This document discusses the clinical presentation and diagnosis of tuberculosis (TB). It presents 3 case studies and discusses the typical symptoms, risk factors, and diagnostic approach for TB. Key points include: 1) TB most commonly presents with nonspecific symptoms like fever, night sweats, and weight loss; 2) diagnostic approach involves sputum smear, culture, chest x-ray and consideration of risk factors; 3) delay in diagnosis can increase transmission and disease severity.

1. ‫الرحيم‬ ‫الرحمن‬ ‫ال‬ ‫بسم‬

2. Clinical Presentation of
Tuberculosis
Dr. Ramadan Fouad Arafa
MBBCh, MSc, MRCP
Physician, Fujairah Hospital

4. Introduction
• TB is one of the world’s deadliest diseases
• 1/3 of the world’s population is infected with TB.
• In 2011, nearly 9 million people around the world
became sick with TB disease. There were around
1.4 million TB-related deaths worldwide.
• Over 95% of TB deaths occur in low- and middle-
income countries, and it is among the top three
causes of death for women aged 15 to 44.

5. • TB is a leading killer of HIV infected people.
• A total of 9,945 TB cases (a rate of 3.2 cases per
100,000 persons) were reported in US in 2012.
• The TB death rate dropped 41% between 1990
and 2011.
• An estimated 20 million lives saved through use
of DOTS and the Stop TB Strategy recommended
by WHO.

6. • Early diagnosis and prompt effective therapy form
the key elements of the TB control programme.
• Delay in diagnosis results in increased infectivity
in the community and it is estimated that an
untreated smear-positive patient can infect 20
contacts before being diagnosed.

7. Situation in UAE 2011
New cases No. % Retreatment No. %
Smear-positive 46 45 Relapse 0 0
Smear-negative 25 24 Treatment after
failure
0 0
Smear not done 2 2 Treatment after
default
3 100
Extrapulmonary 30 29
Total treatment 103 Total retreatment 3 100
Total new and
relapse
103 Total cases
notified
106

8. Factors affecting transmission of TB
1. Degree of infectiousness of the case:
a. Smear positive sputum:
Pts with cavitatory lesions are more infectious
TB with HIV is less infectious
20 cases may be infected from smear positive sputum
case before the index case is diagnosed.
b. Smear negative / culture + ve cases
Less infectious
Responsible for up to 20% of transmission of TB
c. Sputum – ve / culture –ve:
not infectious

9. 2. Duration of the contact with the index case
3. Shared environment:
Class mates
Office workers
Sharing living or bed room
Crowding in poorly ventilated rooms is one of the
most important factors affecting TB transmission.

10. Risk factors for active TB
Primary TB:
• less transmissible even if severe and
disseminated.
• 10% of 1ry TB will develop active TB in their life
time.
• 50% of them will be in first year after infection
• Reinfection
• HIV
• Age: late adolescents and early adults, 25-34 y
and old age.

11. Risk factors for active TB
Factor RR /Odds
Recent infection 12.9
Fibrotic lesions (spontaneously healed) 2 - 20
Comorbidities
HIV -----------------------------------------
Silicosis -----------------------------------
CRF / HD ----------------------------------
DM ----------------------------------------
IV drug use -------------------------------
Immunosuppressive treatment ------
Gastrectomy -------------------------
Jejunoileal bypass ---------------------
Posttransplant period -------------------
21 - 30
30
10 - 25
2- 4
10- 30
10
2- 5
30- 60
20 - 70
Tobacco smoking 2 - 3
Malnutrition and severe underweight 2

12. Case I
• A 35 year old housemaid,
• C/O chest pain with deep breathing with
blood stained sputum for last 2 weeks
• DM II +ve
• CXR

14. Case 2
• Mr V from Philippines was admitted in August
2013
• Fever
• Chest pain in Lt upper part of chest
• Pain is more with breathing
• Lost weight
• Productive cough
• Occasional hemoptysis

15. • Febrile 39.5 ⁰
• HR 112 bpm
• RR 22 breaths/min
• Chest : left bronchial breath sounds, pleural rub
• CVS and abdomen: Unremarkable
• CXR
• CBC
• Electrolytes
• Sputum AFB +ve
• PCR for MTB + ve

17. Case 3
• A 70 year old lady, local
• Admitted with hemoptysis for 1 day
• She has similar attack 4-5 months ago in KSA,
was diagnosed as URTI
• No fever, chest pain, loss of weight, anorexia
or night sweats
• No contact with chesty patients

19. Clinical manifestations of TB
Primary TB
•Asymptomatic
•Fever
•Pleurisy
•More in children
•CXR: middle and lower zones infiltrates
•Hilar and paratracheal lymphadenopathy
•Erythema nodosum
•Pleural reaction

20. • In patients with impaired cell mediated immunity,
primary PTB progress rapidly to clinical illness.
• Pleural effusion presents in 2/3 of cases.
• Primary lesion enlarges and undergoes cavitation
(progressive primary TB).
• Hilar or paratracheal lymphadenopathy
• Enlarged LN may compress bronchi
• Lymph nodes may also rupture into the airway with
development of pneumonia
• Bronchiectasis.
• Hematogenous dissemination

21. POSTPRIMARY (ADULT-TYPE) DISEASE
• Reactivation of LTBI
• Re-infection
• Apical and posterior segments of the upper lobes
• The superior segments of the lower lobes are also
more frequently involved.
• It ranges from small infiltrates to extensive
cavitary disease.
• Cavitation results in satellite lesions within the
lungs that may in turn undergo cavitation.
• Massive involvement may cause pneumonia.

22. • Most patients respond to treatment, with
defervescence, decreasing cough, weight gain,
and a general improvement in well-being
within several weeks.

23. Symptoms of PTB
• Nonspecific and insidious
• Diurnal fever and night sweats, weight loss,
anorexia, general malaise, and weakness.
• Cough.
• Hemoptysis develops in 20–30% of cases
• Dyspnea, ARDS, and chest pain

24. Gray zone cases
• Typical symptoms with normal CXR
• CXR finding is asymptomatic patient
• Symptoms and CXR findings with no sputum
production
• Symptoms and CXR finding with negative AFB
smear
• Exudative pleural effusion with negative
smear
• Suspected TB meningitis. What to do?

25. Diagnosis of TB
• High index of suspicion
• Not difficult with high risk cases
• The longer the delay, the more typical CXR
findings
• Immunosuppressed patients always present with
atypical findings.

26. Diagnosis
• Sputum smear for
AFB x 2 times
• Sputum culture

27. Diagnosis
• Collection of specimens
Proper 2 sputum specimens
In sterile universal container or wide
mouthed screw-capped container
Sent for microscopy & culture

28. Sputum collection
• Sputum induction
–With 5ml of 3% saline given through nebulizer
–Order for sputum culture
• Gastric aspiration
• Bronchoscopy
–On high suspicion for PTB

31. Sputum exam
• Storage & transportation
Should be examined in maximum 5-7 days
If a delay to send the specimen to lab is
unavoidable, it should be stored in a
refrigerator until sent in a cool box

32. Other tests
• IGRA
• NAAT
• Tuberculin skin test
• Chest X-ray
• CBC, ESR
• For EPTB: appropriate sampling

33. IGRA Testing
• IGRAs are used as aids in diagnosing TB infection
• Neither IGRA nor TST can distinguish LTBI from active TB.
• IGRA sensitivity 81% (100% in some studies)
• IGRA specificity 99%
• No cross reaction after BCG or non-TB Mycobacteria
• Persons with a +ve IGRA result should be evaluated for
the likelihood of TB infection, for risks for progression to
active TB, and for symptoms and signs of active TB.

34. NAAT
• Approved by WHO for smear +ve cases.
• Not recommended for smear negative cases.
• An automated molecular test for the detection of
M.TB and resistance to rifampicin
• Sensitivity for TB was 98.2% for smear + ve
sputum sample and 72.5% for smear -ve sputum

35. Automated liquid cultures
• Automated liquid cultures are more sensitive
than solid cultures
• Time to detection is more rapid than solid
cultures
• It can be used to detect Rifampicin resistance.

36. Tuberculin skin testing
• most widely used in screening
• limited value in the diagnosis of active TB.
• Low sensitivity and specificity.
• False-negative reactions are common
• Positive reactions are obtained in BCG –
vaccinated persons and LTBI.

37. Three cutoff points of clinical significance:
• Larger than or equal to 5 mm
Close contacts to persons with newly diagnosed TB
Persons with HIV infection
Patients with organ transplant
Patients taking the equivalent of more than 15 mg/d
of prednisone for one month or more
Patients with fibrotic lesions on chest radiography

38. • Larger than or equal to 10 mm
Patients with medical conditions that increase the
risk of TB
Recent converter - At least 10-mm increase in skin
test in past 2 years (regardless of age)
 Recent immigrants (within 5 y) from a high-
prevalence country
Children younger than 4 years exposed to adults at
high risk for TB
Residents and employees of facilities for long-term
care, including correctional institutions, nursing
homes, homeless shelters, and mental institutions

39. • Larger than or equal to 15 mm - Persons
with none of the above

40. Case definitions

41. • Tuberculosis suspect.
Symptoms suggestive of PTB:
• productive cough
• other respiratory symptoms
• constitutional symptoms
Symptoms related to EPTB involvement

42. • Definite Case of TB:
Positive AFB smear, culture, histologic
features or by newer methods as NAAT
No therapeutic trial to diagnose TB
PTB: one or more sputum sample +ve for AFB

43. Definitions … continued
• NEW CASE: A patient who has never had
treatment for TB or who has taken ATT < 1month.
• RE-TREATMENT CASE: A patient previously
treated for TB, who
–is started on a re-treatment regimen after
previous treatment has failed (treatment after
failure),
–who returns to treatment having previously
defaulted, or
–who was previously declared cured or
treatment completed and is diagnosed with
bacteriologically positive (sputum smear or
culture) TB (relapse).

44. Pulmonary TB
• TB involving the lung parenchyma.
• Miliary TB is classified as pulmonary TB
• TB intrathoracic lymphadenopathy, or TB pleural
effusion, without radiographic abnormalities in the
lungs, constitutes a case of extrapulmonary TB.
• A patient with both pulmonary and extrapulmonary
TB should be classified as a case of pulmonary TB.

45. Extrapulmonary tuberculosis (EPTB)
• TB involving organs other than the lungs, e.g.
pleura, lymph nodes, abdomen, genitourinary
tract, skin, joints and bones, meninges.
• Diagnosis should be based on same criteria of
definite PTB.

46. • Sputum smear negative PTB:
Diagnostic criteria should include:
1.at least 2 sputum smear -ve for AFB;
2. and CXR consistent with active PTB; AND
3. a decision by a clinician to treat with a full course
of ATT and either:
— laboratory or strong clinical evidence of HIV infection or:
— if HIV-negative (or unknown HIV status living in an area
of low HIV prevalence), no improvement to AB (excluding
ATT, fluoroquinolones and aminoglycosides).

47. • Pulmonary TB cases without smear results
are no longer classified as smear- negative
(smear not done or Unknwon).
• In settings with an HIV prevalence >1% in
pregnant women or ≥5% in TB patients, sputum
culture should be performed in patients who
are sputum smear-negative to confirm the
diagnosis of TB.