joint) to the overlying skin, forming ulcers and sinus tracts. Or immune response to TB infection (tuberculids) Extended Modular Program 27 TB of bone and joints advanced age axial > peripheral LL>UL. Extended Modular Program 28 Pott’s Disease is spinal infection, which begins in a vertebral body and often spreads to adjacent vertebrae, with narrowing of the disk space between them. Untreated, the vertebrae may collapse, possibly impinging on the spinal cord. spinal cord compression produces neurologic deficits, including paraplegia; paravertebral swelling may result from an abscess. Extended Modular Program 29 TB arthritis Usually monoarticular Extended Modular Program 30 Miliary TB Miliary TB is most common among: Children < 4 yr Immunocompromised people The elderly Extended Modular Program 31 Diagnosis CBC: lymphocytosis, anemia of chronic illness ESR: high Imaging according to the site Fluid sampling and cytology or tissue biopsy when indicated. Extended Modular Program 32 Diagnosis Chemical analysis and cytology (fluids): low glucose, high protein levels and lymphocytosis. Acid-fast staining, microscopic analysis, and mycobacterial culture of fluid and tissue samples, and, when available, nucleic acid–based testing Chest X Ray: to exclude or prove presence of pulmonary TB Tuberculin skin testing (TST). interferon-gamma release assay (IGRA). Extended Modular Program 33 Tuberculin Test False-positive reactions: causes may include, but are not limited to: Previous TB vaccination with the bacille Calmette-Guérin (BCG) vaccine Infection with nontuberculosis mycobacteria (mycobacteria other than M. tuberculosis). N.B. reactions larger than 15 mm are unlikely to be due to previous vaccination or exposure to environmental mycobacterium. Extended Modular Program 34 False negative tuberculin: Cutaneous anergy (anergy is the inability to react to skin tests because of a weakened immune system), Recent TB infection (within 8-10 weeks of exposure), Very old TB infection (many years). Very young age (less than six months old), Recent live-virus vaccination (e.g., measles and smallpox), Overwhelming TB disease, Extended Modular Program 35 Treatment Antituberculous drugs. Surgery. Nutrition. Extended Modular Program 36 Antituberculous Six to 9 mo of therapy is probably adequate for most sites except the meninges, which require treatment for 9 to 12 mo. Drug resistance is a major concern; it is increased by poor adherence, use of too few drugs, and inadequate susceptibility testing. There are 5 groups of antituberculous dugs: Extended Modular Program 37 1st line drugs 2 Mo---- RIF + INH + + PZI + ETB. 4 Mo ---- RIF + INH Extended Modular Program 38 Isoniazide: 5 mg/kg (4–6 mg/kg) daily, maximum 300 mg 10 mg/kg (8–12 mg/kg) three times weekly, maximum 900 mg Contraindications: Known hypersensitivity. Active, unstable hepatic disease (with jaundice). Pyridoxine should be given to prevent peripheral neuropathy. Extended Modular Program 39 Rifampicin: 10 mg/kg (8–12 mg/kg) daily or 3 times weekly, maximum 600 mg. Contraindications Known hypersensitivity to rifamycins. Active, unstable hepatic disease (with jaundice). Other rifamycins: rifapentine, rifabutin Extended Modular Program 40 Pyrazinamide: 25 mg/kg (20–30 mg/kg) daily 35 mg/kg (30–40 mg/kg) 3 times weekly. Contraindications Known hypersensitivity. Active, unstable hepatic disease (with jaundice). Porphyria. Precautions Patients with diabetes should be carefully monitored (blood glucose concentrations may become labile). Gout may be exacerbated. In patients with renal failure, pyrazinamide should be administered three times per week, rather than daily Extended Modular Program 41 Ethambutol 15 mg/kg (15–20 mg/kg) daily 30 mg/kg (25–35 mg/kg) 3 times weekly. Contraindications Known hypersensitivity. Pre-existing optic neuritis from any cause (the drug causes dose dependent optic neuritis). Plasma ethambutol concentration should be monitored if creatinine clearance is less than 30 ml/min. Extended Modular Program 42 Role of Surgery to drain cardiac tamponade,or CNS abscess To resect infected bowel To decompress spinal cord encroachment Extended Modular Program 43 MDR TB Either INH resistant, rifampicin resistant, MDR TB, extensive resistant TB In cases of MDR and XDR, different protocols using drugs rather than 1st line dugs are used. 2nd line drugs: levofloxacin, moxifloxacin 3rd line drugs: bedaquiline, delamanid, linezolid 4th line: amikacin, capreomycin, kanamycin Summary Extra-pulmonary tuberculosis can occur in many sites. Clinical presentation depends on site of infection. Diagnosis should be confirmed before starting antituberculous drugs. Antituberculous drugs should be given for at least 6 to 9 months with longer duration in tuberculous CNS and bone infections. MDR is a rising issue. During treatment continuous monitoring is important to report drug side effects. Extended Modular Program 45 Test yourself: 16 years old female patient presented with fever and loss of weight of 5 months duration. 4 months later, she developed squint. CSF examination revealed low glucose and high protein content. There is lymphocytosis. According to these findings: a. This case is mostly viral meningitis. b. CSF-PCR for TB is required. c. Ceftriaxone injection should be started immediately. d. Conventional cultures can reveal causative agent. Extended Modular Program 46 Test yourself: Summarize treatment regimen for a patient with tuberculous peritonitis. Extended Modular Program 47 References https://npin.cdc.gov/publication/extrapulmonary-tuberculosis https://www.cdc.gov/tb/hcp/clinical-overview/tuberculosis- disease.html#:~:text=Extrapulmonary%20TB%20disease%2C% 20which%20affects,may%20cause%20headache%20or%20con fusion. Extended Modular Program 48 Extended Modular Program 49

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