Download Extra Pulmonary Tuberculosis

Prof, Magd Galal
Professor of Pulmonary Medicine
Faculty of Medicine For Girls
Al-Azhar University
2015
Definition

• Tuberculosis (TB) is caused by Mycobacterium
tuberculosis.
• In many cases, M tuberculosis becomes latent before it
reactivates. Patients who are infected but who have
no clinical, bacteriological, or radiographic evidence
of active TB are said to have latent TB infection.
Definition

• When there is progression from latent infection to
disease, it most commonly involves the lungs and is
communicable in this form,
•
But may affect almost any organ system including
the lymph nodes, CNS, bones/joints, genito-urinary
tract, abdomen (intra-abdominal organs,
peritoneum), and pericardium.
Definition

 A case with TB in any
site other than
pulmonary is
considered an extra
pulmonary TB (EPTB)
case.
Epidemiology

 EPTB constitutes about 15 to 20 per cent of all cases
of tuberculosis in immunocompetent patients and
accounts for more than 50 per cent of the cases in
HIV-positive individuals.
Epidemiology

Epidemiology

Epidemiology

Introduction

 In the 1980s, after a steady decline during preceding
decades, there was a resurgence in the rate of
tuberculosis in the World Wide that coincided with
the acquired immunodeficiency syndrome epidemic.
 Disease patterns since have changed, with a higher
incidence of disseminated and extra pulmonary
disease now found.
Introduction

 The diagnosis of extra pulmonary tuberculosis can
be elusive, necessitating a high index of suspicion.
Introduction

 Physicians should obtain a thorough history focusing on
risk behaviors for human immunodeficiency virus (HIV)
infection and tuberculosis.
 Antituberculous therapy can minimize morbidity and
mortality but may need to be initiated empirically.
 A negative smear for acid-fast bacillus, a lack of
granulomas on histopathology, and failure to
culture Mycobacterium tuberculosis do not exclude the
diagnosis.
Introduction

 Novel diagnostic modalities such as adenosine
deaminase levels and polymerase chain reaction can
be useful in certain forms of extra pulmonary
tuberculosis.
 In general, the same regimens are used to treat
pulmonary and extra pulmonary tuberculosis, and
responses to anti tuberculous therapy are similar in
patients with HIV infection and in those without.
Introduction

 Treatment duration may need to be extended for
central nervous system and skeletal tuberculosis,
depending on drug resistance, and in patients who
have a delayed or incomplete response.
 Adjunctive corticosteroids may be beneficial in
patients with tuberculous meningitis, tuberculous
pericarditis, or miliary tuberculosis with refractory
hypoxemia.
Clinical Clues to Prompt Suspicion of EPTB

Ascites with lymphocyte predominance and negative bacterial cultures
Chronic lymphadenopathy (especially cervical)
CSF lymphocytic pleocytosis with elevated protein and low glucose
Differential diagnosis of Crohn’s disease and amebiasis
Exudative pleural effusion with lymphocyte predominance, negative bacterial
cultures, and pleural thickening
Clinical Clues to Prompt Suspicion of EPTB
HIV infection

Joint inflammation (monoarticular) with negative bacterial cultures
Persistent sterile pyuria
Tuberculosis-endemic country of origin
Unexplained pericardial effusion, constrictive pericarditis, or
pericardial calcification
Vertebral osteomyelitis involving the thoracic spine
1.
Airborne
infection control
2.
Intensive case
finding and
treatment of TB
3.
Diagnosis and
treatment of LTBI
Principles of Management

 Patients with suspected tuberculosis should have
appropriate specimens sent for acid-fast bacillus (AFB)
staining, mycobacterial culture, and histology.
 Hospitalization is not necessary for tuberculosis to be
diagnosed unless clinically indicated.
 Hospitalized patients in whom infectious (i.e., pulmonary
or laryngeal) tuberculosis is suspected should be placed
in an airborne-infection isolation room and should wear a
surgical mask during transport and in waiting areas.7
Principles of Management

 Health care workers and visitors entering the isolation
room should wear at least N95 disposable respirators, as
should health care workers performing procedures such
as sputum induction, bronchoscopy, jet irrigation of
abscesses, and autopsies.
 All patients with tuberculosis should have counseling
and testing for HIV infection.
 The local health department should be notified of all
confirmed cases of tuberculosis.7
Pathophysiology

 Infection with Mycobacterium tuberculosis requires
inhalation of droplet nuclei. In the course of primary
infection, a period of subclinical bacillaemia usually
occurs and a small number of M
tuberculosis organisms are contained in various body
organs.
 Exposure may be followed by clearance, persistent
latent infection, or progression to primary disease.
Pathophysiology

 Successful containment of TB is dependent on the cellular immune
system, mediated primarily through T-helper cells (TH1 response).
 T cells and macrophages form a granuloma with a centre that
contains necrotic material (caseous centre) and M tuberculosis, and
peripheral granulation tissue consisting primarily of macrophages
and lymphocytes.
 The granuloma serves to prevent further growth and spread of M
tuberculosis.
 These individuals are not infectious and have latent TB infection;
the majority of these patients will have a normal chest x-ray and
positive tuberculin skin test and positive interferon-gamma release
assays.
Pathophysiology

 Pleural TB (particularly primary disease) may occur
from a few mycobacteria gaining access to the
pleural space with a resultant T cell response and
delayed hypersensitivity reaction. The effusion is
due to increased capillary permeability and
decreased lymphatic drainage. As TB pleural
effusion results from intensive inflammatory
response, recovery of M tuberculosis from the pleural
fluid occurs in about 40% of cases.
Pathophysiology

 Skeletal TB is an osteomyelitis that starts in the
growth plates of bones where the blood supply is the
richest, and from there spreads into joint spaces.
Vertebral disease usually starts in the subchondral
cancellous bone, from where it spreads to the cortex
and on to the disc.
 Bone destruction is more extensive on the ventral
aspect leading to anterior wedging. Paraspinous
collections may also develop. Spinal or vertebral TB
has been known historically as Pott's disease.
Pathophysiology

 TB meningitis results from haematogenous spread of M
tuberculosis with the development of submeningeal or
intrameningeal foci called Rich foci. With rupture of a
Rich focus into the subarachnoid space, meningitis
develops.
 This may result from reactivation (more common in
adults) or primary infection (more common in children).
 BCG vaccination is about 64% effective against TB
meningitis in young children.
Pathophysiology

 Abdominal TB includes disease of the intestines, peritoneum, and
mesenteric lymph nodes. In peritoneal TB, the peritoneum
becomes studded with tubercles. As protein-rich fluid is exuded,
ascites accumulate.
 More than 90% of patients with peritoneal TB will have ascites; the
remainder generally have more advanced disease and present with
fibroadhesions ('doughy abdomen').
 TB enteritis may occur secondary to ingestion of infected sputum
or initial haematogenous spread. If the enteric source spreads to
the mesenteric lymph nodes, they may rupture into the
peritoneum. TB enteritis occurs most frequently in the ileocecal
region. Its appearance may be ulcerative or hypertrophic.
Pathophysiology

 Pericardial TB results from contiguous spread from adjacent
mediastinal lymph nodes, or progression of a primary or latent
focus within the pericardium. Some patients present with signs
of cardiac constriction without an acute phase of pericarditis
being noticed.
 Disseminated TB refers to simultaneous involvement of
multiple organ sites that may occur with primary infection
(particularly in immunocompromised individuals) or with
reactivation. Disseminated TB is sometimes called miliary TB;
its lesions are yellowish granulomas 1 to 2 mm in diameter that
resemble millet seeds on chest x-ray. It is due to
haematogenous spread of M tuberculosis.
Tuberculous Lymphadenitis

Tuberculous Lymphadenitis

 Lymphadenitis is the most commonly occurring
form of extrapulmonary tuberculosis. Cervical
adenopathy is most common, but inguinal, axillary,
mesenteric, mediastinal, and intramammary
involvement all have been described.
Tuberculous Lymphadenitis

 Although previously considered a disease of
childhood, lymphadenitis has a peak age of onset of
20 to 40 years
Tuberculous Lymphadenitis

 Patients without HIV infection
typically present with chronic,
non tender lymphadenopathy.
 Patients with HIV infection
usually present with fever, night
sweats, and weight loss.
 The nodes are discrete, firm,
and non tender; with time, a
firm mass of matted nodes
becomes visible .
Tuberculous Lymphadenitis

 If untreated, the nodes become fluctuant and drain
spontaneously with sinus tract formation.
Tuberculous Lymphadenitis

 Excisional biopsy of the lymph nodes with histology, AFB
stain, and mycobacterial culture is the diagnostic
procedure of choice.
 Fine-needle aspiration is more reliable in patients with
HIV infection because of the higher mycobacterial
burden, and in these patients should be the initial
diagnostic procedure.
 Polymerase chain reaction (PCR) for Mycobacterium
tuberculosis on the fine-needle aspiration specimen
enhances test sensitivity.
Tuberculous Lymphadenitis

 During antituberculous therapy, affected nodes may
enlarge or new nodes may appear, representing an
immune response to killed mycobacteria.
 A similar phenomenon in patients with HIV infection
who begin concurrent antiretroviral therapy is a result of
immune reconstitution.
 Lymph node excision usually is not indicated. When
lymph nodes are fluctuant and ready to drain, aspiration
or incision and drainage appear to be beneficial.
Pleural Tuberculosis

Pleural Tuberculosis
 Chest radiography typically
reveals a small to moderate,
unilateral pleural effusion;
about 20 percent of patients
have associated pulmonary
lesions.
 Computed tomography (CT)
of the chest may show
lymphadenopathy,
pulmonary infiltrates, or
cavitation not obvious on
chest radiography .
 Pleural thickening of more
than 1 cm is seen in most
instances.

Pleural Tuberculosis

 Pleural fluid is exudative with a lymphocyte
predominance (i.e., more than 50 percent of white blood
cells in more than 90 percent of effusion;
 in patients with less than two weeks of symptoms, an
initial predominance of neutrophils may be seen.
 Pleural fluid glucose and pH can be low or normal.
 AFB smears of pleural fluid are seldom positive (5 percent
of cases) unless the patient has tuberculous empyema.
 Pleural fluid cultures for M. tuberculosis are positive in
less than 40 percent of cases.
Pleural Tuberculosis

 The combined sensitivity of the analyses of pleural biopsy
specimens (i.e., observation for caseating granulomas, AFB
smear, and culture) is more than 90 percent.
 Tuberculin skin test results are positive in two thirds of
patients.
 Biochemical markers such as adenosine deaminase, interferon
gamma, and lysozyme in the pleural fluid can be useful
 A high level of adenosine deaminase (greater than 47 U per L
[783 nkat per L]) was seen in 99 per cent of tuberculous
effusions.
Pleural Tuberculosis

 In countries with a low prevalence of tuberculosis,
such as the United States, a normal or low level of
pleural fluid adenosine deaminase has a high
negative predictive value and can be used to exclude
tuberculous pleurisy.
 Pleural fluid PCR for M. tuberculosis has a
sensitivity of 80 percent and a specificity of 100
percent.
Pleural Tuberculosis

 Tuberculous pleurisy responds well to medical
therapy, with resorption of pleural fluid in six to 12
weeks.
 The effusion may resolve without therapy, but
tuberculosis later recurs.
 Rare complications include bronchopleural fistula,
empyema, and fibrothorax.
Skeletal Tuberculosis

Skeletal Tuberculosis

 Bone and joint tuberculosis
may account for up to 35
percent of cases of
extrapulmonary tuberculosis.
 Skeletal tuberculosis most
often involves
 The spine,
 Tuberculous arthritis in
weight-bearing joints and
 Extraspinal tuberculous
osteomyelitis.
Skeletal Tuberculosis

 Spinal tuberculosis (Pott’s disease) most commonly
involves the thoracic spine. Infection begins in the
anteroinferior aspect of the vertebral body with
destruction of the intervertebral disc and adjacent
vertebrae.
Skeletal Tuberculosis

 The resulting anterior wedging and angulation of
adjacent vertebral bodies with disc space obliteration
are responsible for the palpable spinal prominence
(gibbus) and a classic radiographic appearance.
Paraspinal and psoas abscesses can develop, with
extensions to the surface or adjacent tissues .
Skeletal Tuberculosis

 Articular tuberculosis is a slowly progressive monoarthritis of the hip or knee.
 Presentation is indolent with




pain,
joint swelling, and
decreased range of motion.
Draining sinuses and abscesses are seen in chronic
cases.
 Systemic symptoms usually are absent.
Skeletal Tuberculosis

Radiographic changes are
nonspecific and include
soft tissue swelling, juxtaarticular osteopenia, joint
space narrowing, and sub
chondral erosions
Skeletal Tuberculosis

 Extra spinal tuberculous osteomyelitis often presents
with local pain and can involve any bone.
 Involvement of adjacent structures may result in
complications such as carpal tunnel syndrome,
tenosynovitis, and facial palsy.
Skeletal Tuberculosis

 Chest radiography shows pulmonary disease in one
half of patients with osteoarticular tuberculosis, but
active pulmonary disease is uncommon.
 Magnetic resonance imaging may be helpful to
 assess the degree of bony destruction and
 to identify soft tissue extension and
 encroachment on adjacent structures such as the
spinal cord.
Skeletal Tuberculosis

 Physicians should consider skeletal tuberculosis in
patients with
 An indolent clinical course manifesting as
osteomyelitis involving the thoracic spine or
monoarticular septic arthritis
 With negative bacterial cultures.
Skeletal Tuberculosis

 Arthrocentesis with mycobacterial cultures of
synovial fluid yields positive results in up to 80
percent of patients with tuberculous arthritis.
 Synovial biopsy also may be diagnostic (caseating
granulomas on histology or positive mycobacterial
culture).
 Bone biopsy for culture and histology is required for
diagnosis of tuberculous osteomyelitis.
Skeletal Tuberculosis

 SOFT TISSUE
TUBERCULOSIS ALONG
THE MEDIAL ASPECT OF
THE LEFT KNEE
 High-signal-intensity soft
tissue abscess(white arrow),
with adjacent bone marrow
edema involving the medial
condyle and a T2
hyperintense focus in the
medial proximal tibia (black
arrow) due to the associated
osteomyelitis
Skeletal Tuberculosis

spina ventosa.
(A) 99m Tc- methylene
diphosphonte (MDP) whole
body anterior and (B) posterior
sweep views in a patient
presenting with backache and
low-grade fever showing
diffuse increased radiotracer
localization in the body of L4
and 5 vertebrae (arrows)
suggestive of spinal TB.
(Kind courtesy: Dr TC Kalawat,
Department of Nuclear
Medicine, Sri Venkateswara
Institute of Medical Sciences,
Tirupati)
Skeletal Tuberculosis

 Aim of the treatment is to
 Control of the infection
 Care of the diseased part
 In the absence of neurologic impairment, unstable
spine, or spinal cord compression, medical therapy
alone should result in an excellent response.
 Surgery may be necessary to
 drain abscesses,
 debride infected tissue, or
 stabilize the spine and relieve spinal cord compression
Skeletal Tuberculosis

 Antibiotic for secondary infection(for persistently
draining sinus which gets secondary infections)
 . Bed sore care and treat other comorbid condition
 Building up of patient’s resistance – High protein diet
.
 Excision of sinus tract - if sinus are persisting.
Skeletal Tuberculosis

 Affected part should be rested during active stage of the
disease.
 In upper limbs this can be done with the help of plaster slab
and
 in lower limbs traction can be applied.
 As the disease comes under control and the pain reduces ,
joint mobilization is begun.
 Gradual mobilization should be encouraged with the help
of suitable braces/appliances after 3-6 months of start of
treatment when the healing is progressing, which are
gradually discarded after about 2 years.
Skeletal Tuberculosis

 Exercise is started as the
joint regains movement and
weight bearing started gradually as osteoporosis
secondary to disease is reversed
 In presence of gross destruction especially in weight
bearing joints, immobilization may be continued to
obtain sound ankylosis .
Skeletal Tuberculosis

 To summarise Distribution
 Spinal Tuberculosis (Pott's Disease)
 Thoracic Spine most commonly involved
 Associated with paraspinous abscess
 Destroys anterior Vertebral body and adjacent
disc
 Results in anterior wedging
 Forms prominence of spine known as Gibbus
 May compress central cord
Skeletal Tuberculosis

 Articular Tuberculosis (most common involvement)
 Monoarticular Arthritis of weight bearing joints
 Presents with insidious monoarticular pain, swelling
 May form superficial abscesses and drain to skin
 Poncet's Disease (rare)
 Acute sterile Polyarthritis
 Associated with visceral involvement
 Tuberculous Osteomyelitis
 May involve any bone
Central Nervous System
Tuberculosis

Central Nervous System
Tuberculosis

Central nervous system tuberculosis includes
 Tuberculous meningitis (the most common
presentation),
 Intracranial tuberculomas, and
 Spinal tuberculous arachnoiditis.
Central Nervous System
Tuberculosis

 Meningitis results from intense inflammation
following rupture of a subependymal tubercle into
the subarachnoid space.
 The ensuing arachnoiditis encases both cranial
nerves and penetrating vessels, leading to cranial
nerve palsies and communicating hydrocephalus.
 Cranial vasculitis may lead to focal neurologic
deficits.
Central Nervous System
Tuberculosis

 Hypersensitivity to tuberculoproteins may cause
meningismus and typical cerebrospinal fluid (CSF)
findings.
 Cerebral edema causes impairment of consciousness,
seizures, and raised intracranial pressure,
 whereas tuberculomas can manifest as spaceoccupying lesions.
Central Nervous System
Tuberculosis

Meningitis
 An initial phase of malaise, headache, fever, or personality
change is followed in two to three weeks by protracted
headache, meningismus, vomiting, confusion, and focal
neurologic findings.
 If untreated, mental status deteriorates into stupor or coma.
 Atypical presentations include a rapid progression simulating
pyogenic meningitis, subtle cognitive decline mimicking
dementia, and a predominant syndrome of encephalitis.
 Convulsions can occur at all stages of the illness.
Central Nervous System
Tuberculosis

 CSF typically reveals moderate lymphocytic pleocytosis
(100 to 500 cells per μL [0.10 to 0.50×109 per L] initially, a
neutrophilic predominance can be seen.
 CSF protein levels range from 100 to 500 mg per dL
(1,000 to 5,000 mg per L) and can be extremely high (2 to 6
g per dL [20 to 60 g per L]), with xanthochromia in the
presence of subarachnoid block.
 CSF glucose concentration usually is less than 45 mg per
dL (2.50 mmol per L).
Central Nervous System
Tuberculosis

 AFB smears on CSF are positive in 10 to 90 percent of
patients; sensitivity can be improved if large
volumes of CSF from multiple lumbar punctures are
examined, CSF is centrifuged and AFB smears are
performed on the pellicle, or an experienced
reviewer examines several high-powered fields
Central Nervous System
Tuberculosis

 CSF culture for M. tuberculosis is positive in 45 to 90
percent of cases but takes four to six weeks.
 CSF PCR for M. tuberculosis has a sensitivity of 56
percent and a specificity of 98 percent, and therefore
should not be used to exclude tuberculous meningitis.
 An elevated CSF adenosine deaminase level supports the
diagnosis in the appropriate clinical setting.
 A CT scan of the head with contrast may reveal basilar
arachnoiditis, infarction, hydrocephalus, or tuberculomas.
Central Nervous System
Tuberculosis

 Empiric antituberculous therapy should be initiated
as soon as clinical, laboratory, or imaging findings
suggest tuberculous meningitis.
 Delay in initiation of therapy has been directly
associated with adverse outcomes.
 Antituberculous therapy is recommended for at least
nine to 12 months.
Central Nervous System
Tuberculosis

 Adjunctive corticosteroid therapy with
dexamethasone (Decadron) for the initial six to eight
weeks in patients with tuberculous meningitis has
been associated with reduced mortality and fewer
neurologic sequelae.
 Mortality is highest in patients younger than five
years, those older than 50 years, and those in whom
illness has been present for longer than two months.
Abdominal Tuberculosis

Abdominal Tuberculosis

 Abdominal tuberculosis may involve




the gastrointestinal tract,
peritoneum,
mesenteric lymph nodes, or
genito-urinary tract.
 Other organs (e.g., liver, spleen, adrenal glands)
usually are affected as a consequence of miliary
tuberculosis.
GASTROINTESTINAL
TUBERCULOSIS

 Symptoms include







abdominal pain,
diarrhea,
weight loss, and
fever.
Melena, rectal bleeding, and
abdominal tenderness also can be present.
A mass in the right lower quadrant is palpable in 25
to 50 percent of patients.
GASTROINTESTINAL
TUBERCULOSIS

Pathophysiology
 Involves any part of Gastrointestinal tract
 Ileocecal most commonly affected
 Risk of contracting gastrointestinal Tb
 Parallels severity of pulmonary disease
GASTROINTESTINAL
TUBERCULOSIS

 Tuberculous enteritis can result from
 swallowing of infected sputum,
 ingestion of contaminated food,
 hematogenous spread, and direct extension from
adjacent organ
 The intestinal lesions can be
 ulcerative (most common),
 hypertrophic, or
 ulcero-hypertrophic. s.35
GASTROINTESTINAL
TUBERCULOSIS

 The ileocecal area and jejunoileum are the most common
sites of involvement.
 Complications include obstruction, perforation, and
fistula formation.
 Rectal lesions usually present as anal fissures, fistulas, or
perirectal abscesses.
 Barium contrast studies and colonoscopy may show
ulcers, strictures, a deformed cecum, incompetent
ileocecal valve, or fistulas.
 An abdominal CT scan can define extraluminal
pathology, especially lymphadenopathy.
GASTROINTESTINAL
TUBERCULOSIS

 Differential Diagnosis
 Crohn's Disease
 Critical to differentiate from Tuberculosis
 Crohn's Treatment disseminates Tuberculosis
 Infection
 Yersinia
 Actinomyces
 Amebiasis
 Colon Cancer
GASTROINTESTINAL
TUBERCULOSIS

 Diagnosis
 Endoscopy
 Mucosal injury
 Ulcerations
 Hypertrophic lesions
 Dense bandlike fibrosis
 Mucosal biopsy shows Acid Fast Bacilli (low yield)
 Culture of biopsy specimens
 CT Abdomen
 Barium Enema
 Shortened and retracted cecum
GASTROINTESTINAL
TUBERCULOSIS

 Complications
 Intestinal Obstruction
 Bowel perforation
 Enteric fistulas
GASTROINTESTINAL
TUBERCULOSIS

 A six-month course of antituberculous therapy is
recommended.
 Surgery is reserved for patients with complications
TUBERCULOUS
PERITONITIS

 Risk Factors
 HIV Infection.
 Cirrhosis.
 Ambulatory Peritoneal Dialysis.
 Pathophysiology
 Results from peritoneal Tuberculosis reactivation
 Symptoms
 Abdominal Pain
 Fever
 Signs
 Ascites
TUBERCULOUS
PERITONITIS

 Laboratory:
 Peritoneal fluid
 Exudative: Serum to Ascites albumin <1.1 g/dl
 White Blood Cells >150/mm3 with Lymphocytes
predominance. A neutrophilic pleocytosis may be seen
with tuberculous peritonitis complicating continuous
ambulatory peritoneal dialysis.
 Send fluid for AFB smear and culture
 One liter is preferred to increase Test Sensitivity
 Measures with highest sensitivity and Specificity
 Adenosine deaminase >33 U/L
 Peritoneal biopsy
GENITOURINARY
TUBERCULOSIS

GENITOURINARY
TUBERCULOSIS


GENITOURINARY
TUBERCULOSIS

 Renal disease may be the result of
 direct infection of the kidney and
 lower urinary tract or
 may present as secondary amyloidosis.
 Patients present with




dysuria,
hematuria, or
flank pain.
More than 90 percent of asymptomatic patients have sterile
pyuria with or without microscopic hematuria
GENITOURINARY
TUBERCULOSIS

 Chest X-ray
 Abnormal in 50%
 Active pulmonary TB in 5-10%
 Sequelae of old TB of past infection.
GENITOURINARY
TUBERCULOSIS

 Fluoroscopy: IVP
 Traditional plain film
IVP is quite sensitive to
renal tuberculosis with
only 10% of affected
patients having normal
imaging.
 Features include:
 parenchymal scars 50%
 moth eaten calyces:
 early finding
 Irregular caliectasis
 phantom calyx
 hydronephrosis
GENITOURINARY
TUBERCULOSIS

 Lower urinary tract
signs (see bladder and
ureteric tuberculosis)
also recognised include:
 Kerr kink3
 sawtooth ureter
 pipe-stem ureter
 beaded or corkscrew
ureter
 thimble bladder



GENITOURINARY
TUBERCULOSIS

 Excretory urography
in a patient with
renal tuberculosis
shows an irregular
cavity at the upper
pole calyx of the right
kidney.
 Note the multiple
tiny calcifications in
the liver, spleen, and
right adrenal gland
due to calcified
tuberculous
granuloma.
GENITOURINARY
TUBERCULOSIS

 Excretory urography
in a woman with a
history of tuberculosis
of the breast. The film
shows irregular
cavitation in the lower
pole calyx of the left
kidney due to renal
tuberculosis.
GENITOURINARY
TUBERCULOSIS

 Lobar calcification in a
large destroyed right
kidney in a patient with
renal tuberculosis. Note
the involvement of the
right ureter.
GENITOURINARY
TUBERCULOSIS
 Excretory urography in
a patient with
tuberculosis of the
ureter and bladder. The
lower end of the right
ureter demonstrates an
irregular caliber with an
irregular stricture at the
right vesico-ureteric
junction.
 Note the asymmetric
contraction of the
urinary bladder, with
marked irregularity due
to edema and
ulceration.


GENITOURINARY
TUBERCULOSIS

 CT is the most sensitive modality for visualising renal calcifications and
 CT IVP is more sensitive at identifying all manifestations of renal
tuberculosis 4.
 early
 papillary necrosis (single or multiple) resulting in uneven caliectasis
 progressive




multifocal strictures can affect any part of the collecting system
generalised or focal hydronephrosis
mural thickening and enhancement
poorly enhancing renal parenchyma, either due to direct involvement or due
to hydronephrosis
 endstage
 progressive hydronephrosis results in very thin parenchyma, mimicking
multiple thin walled cysts
 amorphous dystrophic calcification eventually involves the entire kidney
(known as putty kidney)
GENITOURINARY
TUBERCULOSIS

GENITOURINARY
TUBERCULOSIS

 The role of nephrectomy is controversial and
depends on the degree of renal impairment, bilateral
vs unilateral disease and the status of the lower
urinary tract.
 Nephrectomy, partial nephrectomy or cavernostomy
can be performed both open and endoscopically 5.
GENITOURINARY
TUBERCULOSIS

 Male genital tuberculosis usually is associated with renal
tuberculosis.
 It involves the prostate, seminal vesicles, epididymis, and
testes, in order of incidence.
 Patients usually present with a scrotal mass , and
diagnosis is made by surgery.
 Oligospermia is common and
may be persistent.
GENITOURINARY
TUBERCULOSIS

 Female genital tuberculosis begins in the
endosalpinx and can spread to the peritoneum,
endometrium, ovaries, cervix, and vagina.
 Patients present with pelvic pain, infertility, and
vaginal bleeding. Response to chemotherapy is
excellent for all forms of genital tuberculosis;
 surgery in women is necessary for large tuboovarian abscesses.
MILIARY
TUBERCULOSIS

MILIARY TUBERCULOSIS

 Miliary tuberculosis : refers to any progressive,
disseminated form of tuberculosis; the disease can
occur during primary dissemination or after years of
untreated tuberculosis.
 Miliary disease is seen in
 10 % of patients who have AIDS and pulmonary
tuberculosis,
 38 %of those who have AIDS and extra-pulmonary
tuberculosis.5
MILIARY TUBERCULOSIS

 Presenting symptoms include





fever,
chills,
night sweats,
weight loss, and
anorexia.
 Clinical manifestations depend on the organs involved.
 Fulminant disease including septic shock, acute
respiratory distress syndrome, and multiorgan failure has
been described.
MILIARY TUBERCULOSIS

 A chest radiograph or CT scan reveals numerous 2to 3-mm nodules scattered throughout the lung in
more than 85 percent of patients
MILIARY TUBERCULOSIS

Common laboratory abnormalities include
 normochromic anemia,
 leukopenia or leukocytosis,
 elevated sedimentation rate, and
 hyponatremia.
MILIARY TUBERCULOSIS

 Examination of the sputum, bronchoalveolar lavage,
gastric washings, CSF, blood culture, or biopsies of
liver and bone marrow may be necessary for
diagnosis.
 A tuberculin skin test result is positive in less than 50
percent of patients.
 Antituberculous therapy (and corticosteroids in
select situations) is as previously outlined
TUBERCULOUS
PERICARDITIS

TUBERCULOUS
PERICARDITIS

 Tuberculous pericarditis develops secondary to contiguous
spread from mediastinal nodes, lungs, spine, or sternum, or
during miliary dissemination.
 The onset may be abrupt or insidious with symptoms such as
chest pain, dyspnea, and ankle edema
.
 Cardiomegaly, tachycardia, fever, pericardial rub, pulsus
paradoxus, or distended neck veins may be found on
examination.
 Pericardial biopsy yields a definitive diagnosis more often than
pericardial fluid alone
TUBERCULOUS
PERICARDITIS

 In addition to antituberculous therapy,
corticosteroids are recommended to hasten
resolution of symptoms and to reduce
reaccumulation of fluid.
 The risk of progression to constrictive pericarditis or
mortality is not altered by corticosteroids.
 Open pericardial drainage is favoured over repeated
pericardiocentesis.
TNF-α INHIBITOR–ASSOCIATED
TUBERCULOSIS

TNF-α INHIBITOR–ASSOCIATED
TUBERCULOSIS

 Two recent reports describe several cases of active
tuberculosis occurring after treatment with the TNFα inhibitors infliximab (Remicade) and etanercept
(Enbrel), mainly in patients with rheumatoid
arthritis or Crohn’s disease.
 Tuberculosis was diagnosed sooner after initiation
of infliximab than after initiation of etanercept
(median of 12 weeks versus 12 months).
TNF-α INHIBITOR–ASSOCIATED
TUBERCULOSIS

 Extra pulmonary tuberculosis accounted for 52 to 57
percent of cases.
 As a result, it is now recommended that patients be
screened for latent tuberculosis infection or active
disease before initiation of therapy with a TNF-α
inhibitor.
Treatment of extra pulmonary TB

Treatment of extra pulmonary TB

 Provider-initiated HIV testing is recommended as
part of the evaluation of all TB patients and patients
in whom the disease is suspected.
 HIV testing is especially important in persons with
or suspected of having EPTB because of the
increased frequency of extrapulmonary involvement
in persons with immunosuppression.
 Extrapulmonary TB is considered to be WHO clinical
stage 4 HIV disease
Treatment of extra pulmonary TB

 Pulmonary and extra pulmonary disease should be
treated with the same regimens
 Recommend duration
 9–12 months of treatment for TB meningitis given the
serious risk of disability and mortality, and
 9 months of treatment for TB of bones or joints
because of the difficulties of assessing treatment
response .
Treatment of extra pulmonary TB

 Unless drug resistance is suspected, adjuvant
corticosteroid treatment is recommended for TB
meningitis and pericarditis.
 In tuberculous meningitis, ethambutol should be
replaced by streptomycin.
Treatment of extra pulmonary TB

 Although sometimes required for diagnosis, surgery
plays little role in the treatment of extrapulmonary TB.
 It is reserved for management of late complications of
disease such as hydrocephalus, obstructive uropathy,
constrictive pericarditis and neurological involvement
from Pott's disease (spinal TB).
 For large, fluctuant lymph nodes that appear to be about
to drain spontaneously, aspiration or incision and
drainage appear beneficial
Key Points

 Diagnosis of EPTB poses challenges due to the
diversity of symptoms with which EPTB may
present, the low level of suspicion among clinicians,
and the difficulty in obtaining an adequate sample
for confirmation.
 Raising awareness among non-pulmonary
physicians about EPTB and guidelines for diagnosis
and treatment of EPTB may result in more timely
and adequate diagnosis.
Key Points

 TB can spread from the lungs through the bloodstream to many
sites.
 Symptoms depend on the affected organ but typically include
fever, malaise, and weight loss.
 Diagnose based identification of bacilli in infected fluid or tissue by
microscopic examination and culture and/or nucleic acid
amplification tests.
 Treat with multiple drugs for several months and sometimes with
surgery.
 Drug resistance is a major concern and is increased by poor
adherence, use of too few drugs, and inadequate susceptibility
testing.
Prof; Magd Galal

Cough Etiquette
