Download Diagnosis and Management of TB - Croydon Health Services NHS

Diagnosis and Management of
TB
John Yates
Consultant Infectious Diseases
Diagnosis
• Generally sub-acute illness
• Any persistent symptom may indicate active
tuberculosis
• May be relatively mild
• Any systemic symptoms – fever, weight loss,
night sweats, malaise, anorexia – increase
suspicion
• Exposure history usually irrelevant if high risk
ethnic background
Sites of infection
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About 50/50 pulmonary/non-pulmonary
24% extra-pulmonary LNs
10% intra-throracic LNs
10% pleural
6% bone/joint ( 3% spine)
5% GI
3% CNS
2% miliary
1% GU
Others – skin, eye, breast,
Diagnosis- pulmonary
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Persistent cough +/- haemoptysis
Fever, weight loss, night sweats
Symptoms may be very mild
Usually stethoscope not useful
Breathlessness uncommon unless severe,
disseminated disease
• May be asymptomatic
• Main initial investigation – CXR
• Referral to TB clinic
Diagnosis - pulmonary
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CXR
Sputum, if productive, x3 for smear and culture
Basic blood tests
HIV test
Mantoux/IGRA
CT to guide bronchoscopy/biopsy if unproductive
Broncho-alveolar lavage/induced sputum for
smear and culture
• PCR for smear positive cases/difficult diagnoses
Early pulmonary disease
Patch of nodules
Early pulmonary disease
Late pulmonary disease
cavity
Lymphadenopathy
Asymmetrical
hilar enlargement
Extra-pulmonary
• Cervical lymph nodes – mantoux +/- IGRA,
biopsy for histology/culture
• Other sites imaging/biopsy
• Multifarious presentations
• Main aid to diagnosis is suspicion
• Don’t be put off by normal plain films of
chest/abdo/spine/bone
Extra-pulmonary
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Persistent symptoms > 2 weeks
+/- night sweats/weight loss/malaise
High risk ethnic backgrounds
Elevated ESR/CRP, normocytic anaemia, low
albumin
• Back pain, abdo pain, headache etc
• Please refer to TB clinic
Diagnosis –extra pulmonary
• Immunological tests – negative in 10% active
disease for mantoux
• Targeted imaging – but disease often multifocal e.g. peritoneum, lymph nodes, spine,
chest simultaneously
• Biopsy for histology, smear and culture
Abdominal TB
Ascites
Lymph node
mass
Spinal TB
Increased soft tissue around L4/5
Management
• Risk assessment for Multi-Drug Resistant -MDR TB – 1.5%
cases resistant to rifampicin and isoniazid
• Smear positive cases sent for PCR for drug resistance
• Isolation of smear positive cases for 2 weeks– usually at
home but in hospital if ill or unable due to shared
accommodation/homelessness
• Initiate treatment – quadruple therapy –
rifampicin/isoniazid/pyrazinamide, ethambutol or
moxifloxacin
• Monitored treatment – TB nurses, clinic
• Review with culture results
• MDR cases referred to St George’s