This document discusses tuberculosis, including its clinical features, investigation, diagnosis, and types. It describes the signs and symptoms of primary, milliary, and post-primary tuberculosis. Diagnostic tests for tuberculosis include AFB microscopy, culture, GeneXpert MTB/RIF assay, drug susceptibility testing, Mantoux test, chest radiography, and CT scan. Extrapulmonary tuberculosis is diagnosed through culture or histopathological examination of tissues. Differential diagnoses for various tuberculosis presentations are also provided.

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