By:

Dr.Ahmad Shaheen
Tuberculosis
Tuberculosis (abbreviated as TB for
tubercle bacillus or Tuberculosis) is a
common and often deadly infectious disease
caused by mycobacteria, mainly
Mycobacterium tuberculosis. Tuberculosis
usually attacks the lungs (as pulmonary TB(
Tuberculosis
Commonly affects the lungs/pleura
Extrapulmonary sites:
• Lymph nodes – cervical most common-scrofula
• Bones/joints – spine most common – Pott’s
• GU system – sterile pyuria
• CNS – Elevated CSF WBC (lymphocytes
predominant), low glucose, and high protein in TB
meningitis (insidious onset)
• Abdomen
• Pericardium
Practically any organ can be involved
Pulmonary Tuberculosis
Epidemiology
Most common infectious cause of death
worldwide
Latent phase of TB enabled it to spread to
one third of the world population
8,000,000 new cases each year
3,000,000 infected patients die
Pulmonary Tuberculosis
Incidence
1985-1990 TB cases increased 55% in
Hispanics and 27% in African Americans
Populations at risk
- Foreign-born individuals
- Low socioeconomic status
- Cancer pts
- HIV
- Cigarette smokers
- TNF-a antagonists
- Corticosteroids
Tuberculosis
Epidemiology
Pulmonary Tuberculosis
Transmission
Transmitted by airborne particles 1-5 microns in
size
A single sneeze can release up to 40,000 droplets
Ease of transmission depends on duration and
proximity of contact as well as the number of
bacteria excreted
Infection can result from only 1-5 bacteria
entering a terminal alveolus
Only those with active pulmonary TB are
infectious
Pulmonary Tuberculosis
Transmission
Pulmonary Tuberculosis
Pathogenesis
Inhalation and deposition of the tubercle
bacillus leads to four possible outcomes:
(1) Immediate clearance of the organism
(2) Chronic or latent infection
(3) Rapidly progressive disease (or primary
disease)
(4) Active disease many years after
infection (reactivation disease)
Pulmonary Tuberculosis
Pathogenesis
Pulmonary Tuberculosis
Primary Disease
First exposure to MTB often a symptomatic
Tubercle bacilli establish infection in the lung
after they are carried in droplets (5 to 10 µm to
reach the alveolar space
Innate defense system unable to clear infection,
bacilli proliferate in alveolar macrophages and kill
the cells
Infected macrophages produce cytokines and
chemokines that attract other cells and form a
tubercle
Tubercle enlarges and bacilli enter lymph system
Pulmonary Tuberculosis
Primary Disease
Typically pul. Infiltrates: mid or lower lung fields
with or without hilar adenopathy, these infiltrates
non-specific in appearance and not cavitory
In most cases pneumonitis clears without specific
therapy and latent infections established
In some cases, primary infection may progress,
resembling reactivation disease
Pulmonary Tuberculosis
latent infection
following primary infection many persons remain
asymptomatic with normal CXR
• Exceptions: Nodules, pleural scarring
Organisms remain latent within macrophages
indefinitely
Tuberculosis skin test (T-PPD) very important to
discover these persons
If no preventive therapy given, 1:10 persons with
MTB infection will develop clinical disease at
some time in their lives
Pulmonary Tuberculosis
Reactivation of Disease
Reactivation results when persistent bacteria
suddenly proliferate (unclear as to what
mechanism maintain the latent state or trigger
reactivation)
Reactivation occurs more likely in upper lobes and
superior segment of lower Lobes
Immunosuppressive conditions associated with
reactivation of TB:
- HIV/AIDS - Lymphoma
- ESRD,DM -Corticosteroid use
** Diagnosis maybe difficult as pul sx mild or lacking.
Pulmonary Tuberculosis
Diagnosis

“The first rule of TB diagnosis:

is to think TB….”
Pulmonary Tuberculosis
Diagnosis
Diagnosis of tuberculosis in most cases
clinical diagnosis based upon the clinical presentation
(hx & PE)
Early diagnosis and initiation of effective
therapy
reducing morbidity and mortality from TB
minimize the spread of infection
Pulmonary Tuberculosis
Diagnosis
Screening for prior infection
Tuberculin skin test
Diagnosis of pulmonary TB
Medical history
Physical examination
Chest radiograph
Bacteriologic exam
Other
Diagnosis
Screening for prior infection
Whom to screen
High prevalence and high risk population
How to screen
Mantoux tuberculin test (ie, purified protein
derivative or PPD, tuberculin skin test)
How to interpret
Determine maximum diameter of induration by
palpation
Diagnosis
Screening for prior infection
Mantoux Test
Inject intradermally 0.1
ml of 5TU PPD tuberculin
Produce wheal 6 mm to
10 mm in diameter
Represent DTH (delayed
type hypersensitivity)
Diagnosis
Screening for prior infection

Read reaction 48-72

hours after injection
Measure only
induration
Record reaction in
mm
Diagnosis
Screening for prior infection
Mantoux test Interperation
PPD >/= 5 mm:
HIV patients
Recent contacts of someone with TB
Fibrotic changes on CXR c/w prior TB
Organ transplant recipients
Immunosuppressed (includes patients receiving
the equivalent of 15 mg/day or more of
prednisone for one month or more)
Diagnosis
Screening for prior infection
PPD >/= 10 mm:
Recent arrivals from high-prevalence countries
Injection drug users
Residents and employees of high-risk settings
Mycobacteriology laboratory personnel
Persons with clinical conditions that place them
at high risk
Children <4 years, or children and adolescents
exposed to adults in high-risk categories
Diagnosis
Screening for prior infection
PPD >/= 15 mm:
Low risk people
Routine tuberculin testing not recommended for
low risk populations
Diagnosis
Screening for prior infection
Factors may affect TST Interperation:
False negative
Faulty application
Acute TB (2-10 wks to convert)
Very young age (< 6 months old)
Live-virus vaccination
Overwhelming TB disease
False positive
BCG vaccination (usually <10mm by adulthood)
Non-TB mycobacteria infection
Diagnosis
Screening for prior infection
BOOSTING
Some people with LTBI may have negative skin
test reaction when tested years after infection
Initial skin test may stimulate (boost) ability to
react to tuberculin
Positive reactions to subsequent tests may be
misinterpreted as a new infection
Diagnosis
Screening for prior infection
two-step testing
Use two-step testing for initial skin testing
of adults who will be retested within 1-3
weeks
If first test (+), consider the person infected
If first test (-), give second test 1-3 weeks later
If second test (+), consider person infected
If second test (-), consider person uninfected
Diagnosis
Diagnosis of the disease

Medical history
Physical examination
Chest radiograph
Bacteriologic exam
AFS
Culture
other
Diagnosis
Diagnosis of the disease
Medical History and PE
Symptoms of disease:
-Productive, prolonged cough
duration of ~3 weeks
-Chest pain -Hemoptysis -Fever/Chills
-Night sweats -Appetite loss -Weight loss
-Easily fatigued
History of TB exposure, infection, or disease
Past TB treatment
Demographic risk factors for TB
Diagnosis
Diagnosis of the disease
Diagnosis
Diagnosis of the disease
Chest Radiography
Classical radiograph appearance
Infiltration
Cavitation
Fibrosis with traction
Enlargement of hilar and mediastinal LN
In reactivaiton TB
Classically fibrocavitary apical disease
Primary TB
Middle or lower lobe consolidation
Diagnosis
Diagnosis of the disease
Abnormalities often
seen in apical or
posterior segments
of upper lobe or
superior segments of
lower lobe
May have unusual
appearance in HIV-
positive persons
Cannot confirm
diagnosis of TB!!
cavity in patient‘s RUL
classic" for adult-type, reactivation tuberculosis
Diagnosis
Diagnosis of the disease
No chest X-ray pattern is absolutely typical of TB
10-15% of culture-positive TB patients not
diagnosed by X-ray
40% of patients diagnosed as having TB on the
basis of x-ray alone do not have active TB
Diagnosis
Diagnosis of the disease
Bacteriologic Exam
Specimen Collection:
Obtain 3 sputum specimens for smear examination
and culture
Persons unable to cough up sputum
induce sputum
bronchoscopy
gastric aspiration
Follow infection control precautions during
specimen collection
Diagnosis
Diagnosis of the disease
Three specimens optimal
• Spot specimen on first visit; sputum container
given to patient
• Early morning collection by patient on next day
• Spot specimen during second visit
Diagnosis
Diagnosis of the disease
Smear Examination
Strongly consider TB in patients with smears
containing acid-fast bacilli (AFB)
Results should be available within 24 hours of
specimen collection
Presumptive diagnosis of TB
Not specific for M. Tuberculosis
Diagnosis
Diagnosis of the disease
AFB Smear
Sensitivity: 40-70%
Specificity: 90%
Diagnosis
Diagnosis of the disease
Cultures
Gold standard for TB
diagnosis
Use to confirm diagnosis
of TB
Culture all specimens,
even if smear negative
Results in 4 to 14 days Colonies of M. tuberculosis growing
when liquid medium on media

systems used
Diagnosis
Diagnosis of the disease
Cultures
Sensitivity: 80-85%
Specificity: 98%
Times needed:
Solid medium
• 4-8 wks
Liquid medium
• 2 wks
Diagnosis
Diagnosis of the disease
Other Laboratory Tests for M.tb
Direct/rapid tests for M.tb in sputum
• Nucleic acid amplification\PCR
• Results in 3-5 days
• Limited experience, generally reliable
• May help with decisions on isolation, contact
investigations
• Not useful for follow-up
Genotyping
• New technique; limited field experience
• May be useful epi tool
• No role in patient management
Diagnosis
Summery
High index of suspecion is essential
Tuberculosis skin (PPD, mantoux) test important first step
in identifying infected patients
Lab. Techniques for MTB identification:
* A.F.B. smear and cultures of resp. secretion (e.g.
sputum)
* A.F.B. smear and cultures of potentially infected body
fluids or tissues: CSF, gastric fluid, urine, LN BX bone
marrow BX, joint fluids, etc.
* Rapid methods: PCR (polymerase chain reactions) and
nucleic acid probes
Diagnosis of Pulmonary TB

Cough 3 weeks
If 1 positive,
AFB X 3 If 2/3 positive:
X-ray and
Anti-TB Rx
evaluation If negative:
Broad-spectrum antibiotic 10-14 days
If symptoms persist, repeat AFB smears, X-ray

If consistent with TB
Anti-TB Treatment
Pulmonary Tuberculosis
Treatment
The first rules of TB treatment are:
Enough drugs (4 to start)
The right drugs (antimicrobial sensitivities)
Enough milligrams of each drug (patient weight)
Enough doses (count doses)
Enough attention to detail (monitoring of
laboratory studies and clinical course)
 Pulmonary Tuberculosis
Treatment
First-line Drugs Second-line Drugs
Isoniazid  Cycloserine
Rifampin  Ethionamide
 Levofloxacin*
Rifapentine
 Moxifloxacin*
Rifabutin*
 Gatifloxacin*
Ethambutol
 P-Aminosalicylic acid
Pyrazinamide  Streptomycin
 Amikacin/kanamycin*
 Capreomycin
 Linezolid

* Not approved by the U.S. Food and Drug Administration for use in the treatment of TB
Pulmonary Tuberculosis
Treatment Active Disease
Role of New Drugs
Rifabutin: For patients receiving medications
having unacceptable interactions with rifampin
(e.g., persons with HIV/AIDS)
Rifapentine: Used in once-weekly continuation
phase for HIV-negative adults with drug-
susceptible noncavitary TB and negative AFB
smears at completion of initial phase of treatment
Pulmonary Tuberculosis
Treatment Active Disease
Role of New Drugs
Fluoroquinolones (Levofloxacin, Moxifloxacin,
Gatifloxacin): Used when
-first-line drugs not tolerated;
-strains resistant to RIF, INH, or EMB; or
-evidence of other resistance patterns with
fluoroquinolone susceptibility
Pulmonary Tuberculosis
Treatment Active Disease
Treatment Regimens
Four drugs regimens recommended for treatment of culture-
positive TB, with different options for dosing intervals in
continuation phase
Initial phase: Standard four drug regimen for first 2
months:
• INH 300 mg
• Rifampin 600 mg
• PZA 15-30 mg/kg
• Ethambutol 15-25 mg/kg or streptomycin 15 mg/kg
Continuation phase: additional 4 months or (7
months for some patients) two drugs INH and
rifampin
Pulmonary Tuberculosis
Treatment Active Disease
Why Extend Continuation-Phase
Treatment for 3 Months?
Cavitary disease and positive sputum culture at 2
months associated with increased relapse in
clinical trials
Extended continuation phase decreased relapses in
silicotuberculosis (from 20% to 3%)
Pulmonary Tuberculosis
Treatment Active Disease
When to Extend Continuation-Phase
Treatment for 3 Months?
Cavitary pulmonary disease and positive sputum
cultures at completion of initial phase
Initial phase excluded PZA
Once-weekly INH and rifapentine started in
continuation phase and sputum specimen
collected at the end of initial phase is culture
positive
HIV-infected with positive 2-month sputum
culture
Pulmonary Tuberculosis
Treatment Latent TB Infection
Treatment of Latent TB Infection
Need to exclude active disease before treatment
(avoids single drug therapy of active TB)
• CXR – if changes consistent with TB, send
AFB sputum culture
Single drug therapy appropriate for latent TB –
bacterial load much lower compared with active
TB
Pulmonary Tuberculosis
Treatment Latent TB Infection
Regimens:
Isoniazid (INH) daily or twice weekly under
directly observed therapy
• 9 months of treatment is optimal
• At least 6 months is needed
• 12 months if treatment is interrupted
Rifampin daily
• 4 months of treatment
• Alternative regimen for those exposed to an INH
resistant patient
Pulmonary Tuberculosis
Treatment Latent TB Infection

Rifampin/PZA for 2 months

• Similar in safety and efficacy to 12 month regimen
of INH
• No longer recommended due to hepatic toxicity
(including liver failure leading to death)
Pulmonary Tuberculosis
Treatment
Patients who require non-standard regimens
Drug resistant TB
Drug side effects/toxicity
Other medical conditions
• HIV
• Renal failure
• Liver disease
• Conditions causing malabsorption
Children (sometimes)
Elderly (sometimes)
Pregnant women
Pulmonary Tuberculosis
Treatment
Drug resistant TB
MDR TB
Multidrug-resistant TB (MDR TB) is TB that is resistant to
at least two of the best anti-TB drugs, isoniazid and
rifampin
XDR TB
Extensively drug-resistant tuberculosis (XDR TB) is a
relatively rare type of multidrug-resistant tuberculosis
(MDR TB). It is resistant to almost all drugs used to treat
TB, including the two best first-line drugs: isoniazid and
rifampin. XDR TB is also resistant to the best second-line
medications: fluoroquinolones and at least one of three
injectable drugs (i.e., amikacin, kanamycin, or
capreomycin).
Pulmonary Tuberculosis
Treatment
Drug resistant TB
Choice of drugs depends on resistance pattern
May require second line drug(s)
Requires DOT
Requires >26 weeks of treatment
Usually requires daily therapy
Monitoring for culture conversion, clinical
improvement, side effects/toxicity critical
Pulmonary Tuberculosis
Treatment
INH resistant TB:
Rifampin, PZA, and ethambutol for 6 months
Rifampin resistant TB:
INH, PZA, and streptomycin for 9 months or
INH and ethambutol for 18 months
PZA resistance :
INH and rifampin for 9 months
MDR/XDR TB:
Based on susceptibility patterns
Pulmonary Tuberculosis
Treatment
Drug side effects/toxicity
Some side effects (e.g., nausea) almost universal; do not require
modifications in treatment
Some adverse events uncommon but serious, reversible if identified
early; require monitoring
Hepatitis
Hearing loss
Visual acuity, color vision
Selection of drugs and dosage based on weight, liver function and
renal function can prevent toxicity
Limit use of hepatotoxic drugs in patients with liver disease
Change dosing frequency in patients with renal disease
Some adverse effects cannot be accurately predicted
Hepatitis in patients without known liver disease
Bone marrow suppression or destruction of red blood cells, white
blood cells, platelets
Pulmonary Tuberculosis
Treatment
Monitoring on Treatment
INH: Side effects
• Abdominal pain, nausea, vomiting
• Dark urine
• Icterus , hepatitis
• Easy bruising/bleeding
• Arthralgias
• Rash
• Paresthesias/weakness – peripheral neuropathy is
less likely with pyridoxine
• Anorexia/fatigue
Pulmonary Tuberculosis
Treatment
INH
Elevated transaminases in 10-20% of cases –
especially with EtOH
Should be withheld if transaminases increase
more than 3x the upper limit of normal when
associated with symptoms or 5x the upper limit
of normal in asymptomatic patients
Pulmonary Tuberculosis
Treatment
Rifampin: Side effects
GI upset
Thrombocytopenia
Hepatitis
Flu-like syndrome – if taken irregularly
Multiple drug interactions
Orange bodily secretions due to excretion
Pulmonary Tuberculosis
Treatment
PZA: Side effects
GI upset
Hepatitis
Arthralgias
Hyperuricemia – acute gout uncommon
Ethambutol:
Optic neuritis: reversible decreased red-green color
perception and visual acuity
Not hepatotoxic
Pulmonary Tuberculosis
Treatment
Special Conditions:
Pregnancy:
No evidence that PPD testing is harmful
INH: not teratogenic; hepatotoxicity may be more
likely
Rifampin: generally considered safe – reports of
hemorrhage in the newborn
Ethambutol: okay
Streptomycin: avoid (congenital deafness)
PZA: no published safety data
Breast-feeding is not contraindicated
Pulmonary Tuberculosis
Treatment
Special Conditions:
Pregnancy:
Active TB – treat
Latent TB (immunocompetent host) – defer
therapy until after delivery
Latent TB (HIV or recent converter) –
immediate therapy with INH
Pulmonary Tuberculosis
Treatment
Special Conditions:
HIV:
• Up to 20% of patients with CD4 counts < 200 can
have a normal CXR with active TB – send sputum
before treatment
• Recent contact with someone with active TB: treat
regardless of PPD result
• Extrapulmonary TB more common
• Immune reconstitution
• Same treatment regimens (except rifabutin instead
of rifampin for patients on PIs)
Pulmonary Tuberculosis
Treatment
Special Conditions:
Children
• Same as adults
• Dosage based on weight
• Fewer problems with toxicity
• Harder to administer
• Harder to monitor
• Pills (crushed) vs. liquid preparations
• Some clinicians reluctant to use ethambutol
Pulmonary Tuberculosis
Treatment
Special Conditions:
Elderly
• Same as younger adults
• Dosage based on weight
• Can be difficult to monitor for side effects
• May not tolerate 2 or 3 x per week dosing
Pulmonary Tuberculosis
Treatment
Current Surgical Intervention
Patients with hemoptysis first received Bronchial Artery
Embolization because of the recurrent hemoptysis.
Current indication of Lung Resection for pulmonary
tuberculosis includes MDR-TB with a poor response to
medical therapy, hemoptysis due to bronchiectasis or
Aspergillus superinfection, and destroyed lung as
previously reported, which are consistent with our
indications.
Surgery remains a crucial adjunct to medical therapy for
the treatment of MDR-TB and medical failure lesions.
Pulmonary Tuberculosis
Chemoprophylaxis of TB
Household members and other close contacts of a patient
with active TB.
A positive skin test in persons less than 35 years.
A positive skin test reactive in the immunosuppressed,
persons with leukemia, and Hodgkin's Disease,
HIV + patients with a positive TB test,
The drug of choice for chemoprophylaxis is isoniazid.
Prophylaxis uses only one drug. In patients who are HIV+
and TB+ and have the disease; they are treated for a
minimum of 9 months, The first 2 months using isoniazid
and rifampin and for the next 7 months or longer, use only
2 or 3 of the 2nd line drugs and Isoniazid/Rifampin.
Pulmonary Tuberculosis
Vaccination
Many countries use Bacillus Calmette-Guérin (BCG)
vaccine as part of their TB control programs, especially for
infants. According to the W.H.O., this is the most often
used vaccine worldwide, with 85% of infants in 172
countries immunized in1993
BCG provides some protection against severe forms of
pediatric TB
unreliable against adult pulmonary TB,
Currently, there are more cases of TB on the planet than at
any other time in history
urgent need for a newer, more effective vaccine that would
prevent all forms of TB—including drug resistant strains
—in all age groups and among people with HIV.
Pulmonary Tuberculosis
Infection Prevention
If active pulmonary TB is suspected:
AFB isolation
Negative pressure
Particulate respirator masks
Isolation not required for:
Latent TB
Extrapulmonary TB
Pulmonary Tuberculosis
Infection Prevention
Isolation can be discontinued:
If AFB smears x 3 are negative
An alternative diagnosis is made
If patient has active TB, then:
After 2 weeks of effective therapy
Resolution of cough, fever
Negative or “less positive” AFB smears
Extrapulmonary Tuberculosis
Proportion in all TB in USA :
7% (1963) to 18% (1987) to 20% (now)
Increase maybe due to HIV infection
More in minorities and foreign-borns
Lymphatic TB (30%) > Pleural TB (24%) > Bone
and joint TB (10%) > Genitourinary TB (9%) >
Miliary TB (8%) > Meningeal TB (6%)
(New York, 1995)
Extrapulmonary Tuberculosis
Lymphadenitis TB
Most common form of EPTB
Peak age: children shift to 20-40 y/o
High risk: Asians, female (2x to male), HIV
Hilar, paratracheal and neck lymphnodes
Self-limited (>90%), a little with pulmonary
calcification
Extrapulmonary Tuberculosis
Lymphadenitis TB
Differential Diagnosis:
Non-TB mycobacteria (young age, unilateral and
normal CXR)
Virus or fungus infection
Neoplasm
Diagnosis:
Tuberculin skin test, history and CXR
Total excision biopsy and culture
Extrapulmonary Tuberculosis
Lymphadenitis TB
Treatment
Anti-tuberculous chemotherapy for 6 months
course (1st line: pyrazinamide, isoniazid, rifampin,
streptomycin)
Surgical intervention (drainage and incision aren’t
suggested)
Extrapulmonary Tuberculosis
Bone and joint TB
Pott’s disease
Increasing since 1980s
13-25%: HIV positive in several trials
Location: lumbar spine (29.5%) > thoracic spine
(20.5%) > knee (13.2%) > hip (8.2%) > soft tissue
or muscle (4.5%) (Los Angeles, 1990-1995)
Hematogenous dissemination
Extrapulmonary Tuberculosis
Bone and joint TB
Pathophysiology
Invasion of joint space: direct or indirect
Cartilage preservation
Cold abscess and sinus tract formation
Fibrosis and ankylosis, calcification
Extrapulmonary Tuberculosis
Bone and joint TB
Clinical Presentation
Tuberculous spondylitis
Tuberculous osteomyelitis
Tuberculous arthritis
Tuberculous tensynovitis
Tuberculous myositis
Extrapulmonary Tuberculosis
Bone and joint TB
Tuberculous spondylitis
Most commonly, especially in developing
countries
Back pain and rigidity
Vertebral body involvement and diskitis
Kyphosis and paraplegia
Extrapulmonary Tuberculosis
Bone and joint TB
Tuberculous osteomyelitis
Initial: painful mass attached to bone with soft
tissue swelling
Predilection to metaphysis of long bones
May extend to a joint or tenosynovium
Single in adults; multiple in children, elders,
immunosuppressive and HIV infection
periositis
Extrapulmonary Tuberculosis
Bone and joint TB
Tuberculous arthritis
Large weight-bearing joint like hip, knee
Painful, ankylosed or swollen mono-arthropathy,
limitation of motion
Phemister's triad
radiographic findings that is typical of tuberculous
arthritis.
The triad consists of: narrowing of the interosseous
space , juxta-articular osteoporosis, and juxta-
articular bone erosions located peripherally.
Extrapulmonary Tuberculosis
Bone and joint TB
Tuberculous myositis
More in immunosuppressive and AIDS
Most in psoas muscle involvement
Swelling, less pain; a solitary nodule with cold
abscess, limitation of muscle function; iliac fossa
pain or tenderness in some case
Extrapulmonary Tuberculosis
Bone and joint TB
Diagnosis and DDx
DDx: sarcoid arthritis and pyogenic arthritis;
fungus infection; neoplasm
Monoarthritis, chronic pain, minimal sign
Tuberculin skin test
Plain radiography, open biopsy
CT, MRI, CT-guided fine-needle aspiration biopsy
Extrapulmonary Tuberculosis
Bone and joint TB
Treatment
Early diagnosis
Anti-tuberculosis drugs with minimal operative
intervention for abscess drainage (86% complete
recovery)
Operative decompression (laminectomy should be
avoided)
Arthroplasty
Extrapulmonary Tuberculosis
Genitourinary TB
Developing >> developed countries (400:13)
Male/female=2:1, most 20-40y/o (45-55y/o)
Vague urinary tract symptoms: painless frequent
micturition is common
microscopic hematuria: 50%
Recurrent E. coli infection
Urine pus cell, suprapubic pain, hemospermia,
painful testicular swelling: all rare
Extrapulmonary Tuberculosis
Genitourinary TB
Diagnosis
Tuberculin skin test
Urine examination and culture
Elevated ESR
Plain film, high-dose IV urography, percutaneous
antegrade pyelography
Limited value: endoscopy, biopsy,
ultrasonography and CT
Extrapulmonary Tuberculosis
Genitourinary TB
Pathology
Kidney: chronic parenchymal abscess, large renal
calcification; may spread to ureter, bladder,
seminal visicle
Bladder: bullous granulation from ureteric orifice,
obstruction; fistula to rectum
Epididymis: bloodstream spread, present with
discharging sinus; may spread to testis
 Show Desktop.scf
In this intravenous urogram the right kidney and ureter appear normal, but the left pelvicalyceal
system is dilated with clubbed calyces. The lower pole calyces appear to be calcified. These
calcifications continue along the line of the left ureter. the ureter is irregularly narrowed. Retention
of contrast in left ureter and pelvicalyceal system, but not on the right side, implies a degree of
obstruction.
Extrapulmonary Tuberculosis
Genitourinary TB
Treatment
Anti-tuberculous chemotherapy (effective)
Surgery (>80%): nephrectomy,
nephroureterectomy, epididymectomy and
reconstructive surgery
Extrapulmonary Tuberculosis
Cutaneous TB
Uncommon (<1% in the west) but increase
very rapidly in recent years
May contagious spread
Exogenous source: Tuberculous chancre and
prosector’s wart
Endogenous source: scrofuloderma
Hematogenous source: Lupus vulgaris (apple jelly
nodules) and multiple soft tissue cold abscess
(most in AIDS)
Tuberculous masitis: most in 20-50 y/o female
Extrapulmonary Tuberculosis
Cutaneous TB
Diagnosis and Treatment
Excisional biopsy for AFB
stain and culture
ELISA and PCR
Tx: chemotherapy (isoniazid is
first) and surgery (excisional
biopsy and debridement)
Extrapulmonary Tuberculosis
CNS TB
Pathogenesis and clinical presentation
Tuberculous meningitis (TBM)
May produce damage to vessels, infarction of
brain, edema, fibrosis
Predilection: base of brain
In AIDS: cerebral abscess or tuberculomas
Space-occupying sign: headache, seizure,
paralysis, personality change, CN defects, neck
stiffness, papilledema
Extrapulmonary Tuberculosis
CNS TB
Diagnosis and Treatment
CSF: clear or slightly opalescent; elevated protein
and low glucose (virus: high)
AFB and culture: limited
Meningeal biopsy: may contaminating
CT and MRI: helpful
Tx: chemotherapy, surgery and steroids
Extrapulmonary Tuberculosis
Miliary TB
Lympho-Hematogenous dissemination of
TB
Commonly affects the lungs, liver, spleen,
bone marrow, kidneys, and adrenals
Can occur at the time of primary infection
or reactivation
CXR – diffuse nodules <2 mm
PPD and sputum for AFB can be negative -
bone marrow or liver biopsy may be
helpful
Chemotherapy for 9-12 months (HIV at
least 12 months) or steroids (controversial,
prevent reactivation and infection)
Extrapulmonary Tuberculosis
Other
Otologic Tuberculosis
Ocular Tuberculosis
Cardiovascular Tuberculosis
Tuberculous Peritonitis
Tuberculous Enteritis
Tuberculosis of the liver and biliary tract