Management of EPTB

1. MANAGEMENT OF EXTRA-PULMONARY
TUBERCULOSIS(EPTB)
1
Dr Ravi Kumar Sharma
(Assistant Professor)
Dept. of Respiratory Medicine
GMC Haldwani, Uttarakhand

2. OVERVIEW
• Types of EPTB
• Discussion one by one
• Clinical Presentation
• Workup
• ‘6 R’ in TB Care
• Management
• QnA
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3. Types of EPTB
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4. TB LYMPHADENITIS
When to suspect/presentation
Swelling (>1 cm) in neck, armpit or
groin (>2 cm) +/- redness,
fluctuation, sinus
discharge
• May or may not be associated
with fever, weight loss, night
sweats or cough
• History of similar swelling in the
past / past history of tuberculosis
• History of contact
Diagnostic Confirmation/Workup
Routine Blood work
LN Sampling
FNAC
Cytology
CBNAAT
Treatment
6 month
standard ATT
2 HRZE + 4 HRE
Steroid( Oral /IV)
NO
Remarks
Some patients with LNTB have residual
lymphadenopathy at the end of treatment,
>1 cm in size:
• Partial responders (clinical features have
persisted or reappeared): additional 3
months of HRE, followed by a biopsy sent for
histology and TB culture.
• Residual fibrotic LN(clinical features have
resolved): ATT need not be extended.
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5. PLEURAL TUBERCULOSIS
When to
suspect/presentation
Cough > 2wk
chest pain
SOB
Constitutional symptoms
Diagnostic
Confirmation/Workup
Routine Blood work
Chest X Ray
Diagnostic Pleural fluid
Analysis
Treatment
6-month standard ATT
2 HRZE + 4 HRE
Steroid( Oral /IV)
NO
Remarks
Follow-up CXR is
recommended 2 month
after starting treatment
to assess progress.
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6. PERICARDIAL TUBERCULOSIS
When to
suspect/presentation
• Chest discomfort,
shortness of breath,
orthopnoea
• Features of CHF
• Ascites out of proportion
to minimal or absent
pedal edema
• Tamponade –
hypotension, tachycardia,
raised JVP
• Constitutional symptoms
Diagnostic
Confirmation/Workup
Routine Blood work
Chest X Ray
pericardiocentasis and
Pericardial Fluid Analysis
Treatment
6 month
standard ATT
2 HRZE + 4 HRE
Steroid( Oral /IV)
YES
Prednisone in a dose of 1mg/kg for 4
weeks followed by 0.5mg/kg for 4 weeks
and tapers gradually over next two to four
weeks.
Total Duration; 3 months
Remarks
corticosteroids
indicated
6
water bottle Heart

7. CENTRAL NERVOUS SYSTEM TUBERCULOSIS
When to suspect/presentation
Fever
(Duration of 5 days or more )
• Headache & Vomiting
• Altered sensorium
• Cranial nerve palsy
• Hemiparesis/any limb weakness
• Seizures
• Neck pain and stiff ness
Constitutional symptoms
• Active TB elsewhere
• Past history of TB & ATT
• Contact with TB patient
• HIV +ve
• Low socio-economic status
• High endemic area
Diagnostic Confirmation/Workup
Routine Blood work
• Chest X-Ray- PA view
• USG whole abdomen
• Mantoux (optional)
• NCCT/CECT head- Preferred as
initial investigation
• MRI brain (OPTIONAL)
• LP-CSF( Mandatory)- Analysis
Prudent to perform CT head
before CSF in the presence of
papilledema & /or
focal deficits
Treatment
12 month, can be extended to 18 month
2HRZE/S +10 HRE
2 HRZS +10 HRZ
( This recommendation is sent to NTEP )
Steroid( Oral /IV)
Yes
dose of 0.4mg/Kg
(dexamethasone),
to be tapered over
6-8 weeks.
Remarks
Surgical intervention
may be needed in case
of Hydrocephalus
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8. ABDOMINAL TUBERCULOSIS
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9. ABDOMINAL TUBERCULOSIS
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10. ABDOMINAL TUBERCULOSIS
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11. MUSCULOSKELETAL TUBERCULOSIS
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12. MUSCULOSKELETAL TUBERCULOSIS
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13. MUSCULOSKELETAL TUBERCULOSIS
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14. CUTANEOUS TUBERCULOSIS
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15. CUTANEOUS TUBERCULOSIS
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16. CUTANEOUS TUBERCULOSIS
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17. CUTANEOUS TUBERCULOSIS
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18. CUTANEOUS TUBERCULOSIS
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19. OCULAR TUBERCULOSIS
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20. OCULAR TUBERCULOSIS
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21. OCULAR TUBERCULOSIS
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22. OCULAR TUBERCULOSIS
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23. KEY POINTS
• The common forms are laryngeal, sinonasal,
oropharyngeal, para/ retropharyngeal TB,
salivary gland TB, thyroid gland TB, TB otitis
media and TB mastoiditis.
• Laryngeal TB is highly infectious and needs
appropriate precautions.
• Tissue sampling is key to diagnosis.
• ATT regimen is similar to other forms of EPTB
given for a total duration of 6-12 months.
• Longer duration preferred in cases of bony
involvement
Laryngeal TB
History:
• Hoarseness is the most common symptom.
chronic productive cough,
• dysphagia/odynophagia
• stridor.
Examination:
Indirect laryngoscopy/fiberoptic laryngoscopy
shows diffuse erythema/oedema,
granulomatous/polypoidal/exophytic/ulcerative
lesions of the vocal cords,
Moth-eaten appearance of VC
Pale granulations.
The most important differential diagnosis of
laryngeal TB is carcinoma larynx, which can only
be differentiated by histopathology.
Otorhinolaryngeal (ENT)
Tuberculosis

24. TB otitis media/mastoiditis:
• very rare presentation of EPTB.
• It is commonly misdiagnosed even by experienced
practitioners.
• Patients may give a history of successful treatment
attempts, including surgery (mastoidectomy).
• Half of the cases have no other evidence of present
or past TB.
• It mimics chronic suppurative otitis media.
History:
1. Painless chronic ear discharge
(despite antibiotics use)
2. Early severe hearing loss
Complications:
1. Facial nerve palsy,
2. Mastoid bone necrosis
Examination by otoscopy:
1. Multiple tympanic membrane perforations is
characteristic
2. Exuberant, pale granulation tissue may be seen
Sinonasal TB
History:
May simulate Granulomatosis with
Polyangiitis.
History of persistent nasal discharge
(despite antibiotics use),
nasal obstruction
epistaxis and
headache.
Examination: Abundant polypoid or
avascular pale granulation tissue will be
seen
Oropharyngeal TB:
History:
dysphagia,
odynophagia,
dyspnea and/or drooling of
saliva.
Examination:
significant edema of the
oropharyngeal region (palate
and uvula) which may extend
to epiglottis (“Turban
epiglottitis)
Deep Neck Cold Abscess:
• It may be retropharyngeal or parapharyngeal abscess.
• Most cases are bacterial –
• Tuberculous abscesses are rare, chronic, and
• secondary to TB of the cervical spine, petrous apex or the lung.
Otorhinolaryngeal (ENT)
Tuberculosis

25. Diagnostic Algorithm
• ATT regimen: total duration
of 6-12 months.
• Longer duration in cases of
bony involvement
Otorhinolaryngeal
(ENT) Tuberculosis

26. FEMALE GENITAL TUBERCULOSIS
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27. DIAGNOSIS OF FEMALE GENITAL TB
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28. DIAGNOSIS OF FEMALE GENITAL TB
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29. DIAGNOSIS OF FEMALE GENITAL TB
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30. FEMALE GENITAL TB
(STEPWISE DECISION)
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31. FEMALE GENITAL TB
(STEPWISE DECISION)
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32. DIAGNOSTIC ALGORITHM FOR FEMALE
GENITAL TUBERCULOSIS
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33. DRUG SENSITIVE-TB TREATMENT AS PER
NTEP
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34. BASIC ‘6R’ RULE FOR TB TREATMENT
1. Right Diagnosis
2. Right Drugs; (ATT regimen as per NTEP )
3. Right Dosages;( As per weight of Pts)
4. Right Time; ( All drugs on fix time, No dose splitting)
5. Right Duration; 6,9,12 months as prescribed, regular intake
6. Register and report all cases to NTEP; MANDATORY
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35. AKT 4 VS AKURIT 4
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4 FDC (Four drugs- H R Z E are combined
in a single pill)

36. TREATMENT DURATION OF ATT IN EPTB
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37. To conclude..
• TB is a MAJOR health problem in our
country
• Early diagnosis and effective ATT are THE
keys to eliminating disease
• Remember the 6R rule in TB care
• NO irrational, ineffective, or substandard
ATT
• Adherence to NTEP guidance for an
effective outcome
• Mandatory Notifications of all TB cases
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38. Refer to full document for more reading on the topic;
1. https://tbcindia.gov.in/showfile.php?lid=3681
2. https://main.icmr.nic.in/sites/default/files/upload_documents/I
CMR_STW_PTB_EPTB.pdf
3. https://tbcindia.gov.in/WriteReadData/l892s/5585665076Index
-TB%20Guidelines.pdf
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