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CLINICAL OVERVIEW

Tuberculosis

Elsevier Point of Care (see details)

Updated September 13, 2018. Copyright Elsevier BV. All rights reserved.

Urgent Action

Report all suspected cases (while awaiting culture results) and confirmed cases of tuberculosis to local
and state health departments as required by law

Synopsis

Key Points

Tuberculosis is a transmissible bacterial infection usually caused by Mycobacterium tuberculosis.

Tuberculosis is classified as latent, primary progressive, and reactivated

Persons at higher risk for infection or at higher risk of progression to active disease if infected should be
screened for latent tuberculosis with a tuberculin skin test or interferon-γ release assay

In the primary or reactivation stages, patients may present with pulmonary involvement,
extrapulmonary involvement (more rarely), or both. Presentation depends on stage of disease and
underlying health of affected person

The diagnostic approach to active pulmonary tuberculosis includes 3 sequential sputum samples for
acid-fast bacilli smears, nucleic acid amplification testing, and sputum culture for Mycobacterium
tuberculosis

Drug-susceptible pulmonary tuberculosis is treated with a 6-month multidrug regimen, which includes
isoniazid, rifampin, ethambutol, and pyrazinamide

Multidrug-resistant tuberculosis infection is present when a strain is resistant to at least the first line
drugs isoniazid and rifampin
Extensively drug-resistant tuberculosis is present when strains are resistant to at least the first line drugs
of isoniazid and rifampin, a fluoroquinolone, and an aminoglycoside

Therapy for multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis requires second
line drugs to be continued for 18 to 24 months

Pitfalls

Reactivation tuberculosis may mimic community-acquired pneumonia and should always be considered,
at least initially, in the differential diagnosis

Patients with multidrug-resistant tuberculosis are at high risk for treatment failure and additional drug
resistance

When treatment failure is diagnosed, never add a single drug to a failed treatment regimen. Drugs
should always be added in groups of 2 or 3 to prevent further acquired resistance 1

Terminology

Clinical Clarification

Tuberculosis is a chronic, life-threatening, necrotizing granulomatous disease caused by Mycobacterium

tuberculosis, most commonly affecting lungs. May infect any organ in the body, but most common
extrapulmonary sites include lymph nodes, pleura, bones, and joints

Classification 2

Primary tuberculosis infection

Patient is usually asymptomatic

Bacterial replication occurs locally

Occult bacterial dissemination occurs until innate immunity stops the process (majority of cases)

Primary progressive tuberculosis occurs in a small percentage of cases within 2 years of infection
(occurring more frequently among patients at the extremes of age and among debilitated or
immunosuppressed patients)

Remainder of cases become latent tuberculosis infection (in immunocompetent persons)

Latent tuberculosis infection

After primary tuberculosis infection in a patient with intact immune system, most cases remain latent
and inactive

Patient is asymptomatic and noncontagious

tuberculosis; nonprimary tuberculosis)

Develops after latent tuberculosis infection in 5% to 10% (historically), but risk may be much greater in
high-risk groups 3

Reactivation tuberculosis is typically pulmonary and occurs more than 2 years after primary infection

Diagnosis

Clinical Presentation

History

Patients with latent tuberculous infection are asymptomatic but may have a history of exposure

Primary tuberculosis infection

Most commonly, patient is asymptomatic

Primary progressive tuberculosis

Usually presents as atypical pneumonia

Fever and chills

Pleuritic chest pain

Dyspnea

Nonproductive cough

Reactivation tuberculosis

Usually presents with insidious onset of pulmonary and constitutional symptoms

Fever

Night sweats

Weight loss

Productive cough with purulent or bloody sputum for longer than 3 weeks

Extrapulmonary tuberculosis (accounts for 15% of cases in immunocompetent patients, 50% to 70% of
cases in immunocompromised patients) 4

Tuberculous lymphadenitis (most common of the extrapulmonary presentations)

Often afebrile if occurring without pulmonary tuberculosis

Supraclavicular and posterior cervical painless adenopathy is most common presentation

Pleural tuberculosis (second most common of extrapulmonary presentations; occurs in 4% of patients

with tuberculosis) 4

Abrupt onset of symptoms

Fever

Pleuritic chest pain

Dyspnea due to pleural effusion

Miliary (widely disseminated hematogenous tuberculosis; seen in 1%-2% of all tuberculosis cases) 5

Fever

Night sweats

Weight loss

Usually no localizing symptoms

Tuberculosis meningitis

Fever lasting less than 2 weeks

Headache

Stiff neck

Confusion or somnolence