Tuberculosis: Pathophysiology,
Clinical Features, and
Diagnosis
Nancy A. Knechel, RN, MSN, ACNP
T
uberculosis has recently tries with high prevalence, and the
reemerged as a major growing numbers of the homeless
health concern. Each and drug abusers.3 With 2 billion
year, approximately 2 persons, a third of the world popu-
million persons world- lation,1 estimated to be infected
wide die of tuberculosis and 9 mil- with mycobacteria, all nurses, regard-
lion become infected.1 In the United less of area of care, need to under-
States, approximately 14000 cases stand the pathophysiology, clinical
PRIME POINTS
of tuberculosis were reported in 2006, features, and procedures for diagno-
a 3.2% decline from the previous sis of tuberculosis. The vulnerability
• The vulnerability of year; however, 20 states and the of hospitalized patients to tubercu-
hospitalized patients to District of Columbia had higher losis is often underrecognized because
tuberculosis is often rates.2 The prevalence of tuberculo- the infection is habitually considered
underrecognized because sis is continuing to increase because a disease of the community. Most
the infection is habitually of the increased number of patients hospitalized patients are in a subop-
considered a disease of the infected with human immunodefi- timal immune state, particularly in
community. ciency virus, bacterial resistance to intensive care units, making exposure
medications, increased international to tuberculosis even more serious
• Read the article to find travel and immigration from coun- than in the community. By under-
out how to obtain a defin-
standing the causative organism,
itive diagnosis of tubercu- pathophysiology, transmission, and
losis. CEContinuing Education diagnostics of tuberculosis and the
This article has been designated for CE credit.
• Learn about tuberculosis A closed-book, multiple-choice examination fol-
clinical manifestations in patients,
test like the QuantiFERON- lows this article, which tests your knowledge of critical care nurses will be better
the following objectives:
TB Gold test and how it is prepared to recognize infection,
1. Identify 3 reasons why the prevalence of
being used. tuberculosis is continuing to increase prevent transmission, and treat this
2. List at least 2 diagnostic tests for tuberculosis increasingly common disease.
• Nurses should advocate 3. Describe 2 medically challenging physiological
characteristics of tuberculosis caused by the
for prompt isolation of lipid barrier of mycobacteria. Causative Organism
patients with suspected or ©2009 American Association of Critical- Tuberculosis is an infection
confirmed tuberculosis. Care Nurses doi: 10.4037/ccn2009968 caused by the rod-shaped,
status of the patient’s immune sys- Although coinfection with human results of diagnostic tests (Table 2)
tem. Stages include latency, primary immunodeficiency virus is the most are the only evidence of the disease.
disease, primary progressive disease, notable cause for progression to Although primary disease essentially
and extrapulmonary disease. Each active disease, other factors, such exists subclinically, some self-limiting
stage has different clinical manifes- as uncontrolled diabetes mellitus, findings might be noticed in an
tations (Table 1). sepsis, renal failure, malnutrition, assessment. Associated paratracheal
smoking, chemotherapy, organ lymphadenopathy may occur because
Latent Tuberculosis transplantation, and long-term cor- the bacilli spread from the lungs
Mycobacterium tuberculosis ticosteroid usage, that can trigger through the lymphatic system. If
organisms can be enclosed, as previ- reactivation of a remote infection the primary lesion enlarges, pleural
ously described, but are difficult to are more common in the critical effusion is a distinguishing finding.
completely eliminate.15 Persons with care setting.8,19 Additionally, persons This effusion develops because the
latent tuberculosis have no signs or 65 years or older have a dispropor- bacilli infiltrate the pleural space
symptoms of the disease, do not feel tionately higher rate of disease than from an adjacent area. The effusion
sick, and are not infectious.19 How- any does other age group,20 often may remain small and resolve spon-
ever, viable bacilli can persist in the because of diminishing immunity taneously, or it may become large
necrotic material for years or even a and reactivation of disease.21 enough to induce symptoms such
lifetime,9 and if the immune system as fever, pleuritic chest pain, and
later becomes compromised, as it Primary Disease dyspnea. Dyspnea is due to poor
does in many critically ill patients, Primary pulmonary tuberculosis gas exchange in the areas of affected
the disease can be reactivated. is often asymptomatic, so that the lung tissue. Dullness to percussion
DNA and RNA, facilitating rapid the infection becomes latent, spu- malnourished, because these patients
detection of microorganisms; the tum specimens are negative for the cannot mount an immune response
tests have been approved by the organisms, and findings on chest to the injection, and in 20% to 25%
Food and Drug Administration.32 radiographs are typically normal. of patients who have active tubercu-
One method is the polymerase These patients also do not have losis, because there is a time lag of
chain reaction assay, which can be signs or symptoms of infection, and 2 to 10 weeks between infection and
used to differentiate M tuberculosis they are not infectious to others. the T-lymphocyte response required
from other mycobacteria on the Tuberculin skin testing is the most for a positive skin reaction. False-
basis of genetic information and common method used to screen for positives can occur in patients who
provides results within hours. latent M tuberculosis.3 have infections caused by mycobac-
Although the test can provide rapid The tuberculin skin test is per- teria other than M tuberculosis or
confirmation of M tuberculosis in formed by intradermally injecting who have been given BCG vaccine.35
sputum specimens positive for acid- 0.1 mL of intermediate-strength The tuberculin skin test was
fast bacilli, it has limitations, includ- purified protein derivative (PPD) that the only test available to detect latent
ing high cost, low sensitivity, and contains 5 tuberculin units. After 48 tuberculosis until an interferon-
low availability. A polymerase chain to 72 hours, the injection site is exam- release assay, called QuantiFERON-TB
reaction assay positive for M tuber- ined for induration but not redness test, was approved by the Food and
culosis in conjunction with a sputum (Figure 3, Table 3). Although the Drug Administration in 2001. Then,
smear positive for the organism test is useful because the PPD elicits in 2005, a new interferon-assay,
indicates true tuberculosis, but in a a skin reaction via cell-mediated called QuantiFERON-TB Gold was
patient with a sputum smear nega- immunity when injected in patients approved and is intended to replace
tive for the organism, the positive previously infected with mycobacte- the QuantiFERON-TB test, which is
polymerase chain reaction assay ria, it is limited because it is not spe- no longer commercially available. In
should be considered carefully cific for the species of mycobacteria. both tests, the cell-mediated reactiv-
along with clinical indicators. The Many proteins in the PPD product ity to M tuberculosis is determined
results of these assays can not be are highly conserved in various by incubating whole blood with an
relied on as the sole guide for isola- species of mycobacteria. Also, the antigen and then using an enzyme-
tion or therapy.33 test is of limited value in patients linked immunosorbent assay to
with active tuberculosis because of measure the amount of interferon-γ
Diagnosing Latency its low sensitivity and specificity. released from white blood cells. In
Once patients recover from a False-negatives can occur in patients the QuantiFERON-TB Gold test, 2
primary M tuberculosis infection and who are immunocompromised or synthetic antigenic proteins specific
•
Also, because functional recovery recommendations would be an
often lags behind microbiological appropriate action for nurses. d tmore
cure, the aim of nutritional inter- To read more about tuberculosis, read “The
vention should be to restore lean Emotional Support and Education Pursuit of Healthcare” by Christopher W.
Bryan-Brown and Kathleen Dracup in the
tissue.23,39 Nurses should also encour- In addition to the direct respon- American Journal of Critical Care, 2004;13:
age patients to engage in physical sibilities of nursing, many nurses 368-370. Available at www.ajcconline.org.
1. How many people worldwide become infected with tubercu- 7. After being ingested by macrophages, the myocobacteria continue to
losis each year? multiply slowly with bacteria cell division occurring how often?
a. 2 million c. 14 million a. Every 20 to 32 hours c. Every 25 to 32 hours
b. 9 million d. 20 million b. Every 25 to 30 hours d. Every 20 to 30 hours
2. How many people in the world are estimated to be infected 8.The initial immune process continues for how long?
with mycobacteria? a. 2 to 10 weeks c. 2 to 12 weeks
a. 9 billion c. 20 billion b. 4 to 12 weeks d. 4 to 10 weeks
b. 14 billion d. 2 billion
9. Which of the following is the necrotic environment that is character-
3. What makes an intensive care unit patient’s tuberculosis ized by low oxygen levels, low ph, and limited nutrients?
exposure more serious than community exposure? a. Caseous necrosis
a. A suboptimal immune state b.Frontal necrosis
b. Mycobacteria infection c. Immune necrosis
c. Resistant bacteria infection d.Fibrotic necrosis
d. Advanced pneumonia
10. What age group has a disproportionately higher rate of disease
4. Tuberculosis is an infection caused by what rod shaped, than any other age group?
non–spore-forming aerobic bacterium? a. 50 years and older
a. Aspergillius b. 35 years and older
b. Mycobacterium c. 40 years and older
c. Enterococcus d. 65 year and older
d. Streptococcus
11. Why are the results of primary pulmonary tuberculosis diagnostic
5. Which of the following is a challenge created by the lipid bar- test often the only evidence of disease?
rier of Mycobacterium tuberculosis? a. Because primary tuberculosis is not diagnosed
a. Resistance to antibiotics b.Because primary tuberculosis is misdiagnosed
b. Immune response c. Because primary tuberculosis exists subclinically
c. Physical defense d.Because primary tuberculosis is asymptomatic
d. Misdiagnosis
12. Upon diagnosing an abnormal chest radiograph, the first laboratory
6. M tuberculosis is spread by which of the following? test used to detect tuberculosis will examine which of the following?
a. Skin contact with bacterium a. Sputum smear for acid-fast bacilli
b. Ingestion of bacteria b.Bronchoscopy findings
c. Airborne droplets c. Purified protein derivative test
d. Infection by blood stream d.Sputum culture
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