Extrapulmonary Tuberculosis

Ri 91-7-29

Tuberculosis
An ancient infection Tubercle bacillus discovered in 1882 WHO: 8,000,000 active cases in 1990 Developing countries (95%) Developed countries: HIV infection

Tuberculosis
Pathogenesis
Chronic necrotizing bacterial infection Tubercle bacilli: Mycobacterium tuberculosis (MTB) Optimal growth: PO2140mmHg Hematogenous dissemination and lymphatic spread Modified form of tuberculosis (AIDS)

Tuberculosis
Clinical stages
Stage 1: Onset (macrophage inhalation) Stage 2: Symbiosis Stage 3: Early caseous necrosis Stage 4a & 4b: Interplay of cell-mediated immunity and tissue-damaging delayed-type hypersensitivity Stage 5: Liquefaction and cavity formation

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)

Tuberculosis Lymphadenitis (1)

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

Tuberculosis Lymphadenitis (2)

Differential Diagnosis
Nontuberculous mycobacteria (young age, unilateral and normal CXR) Virus or fungus infection Neoplasm Tuberculin skin test, history and CXR Total excision biopsy and culture

Tuberculosis Lymphadenitis (3)

Treatment
Anti-tuberculous chemotherapy for 6 months course (1st line: pyrazinamide, isoniazid, rifampin, streptomycin) Surgical intervention (drainage and incision arent suggested)

Bone and joint Tuberculosis (1)

Potts 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

Bone and joint Tuberculosis (2)

Pathophysiology
Invasion of joint space: direct or indirect Cartilage preservation Cold abscess and sinus tract formation Fibrosis and ankylosis, calcification

Bone and joint Tuberculosis (3)

Clinical Presentation
Tuberculous spondylitis Tuberculous osteomyelitis Tuberculous arthritis Tuberculous tensynovitis Tuberculous myositis

Bone and joint Tuberculosis (4)

Tuberculous spondylitis
Most commonly, especially in developing countries Back pain and rigidity Vertebral body involvement and diskitis Kyphosis and paraplegia

Bone and joint Tuberculosis (5)

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

Bone and joint Tuberculosis (6)

Tuberculous arthritis
Large weight-bearing joint like hip, knee Painful, ankylosed or swollen monoarthropathy, limitation of motion Rice bodies, pannus, granulation, necrosis, narrowing of the joint space

Bone and joint Tuberculosis (7)

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

Bone and joint Tuberculosis (8)

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

Bone and joint Tuberculosis (9)

Treatment
Early diagnosis Anti-tuberculosis drugs with minimal operative intervention for abscess drainage (86% complete recovery) Operative decompression (laminectomy should be avoided) Arthroplasty

Genitourinary Tuberculosis (1)

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

Genitourinary Tuberculosis (2)

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

Genitourinary Tuberculosis (3)

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

Genitourinary Tuberculosis (4)

Treatment
Anti-tuberculous chemotherapy (effective) Surgery (>80%): nephrectomy, nephroureterectomy, epididymectomy and reconstructive surgery

Cutaneous Tuberculosis (1)

Uncommon (<1% in the west) but increase very rapidly in recent years May contagious spread Exogenous source: Tuberculous chancre and prosectors 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

Cutaneous Tuberculosis (2)

Diagnosis and Therapy
Excisional biopsy for AFB stain and culture ELISA and PCR Tx: chemotherapy (isoniazid is first) and surgery (excisional biopsy and debridement)

CNS Tuberculosis (1)

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

CNS Tuberculosis (2)

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

Miliary Tuberculosis
Lympho-hematogenous dissemination Infants and children: primary Elders or HIV infection: reactivation Fever, weakness, anorexia, Wt loss, cough Dx: CXR, HRCT Tx: Chemotherapy for 9-12 months (HIV at least 12 months) or steroids (controversial, prevent reactivation and infection)

Other EPTB
Otologic Tuberculosis Ocular Tuberculosis Cardiovascular Tuberculosis Tuberculous Peritonitis Tuberculous Enteritis Tuberculosis of the liver and biliary tract

HIV and EPTB

Immunosuppression increases infection and makes its symptoms become atypical TB: most cause of death in 24-44 y/o AIDS EPTB occur in 40-80% in HIV(+). Lymph node involvement is the most, but miliary, CNS or cutaneous TB are more than HIV(-) Prudent chemotherapy, TST for prevetion (if > 5mm, then INH chemoprophylaxis) Multipledrug-resistent TB

Molecular methods and EPTB

Detection: Nucleic acid amplication test (MTD test and AMT test), show high sensitivity (95-96%) in AFB(+) but low sensitivity (45-53%) in AFB(-) MTD2 test (sensitivity 100%, specificity 99.6%) Mycobacterium tuberculosis direct test Amplicor mycobacterium tuberculosis test

Thank you for your Attetion!

May Fortune be with You