Tuberculosis PDF - Red Whale

Red Whale | Tuberculosis 04/12/2024, 20:19 Tuberculosis TB is not something we are going to be managing ourselves in primary care, but we need to be alert to the possibility of the diagnosis and be aware of the rel...

Red Whale | Tuberculosis 04/12/2024, 20:19 Tuberculosis TB is not something we are going to be managing ourselves in primary care, but we need to be alert to the possibility of the diagnosis and be aware of the relevant tests and treatment regimens. The aim of this article is not to give you an in-depth knowledge of TB but to provide a brief overview of current management, so here I have summarised the parts of the NICE guidance as they are relevant to us in primary care. I've not gone into detail on the non-respiratory types of TB (e.g. meningeal, pericardial, bone TB), and of course your local team will be working to some local protocols as well as national protocols. To clarify certain areas of NICE guidance, I have also referred to the 'Green Book', DH 2021 and BMJ 2021;374:n1590. TB in context Worldwide, the disease affects 10 million people. In the UK, the incidence was 9.6/100 000 (just over 6000 cases) in 2015, but there are huge variations depending on the area of the country. A PHE report in 2014 showed that approximately 75% of cases are among people born outside the UK, but only 15% of these were diagnosed in recent migrants (diagnosed within 2 years of entering the UK) (TB In the UK, PHE 2014). In the UK, there is a strong link between deprivation and the risk of TB. This article was reviewed in February 2024. Symptoms https://www.redwhale.co.uk/content/tuberculosis Page 1 of 7 Red Whale | Tuberculosis 04/12/2024, 20:19 Here's a reminder of the common presentations of TB (European Respiratory society, Breathe 2022;18:210149). REMEMBER: active TB can be insidious in onset and hard to detect in the early stages. Although TB can occur in anyone, it is most common in those who are in high-risk groups. High-risk populations Consider TB in those who are at high risk AND who have the relevant clinical features. High-risk individuals are those: Born in high-prevalence areas. In 2020, eight countries accounted for two-thirds of the global total of TB cases: India, Indonesia, China, the Philippines, Pakistan, Nigeria, Bangladesh and South Africa (WHO Global tuberculosis report 2020). With HIV, diabetes, chronic renal failure, previous gastrectomy, occupational lung disease, cancer or post-transplant. On immunosuppressants (prolonged courses of steroids, chemotherapy, anti-tumour necrosis factors (anti-TNF)). In deprived populations: deprivation is a major risk factor for TB: The most deprived 10% of the UK population has a TB rate more than 7 times higher than the least deprived 10% of the population, and they are also more likely to have multi-drug- resistant TB. Who are homeless, institutionalized, or living in prison or overcrowded conditions. With alcohol problems, or who are intravenous drug users. Who have had previous (especially incomplete) treatment for TB. Who have had close contact with someone with active TB (e.g. https://www.redwhale.co.uk/content/tuberculosis Page 2 of 7 Red Whale | Tuberculosis 04/12/2024, 20:19 sharing a house, work colleagues who work in close proximity). Clinical features that may make you suspect active TB in high-risk individuals: Cough. Weight loss. Fever. Night sweats. Anorexia. Malaise. Think pulmonary TB if: Cough persisting for more than 3w. May be associated with sputum, breathlessness or haemoptysis. Think extrapulmonary TB if: Cervical lymphadenopathy. Bone pain, joint pain and swelling or back pain. Abdominal pain. Confusion, visual problems or persistent headache (cerebral TB). Skin lesions (e.g. erythema nodosum, lupus vulgaris affecting the face). Breathlessness, chest pain or ankle swelling (pericardial TB). Remember that people from ethnic minority groups or those with HIV are more likely to present with extrapulmonary TB. A reminder about the Mantoux test (from the Green Book, DH 2022): The Mantoux test is an intradermal skin test. Interpretation is based on diameter of induration (not redness) when read 48–72h after a test. Interpretation can be affected by steroid use, some respiratory disease https://www.redwhale.co.uk/content/tuberculosis Page 3 of 7 Red Whale | Tuberculosis 04/12/2024, 20:19 and things such as glandular fever. The interferon gamma test is a blood test. The decision on which to use is a specialist one! What about a vaccine? A number of trials of TB vaccines are ongoing. A 3-year follow-up trial of patients in sub-Saharan Africa who tested positive with the interferon gamma test, and did not have active disease or HIV, showed that the vaccine on trial did reduce the chance of developing active TB by 50%, but with wide confidence intervals of 2.1–74%! (NEJM 2019;381:2429) NICE guidance on TB NICE on tuberculosis (NICE CG117, 2011, updated 2024) BCG immunisation Neonates NICE recommends that PCTs should offer neonatal BCG immunisations to all if the PCT has a high incidence of TB (defined as ≥40/100 000 in the Green Book). In low-incidence areas (