TB diagnosis and Treatment

Diagnosis Active TB

Initial test should be a chest Xray (as with all respiratory

infections)
o Upper lobe infiltrates with cavitation
o Pleural effusions
Sputum Acid Fast Bacilli smear and culture for mycobacteria
must be done THREE times to EXCLUDE TB
o Sputum early morning 3 consecutive days
Stain with ziehl Neelsen
Auramine-rhodamine fluorescent stain
o Cultures take 4-8 weeks, slow growing
PCR
Pleural biopsy is the most accurate diagnostic test

Diagnosis Latent TB
o Test based on cell-mediated immunity TH1 cells. A protein
derivative is injected and look for INDURATION 48-72 h later
o Dont look at erythema
o May have allergic reaction to PPD within hours with
wheal and flare reaction and NO INDURATION
Done on people who are at risk
o HIV
o Annually for healthcare workers
If Positive PPD do chest Xray to get baseline (dont
repeat PPD)
o If people exposed to sick then do a second PPD test 8-12
weeks after
o ALWAYS DO BEFORE TNF-alpha inhibitors (Chrons, UC
etc)
Mantoux tuberculin skin test with Purified protein derivative
(PPD)
o If first PPD do twice because false negatives high
15 mm
Those with no risk factors
10mm
Recent immigrant
Prisoner
Healthcare worker
Nursing home residents
Close contact with TB
Alcoholic, diabetes, hematologic malignancy
5mm
HIV +

Steroid user
Close contact someone with ACTIVE TB
Abnormal chest xray
Organ transplant recipient
Sarcoidosis (wont have a reaction because TH1 cells are
sequestered)
o False Positive if BCG and nontuberculous mycobacteria
o False Negative: HIV, immunodeficient people
o Positive chest xray sputum AF stain and culture +
treatment + HIV testing
Conversion
Negative PPD 5mm after exposure 8 weeks MEANS EXPOSED
Booster Response
Had a negative PPD positive on a second PPD
WITHOUT EXPOSURE
Due to BCG or nontuberculous mycobacteria
IGRA interferon-gamma release assay with antigen specific for TB
screen for latent TB
o Higher specificity
o Limited in immunosuppressed patients
o Advantage is that it does not cross react with BCG vaccine

Treatment Active TB
Use Directly observed therapy (DOT)
RIPE (Rifampin, INH, Pyrazinamide, Ethambutol)
o 2 months 4 drugs(RIPE), 4 months 2 drugs (RI)
o can stop ethambutol the susceptibility is known
o Continuation phase: Extend treatment (INH and rifampin)
to 9 months for
Cavitary TB+ positive sputum after two months
treatment
osteomyelitis
military TB
meningitis (12 month + corticosteroids)
Pregnancy , other reasons Pyrazinamide was not
used
Advantages of different medications
o Pyrazinamide active against bacilli residing in macrophages
Obtain monthly smears and chest xrays
Other drugs
o Aminoglycosides
Streptomycin (ototoxicity, nephrotoxicity)

 Amikacin (ototoxicity, nephrotoxicity)

o Quinolones (GI upset, tendinopathy, increase QT
prolongation)
Side effects of medication
o INH, Rifampin, and Pyrazinamide
Stop meds when TRANSAMINASES
1. Symptomatic and 3X the upper limit of normal
2. Asymptomatic and 5X the UPPER limit of normal
o If hepatotoxicity STOP MEDS
#1 get expert consultation
aminoglycoside + EMB and a fluoroquinolone
(levofloxacin and moxifloxacin)
DO FOR 18-24 MONTHS IF JUST THIS
when transaminases drop to normal restart meds one
at a time starting with RIFAMPIN INH
dont add Pyrazinamide if start rising

o Before starting medication want baseline levels of

Liver function, bilirubin, alkaline phosphatase
Hep B and C
CBC
Serum creatnine
Uric acid levels
Vision acuity and red-green color discrimination
o Steroids decrease risk of constrictive pericarditis
and neurological complication of meningitis
o Treatment in HIV patients: same but use Rifabutin, less
cytochrome interactions
o Pregnant women treat with INH, rifampin, and
ethambutol
-avoid pyrazinamide and streptomycin

Treatment latent TB

Positive PPD or IGRA chest xray rule out active TB

o 9 months INH 300mg + B6 (pyridoxine) 25mg
o decreases risk of reactivation by 90% (10% to 1%)
o risk of INH induced hepatitis increases with age so need to
weigh benefits vs harm
Others
o if INH resistant use Rifampin 4 months
o daily INH and rifampin 3 months
o floroquinolone for 12 months if MDR TB

Prophylaxis for those close to TB patients

Rifampin

TB transmission and control

Only pulmonary TB is contagious via respiratory droplets

Need to be placed in a negative pressure room/ airborne
infection isolation room and wear a surgical mask
Visitors need a N95 mask or PAPR (powered air-purifying
respirator)
This is reportable to the local health department
Can be released once THREE negative acid fast bacilli
sputum smear results identified + need a chest
radiograph for future comparisons