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1. TUBERCULOSIS
CLINICAL FEATURES
INVESTIGATION AND DIAGNOSIS
ROSHAN JHA
MBBS 8TH BATCH

2. TUBERCULOSIS TYPES
1. PRIMARY
2. POST PRIMARY
3. MILLIARY
4. EXTRA PULMONARY

3. 1. PRIMARY TUBERCULOSIS
 Mostly asymptomatic
 Brief febrile illness in some
 Occasional pleuritic chest pain
 Hypersensitivity manifestation
erythema nodosum
phylentectacular conjunctivitis

4. Signs (Primary TB)
 No detectable sign in most cases
 If host response is
Loss of appetite
Weight loss
Cough (unsusual)
Wheeze
Crepitations (occasional)

5. RADIOLOGY (primary TB)
LYMPHADENOPATHY (CHILDREN)
-hilar, paratracheal
PARENCHYMAL LESION
-consolidation, ghons focus
PLEURAL EFFUSION
-in 30-40% of cases

6. .
Differential Diagnosis
1. TB
2. Hamartoma
3. Malignancy
4. Hyadatid cyst

8. .
Differential
diagnosis of hilar
lymphadenopathy
1.TB
2.Sarcoidosis
3.Bronchial
carcinoma
4.Lymphoma
5.Metastases

9. .

10. DIAGNOSIS (primary TB)
CLINICAL FEATURES (NOT SPECIFIC)
TUBERCULIN TEST
RADIOLOGY
AFB micriscopy
If diagnosis is in doubt,
Trial of 2 weeks of NONTUBERCULAR THERAPY

11. 2. MILLIARY TUBERCULOSIS
a) Acute/classical
• Infants, young children
• Acute /subacute febrile
illness
• Malaise, anorexia,wt loss
SIGNS
• Crepitations in later stage
• Choroidal tubercles in
90%
• Enlarged spleen
b) Cryptic/disseminated
• Elderly
• Fever of unknown origin
• Malaise
• Insidious onset of wt loss
• Tuberculin –ve
• Choroidal tubercles absent

12. RADIOLOGY (Milliary TB)
 Chest x-ray
May be normal
Faint, evenly distributed shadows,1-2 mm
scattered to both lung fields
Bilateral pleural effusion may occur
 Radiological signs clear after treatment
 Residual calcification may be there

13. DD of Miliary mottling
1.TB
2.Histoplasmosis
3.Sarcoidosis
4.Pneumoconiosis
5.Chicken pox

14. 3. POST PRIMARY TUBERCULOSIS
 Clinical features
- Gradual onset
- over weeks or months

15. General symptoms (Postprimary TB)
i. Loss of appetite
ii. Weakness, tiredness, malaise
iii. Febrile symptoms & night sweats
(advanced cases)
iv. Cough
v. Chest pain

16. General symptoms – Cough
 ~90%
 Initially non-productive
 Sputum- mucoid/purulrnt/blood stained
 Haemoptysis- 20-30%
◦ Most commonly due to rupture of bronchial
artery
 Chest radiography should be done for any
cough > 2 weeks

17. .
 Chronic cough with hemoptysis
1.Tuberculosis
2. Bronchiectasis
3. lung ca.
4. Cardiovascular causes

18. General symptoms – Chest pain
 Dull aching
 Tightness
 Pleuritic pain

19. Other Postprimary TB symptoms
 Breathlessness in extensive cases
 Recurrent colds
 Amenorrhea in severe tuberculosis

20. PHYSICAL SIGNS (Postprimary TB)
 May not be present
 Pallor
 Clubbing (unusual)
 Rhonchi (occasional due to partial obstruction)
 Amorphic breath sounds – in areas with large
cavities

21. SYSTEMIC (Postprimary TB)
 Fever (80% )
-low grade
-Intermittent
-Evening rise of temperature

22. HAEMATOLOGICAL SIGNS
(Postprimary TB)
 Mild anemia
 Leukocytosis
 Thrombocytopenia
 Increased ESR & CRP

24. INVESTIGATIONS
(Postprimary TB)
 AFB microscopy
◦ Presumptive diagnosis
◦ sample- sputum, tissue
◦ 2 or 3 morning sputum samples preferred

25. ZN STAINING (Procedure)
i. Take air dried smear & heat fix it.
ii. Put carbol fuschin, heat the soln till vapour seen
iii. After12-15sec wash it with running tap water
iv. Put 25% sulphuric acid & wait for 4-8 sec
v. Wash under running tap water
vi. Pour counter stain
vii. Wash and dry. Put immersion oil, focus.
viii. Bacilli appears RED on blue background

26. FLUORESCENT STAINING
- Auramine rhodamine staining

27. CULTURE
Definitive diagnosis
 LJ medium
- takes 4 to 6 weeks to appear
 Liquid media (like radioactive BACTEC)
- Faster growth (1-3 weeks)

28. GENE XPERT MTB/RIF ASSAY
 Is a nucleic acid amplification test.
 Can rapidly diagnose
◦ Mycobacterium TB complex
◦ resistance to Rifampicin.
 Gives result in less than 2 hours
 To diagnose MDR-TB & HIV associated TB

29.  for Isoniazide and Rifampicin
to detect MDR-TB
if MDR-TB positive
Test for 2nd line anti TB drugs
DRUG SUSCEPTIBILITY TEST

30. DRUG SENSITIVITY
 Particularly important in
Previous history of TB
Treatment failure
From areas of high resistance
HIV +ve

31. MANTOUX TEST
 0.1ml of PPD injected in flexor surface of
forearm
 Site of injection examined after 48-72 hrs
for zone of induration
<6mm = negative
6-10 mm = doubtful
>10mm = positive

32.  False positive
i. Previous BCG vaccination
ii. Infection with non-tuberculous mycobacteria
 False negative
i. Technical flaws
ii. Severe TB
iii. HIV, immunosupressive drugs
iv. Diabetes
v. Sarcoidosis
vi. Extremes of age

33. RADIOLOGY
TB may present with
 Classically, upper lobe disease with
-Infiltrates
-Cavities
BUT,
- any radiological pattern
- from normal or solitary pulmonary nodule
to diffuse alveolar infiltrate

34. DD of Cavity in Lung
1.Tuberculosis
2.Neoplasm
3.Infarct
4.Wegener’s disease
5.Abcsess

35. CT SCAN
 To interpret questionable findings on X-ray
 Helps in evaluating parenchymal
involvement,bronchogenic spread of
infection,cavitation
 To diagnose extrapulmonary tuberculosis

36. .If Radiography is confused with
Broncogenic Carcinoma
- FIBEROPTIC BRONCHOSCOPY
- with bronchial brushing
- & endobronchial/transbronchial biopsy of
lesion

37. OTHER METHODS
Nucleic acid amplification test
ADA in pleural fluid
INF-Y in pleural fluid
MPB64 skin patch test
- detects active but not latent TB

38. DIAGNOSIS (extrapulmonary TB)
- By culture
- By histopathological examination of
tissues