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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

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