PULMONARY AND EXTRAPULMONARY TB

1. PULMONARY &EXTRAPULMONARY
TUBERCULOSIS
Prepared by AIME NSENGIYUMVA Doc III Student @
University of RWANDA

2. General Considerations
Mycobacterium tuberculosis is a multisystemic disease
with myriad presentations and manifestations,.
It is caused by M.tuberculosis
It was isolated by Robert Koch in 1882
It is confined to the lungs but may spread to
part of the body
The prevalence of drug-resistant TB is also increasing
worldwide

3. microbiology
the genus Mycobacterium
• M. tuberculosis complex
• M. Tuberculosis complex
consists of:
M. tuberculosis,
 M. bovis,
 M. africanum,
M. microti, M. canetti
M. tuberculosis
• rod-shaped,
• non-spore-forming,
• thin aerobic bacterium
• measuring 0.5 μm by 3 μm
• slow-growing
• facultative intracellular
parasite

4. Pulmonary tuberculosis
• Introduction
• Epidemiology
• Transmission and pathogenesis
• Risk factors
• Clinical presentation
• Investigations
• Diagnosis
• Treatment
• Drug resistance
• Take home message

5. Pulmonary tuberculosis
• The lungs are the most common site for the development of TB; 85%
of patients with TB present with pulmonary complaints.
• Extrapulmonary TB can occur as part of a primary or late, generalized
infection
common sites LN,BONE, BRAIN, PLEURA,PERITONEUM, …

6. Epidemiology
• GLOBAL BURDEN
 more than 2 billion people are estimated to be infected with TB
1.4 million people died from TB in 2019 including 208 000 people
with HIV
In 2019, 10 million people fell ill TB worldwide.
MDR-TB remains a public health crisis and a health security threat.

7. EPIDEMIOLOGY
• RWANDA
TB incidence rates in Rwanda (86 incident TB cases -new and relapse- per 100,000
habitants in Rwanda in 2012 it is decreasing since 2006
• 557 MDR cases were diagnosed between 2005 and 2012
CDC Country profile 2017
Incidence 57/10000
Mortality 4,9/100000
Treatment success 80% in 2016
TB patients known with HIV 22%

9. Transmission
• M. tuberculosis is carried in airborne
particles,
• called droplet nuclei,
• 1– 5 microns in diameter.
They are generated when persons
who have pulmonary or laryngeal TB
disease
cough, sneeze, shout, or sing
• M. tuberculosis is transmitted through
the air, not by surface
• can remain suspended in the air for
several hours,

10. Factors that Determine the Probability of
M.tuberculosis Transmission
• Infectiousness of the TB patient
• Environment in which the exposure occurred
• Frequency and duration of the exposure
• immune status of the exposed individual

11. Not everyone infected with TB bacteria becomes sick. As a result, two
TB-related conditions exist:

12. Pathophysiology
1. Droplet nuclei containing
tubercle bacilli are inhaled, enter the lungs,
and travel to the alveoli.
2. Tubercle bacilli multiply in
the alveoli

13. 3. A small number of tubercle
bacilli enter the bloodstream and
spread throughout the body
4. Within 2 to 8 weeks, macrophages
ingest and surround the tubercle bacilli
The cells form a barrier shell, called a
granuloma, that keeps the bacilli
contained and under control (LTBI)

14. Pathophysiology
• If the immune system cannot
keep the tubercle bacilli under
control, the bacilli begin to
multiply rapidly (TB disease).
• This process can occur
in different areas in the
body, such as
the lungs, kidneys, brain, or
bone

15. Diagnosis
Medical History
Symptoms of disease: cough ≥3 weeks, chest Pain hemoptysis
,Tachypnea, lymphadenopathy
Systemic sx; night sweats ,fever, weight loss, anorexia,
History of TB exposure, infection, Past TB treatment
Demographic risk factors for Tb
Medical conditions that increase risk for TB disease: HIV ,CRF,DM,
Alcoholics, Malnourished, Malignancy

16. Screening with TST (MANTOUX)
• A reaction of less than 5 mm is considered
negative
• 5-9 mm is considered positive (+)
• 10-19 mm is considered positive (++)
• more than 20 mm is considered positive
(+++)
• A positive tuberculin skin test indicates
tuberculous infection, with or without
disease

17. Imaging &Lab workup
• CXR : hilar/mediastinal LN, Infiltrate or consolidation ,Cavitations, nodules,
effusion, pleural effusion,
• A Tuberculin skin test (TST)
• acid-fast bacilli (AFB) smear: sputum, 3x, 8hrs apart ,1 in mrng
• nucleic acid amplification (NAA) testing
• FBC, HIV test, plasma Liver enzymes, urea and creatinine

18. Complications

19. EXTRAPULMONARY TB
TOPIC 2

20. TB LYMPHADENITIS
• Commonest extrapulmonary site
• Children & young adults
• Cervical LN involvement- commonest
• Firm discrete or matted lymph nodes
• Occasionally abscess or sinus
• Dx- FNAC or biopsy
• Rx 2RHZE + 4RH:6 months
• Surgery- NOT required

21. Pleural-Pericardial-Peritoneal TB
• Pleural TB causes pleural effusion
• Pericardial TB causes pericardial effusion
• Peritoneal TB causes ASCITES
• SYMPTOMS
• non-specific: fever, cough, chest pain, SOB, abdominal swelling
• Signs
• pleural effusion
• pericardial tamponade/constrictive pericarditis
• ascitis

22. Pleural-peritoneal-pericardial
• Ix: X-ray , EKG
• DX: Pleural-pericardio-paracentesis and send fluid for analysis, AFB
Smear,culture, Fluid ADA: increased
• abdominal ultrasound
• Cardiac ultrasound
Rx: 2HRZE + 4HR
• Steroids in pericardial TB

23. Fluid analysis
Tuberculous pleural effusion
• Color : straw colored
• cell count: lymphocyte
predominance
• Protein: >3.0 g/d
• Glucose: between 60-100 mg/dl
• pH <7.40
• (LDH): elevated
• (AFB) smear
• and culture
Ascitic fluid analysis
• straw-colored
• SAAG <1.1 g/dL
• leukocyte count of 150 to 4000
cells/mm3,
• with a relative lymphocytic
pleocytosis
• Protein >3.0 g/dl
• The cell count is 150 to 4000
cells,predominantly lymphocytes

24. CNS Tuberculosis
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
• Symptoms- headache, fever, seizures, altered sensorium, III/VII/VIII
nerve palsy
• Signs: Neck stiffness with Kernig’s/Brudzinski sign +ve

25. CNS Tuberculosis Diagnosis and Treatment
• CSF: clear or slightly opalescent; elevated protein and low glucose (virus:
high)
• AFB and culture: limited
• Meningeal biopsy
• CT and MRI: helpful
TUBERCULOMA
Thick ring-enhancing lesion ± cavitation on CT
• Tx: Tuberculosis Meningitis 2 (RHZe) / 10(RH)
• surgery

26. SKELETAL TB
• Pott’s spine-
• Lower thoracic/lumbar spine commonly involved
• May involve contiguous vertebrae with disc involvement
• Cold abscess is usually bilateral
• Can lead to vertebral collapse with spinal instability, gibbous deformity &
spinal cord compression
• Arthritis-
• Mostly monoarticular
• Hip joint most commonly involved
• Slowly progressive destruction of joint
• Osteomyelitis- cold abscess of any bone

27. SKELETAL TB
• Dx- X-ray, MRI, microscopy & culture of infected material
• Rx- ATT.
- osteo-articular TB: 2 (RHZe) / 10 (RH)
• Surgery-
• Diagnostic
• Abscess drainage
• Debridement of infected material
• Decompression & stabilization of spinal cord
• Follow-up- best clinically- pain, constitutional symptoms, mobility,
neurologic improvement

28. MILIARY TB
• Hematogenously disseminated
• More common in immunocompromised
• Symptoms- non-specific
• Sign- choroidal tubercle on retinal exam
• Dx- CxR- miliary tubercles
• Rx- standard ATT

29. MDR TB
• resistance to at least Rifampicin and Isoniazid confirmed by drug sensitivity test
(DST)
• causes
• Non adherence/poor compliance
• when is MDR to be suspected?
every failure of treatment despite a regular, correct and supervised treatment
 TB case diagnosed among the contacts of a know MDR-TB patient
 any re-treatment
Investigations: Sputum culture with sensitivity test Bronchoalveolar lavage
• Tx : 6(Km-Z-Lfx-Pto-Cs) 14(Km-Z-Lfx-Pto-Cs) duration: 20 months

30. Management
• First-treatment (adults from 15 years)
• 2 RHZE / 4 RH (total duration: 6 months)
• Indications: New cases.
•

31. • Retreatment
• 2 SRHZe / 1 RHZE / 5 RHE (total duration: 8 months)
• Indications: relapses, failures to first treatment, patients
who return to treatment after default, « other» cases
previously treated.

32. TYPE OF TB REGIMEN DURATION
PULMONARY TB 2 RHZE / 4 RH 6 Months
Retreatment 2 SRHZe / 1 RHZE / 5 RHE 8Months
TB MENINGITIS 2 (RHZe) / 10(RH) 12months
osteo-articular TB 2 (RHZe) / 10(RH) 12 Months
Pleural & peritoneal 2 RHZE / 4 RH 6 Months
Tb adenitis 2RHZE/4RH 6Months
MDR TB 6(Km-Z-Lfx-Pto-Cs)
14(Km-Z-Lfx-Pto-Cs)
20 MONTHS

33. Clinical monitoring
• Clinical monitoring — Patient education regarding symptoms of
hepatitis and other possible drug toxicities
• Patients should be instructed to report signs or symptoms of toxicity
• During treatment of pulmonary tuberculosis, sputum should be
obtained for AFB smear and culture at monthly intervals until two
consecutive cultures are negative
• Completion of therapy — Completion of the duration of therapy and
the total number of doses administered
• Interrupted therapy — In some cases, the specified number of doses
cannot be administered within the targeted time period

34. TAKE HOME MESSAGE
• TB IS A GLOBAL BURDEN
• IT PRESENTS IN DIFFERENT PATTERNS DEPENDING TO AFFECTED
SYSTEM
• SUSPICION IS A KEY TO DIAGNOSIS AND MANAGEMENT
• PATIENT EDUCATION IS A KEY O SUCCESSFUL TREATMENT
• PREVENTION IS POSSIBLE
• TB RESISTANCE IS A GLOBAL THREAT THAT NEEDS TO BE PREVENTED

35. References
• Uptodate
• Medscape
• WWW.CDC.GOV /COUNTRY PROFILE
• WHO Guidelines on tuberculosis 2019
• Handbook of TB, HIV-TB in Rwanda (RBC)
• HARRISON’S PRINCIPLE OF INTERNAL MEDICINE 19TH EDITION
• World Health Organization. Global Tuberculosis Report 2017. Available at:
http://www.who.int/tb/publications/global_report/en/ (Accessed on November 03, 2017).
• Tuli SM. Tuberculosis of the Skeletal System, Jaypee Brothers Medical Publishers, New Delhi
2016.
• Centers for Disease Control and Prevention. Regional Training and Medical Consultation
Centers (RTMCCs). Available at: http://www.cdc.gov/tb/education/rtmc/default.htm
(Accessed on May 21, 2010).
• Internal medicine guidelines 2012(RBC)