Tuberculosis


Epidemiology

US Incidence of Tuberculosis

Global Incidence of Tuberculosis

Epidemiology of Tuberculosis Pleuritis

Risks of Tuberculosis Transmission During Air Travel

Risk Factors for Tuberculosis (Adapted from Lancet, 2011) [MEDLINE]

Use of Anti-TNFα Medications in Populations at Risk for Developing TB


Microbiology


Physiology

-Disease Progression: some infected persons may develop primary TB
–TB organisms remains present but inactive and may cause reactivation TB later
–5% of patients wth latent disease wil develop active TB within 2 yrs and an additional 5% will develop active TB at a later time
–Although most TB is due to reactivation, cases of exogenous reinfection with a second strain of TB can occur

-TB pleuritis: results from rupture of a subpleural caseous focus into the pleural space with delayed hypersensitivity reaction
–Anti-lymphocyte serum blocks effusion development in animal models
–AFB burden is low and T-cells sensitized to tuberculous protein are present in TB pleuritis pleural fluid
–Some patients have a sequestration of PPD-reactive T-cells in pleural space or some have circulating adherent cells that suppress the circulating sensitized T-cells (these may explain 30% rate of PPD-negativity in TB pleuritis)
–Role of Delayed Hypersensitivity: mice immunized (in footpad) with TB protein (killed TB bacilli) develop pleural effusions when they receive intrapleural PPD 3-5 weeks later
—Development of effusions is inhibited by treatment anti-lymphocyte serum
—Neutrophils invade pleural space early (within the first 24 hrs) -> recruitment of monocytes (between day 2-5) -> lymphocyte predominance (they respond to PPD only after day 5) -> inflammation causes impaired lymphatic clearance of protein from pleural space


Diagnosis

Erythrocyte Sedimentation Rate (ESR) (see Erythrocyte Sedimentation Rate)

Serum C-Reactive Protein (CRP) (see Serum C-Reactive Protein)

Tuberculin Skin Test (TST) (see Tuberculin Skin Test)

General Comments

Tuberculin Skin Testing (TST) of Contact of Patient with Infectious Tuberculosis

Tuberculin Skin Testing (TST) in Pregnancy (see Pregnancy)

Two-Step Tuberculin Skin Testing (TST)

Interpretation of Tuberculin Skin Test (TST) (Per CDC Recommendations, Accessed 9/16) [LINK]

Interferon–γ Release Assay (IGRA)

General Comments

Interferon–γ Release Assay (IGRA) Testing of Contacts of Patient with Infectious Tuberculosis

Interferon–γ Release Assay (IGRA) Testing in Pregnancy

Sputum Acid Fast Bacteria (AFB) Stain and Culture (see Sputum Culture)

Technique

Frequency of Positive Acid-Fast Bacteria (AFB) Smear/Culture in Miliary Tuberculosis (Am J Med, 1990) [MEDLINE]

Clinical Efficacy

Nucleic Acid Amplification Tests (NAAT)

Xpert MTB/RIF Assay


Clinical Manifestations-Latent Tuberculosis

Risk of Progression for Latent Tuberculosis to Tuberculosis Disease

Recommendations for Chest X-Ray (CXR) in the Setting of Latent Tuberculosis (see Chest X-Ray) (Per CDC Recommendations, Accessed 9/16) [LINK]

Recommendations for Latent Tuberculosis Testing in the Setting of Human Immunodeficiency Virus (HIV) Infection (see Human Immunodeficiency Virus)


Clinical Manifestations-Primary Tuberculosis

General Comments

Pulmonary Manifestations (Acta Tuberc Scand, 1957) [MEDLINE]

General Comments

Cough (see Cough)

Hilar/Mediastinal Lymphadenopathy (see Mediastinal Mass)

Exudative Pleural Effusion (Tuberculous Pleuritis) (see Pleural Effusion-Exudate)

Pleuritic Chest Pain (see Chest Pain)

Pulmonary Infiltrates (Pneumonia-Like Presentation)

Right Middle Lobe (RML) Atelectasis (see Atelectasis): may occur in association with hilar lymphadenopathy

Other Manifestations


Clinical Manifestations-Reactivation Tuberculosis

General Comments

Dermatologic Manifestations

Hematologic Manifestations

Increased Risk of Venous Thromboembolism (see Deep Venous Thrombosis and Acute Pulmonary Embolism)

Infectious Manifestations

Sepsis (see Sepsis)

Otolaryngologic Manifestations

Laryngeal Tuberculosis

Pulmonary Manifestations

General Comments

Bronchiectasis (see Bronchiectasis)

Endobronchial Tuberculosis

Extensive Pulmonary Destruction

Exudative Pleural Effusion (Tuberculous Pleuritis) (see Pleural Effusion-Exudate)

Increased Risk of Chronic Pulmonary Aspergillosis (see Chronic Pulmonary Aspergillosis)

Increased Risk of Lung Cancer (see Lung Cancer)

Isolated Hilar/Mediastinal Lymphadenopathy (see Mediastinal Mass)

Pneumothorax (see Pneumothorax)

Pulmonary Infiltrates/Pneumonia

Pulmonary Gangrene (see Necrotizing Pneumonia and Pulmonary Gangrene)

Rasmussen’s Aneurysm

Tuberculoma (see Lung Nodule or Mass)

Tuberculous Empyema

Upper Lobe Fibrocalcific Pulmonary Infiltrates (see xxxx)

Gastrointestinal Manifestations

Anorexia (see Anorexia)

Painful Ulcers of Mouth/Tongue/Larynx/Gastrointestinal Tract (see xxxx)

Weight Loss (see Weight Loss)

Neurologic Manifestations

Renal Manifestations

Rheumatologic Manifestations

Other Manifestations

Tuberculosis in Pregnancy (see Pregnancy)

Tuberculosis Associated with Human Immunodeficiency Virus (HIV) Infection (see Human Immunodeficiency Virus)


Clinical Manifestations-Miliary (Disseminated) Tuberculosis

Epidemiology

Physiology

Diagnosis

Frequency of Positive Acid-Fast Bacteria (AFB) Smear/Culture in Miliary Tuberculosis (Am J Med, 1990) [MEDLINE]

Clinical

General Comments

Breast Manifestations

Cardiovascular Manifestations

Dermatologic Manifestations

Endocrine Manifestations

Gastrointestinal Manifestations

Hematologic Manifestations

Infectious Manifestations

Neurologic Manifestations

Ophthalmologic Manifestations

Otolaryngologic Manifestations

Pulmonary Manifestations

Renal Manifestations

Rheumatologic/Orthopedic Manifestations

Tuberculous Lymphadenitis


Prevention

Bacillus Calmette-Guerin (BCG) Vaccination (see Bacillus Calmette-Guerin)


Treatment of Latent Tuberculosis (Per CDC Recommendations, Accessed 9/16) [LINK]

General Comments

Regimens

Isoniazid (INH) 9 Month Regimen (see Isoniazid)

Isoniazid (INH) 6 Month Regimen (see Isoniazid)

Isoniazid (INH) + Rifapentine (RPT) 3 Month Regimen (see Isoniazid and Rifapentine)

Rifampin 4 Month Regimen (see Rifampin)

Monitoring

Clinical Efficacy


Treatment of Drug-Susceptible Tuberculosis (American Thoracic Society, ATS/Centers for Disease Control and Prevention, CDC/Infectious Diseases Society of America, IDSA 2016 Clinical Practice Guidelines) (Clin Infect Dis, 2016) [MEDLINE]

General Comments

Indications for Directly-Observed Therapy (DOT)

Indications for Therapeutic Drug Monitoring

Management of Treatment Interruption

Preferred Regimen (Regimen 1) (Recommendation 3a, Strong Recommendation, Moderate Certainty in the Evidence)

Monitoring

Rash

Hepatotoxicity (see Drug-Induced Hepatotoxicity)

Drug Fever

Optic Neuritis (see Optic Neuritis)

Special Treatment Considerations

Tuberculous Pleuritis

Pott’s Disease

Tuberculous Pericarditis

Tuberculous Meningitis

Culture-Negative Pulmonary Tuberculosis

Clinical Efficacy

4 Month Fluoroquinolone-Based Tuberculosis Treatment Regimens


Treatment of Drug-Resistant Tuberculosis (Per CDC Recommendations, Accessed 9/16) [LINK]

Definitions

Epidemiology


Treatment of Tuberculosis in Association with Human Immunodeficiency Virus (HIV) Infection (see Human Immunodeficiency Virus) (American Thoracic Society, ATS/Centers for Disease Control and Prevention, CDC/Infectious Diseases Society of America, IDSA 2016 Clinical Practice Guidelines) (Clin Infect Dis, 2016) [MEDLINE]

General Comments

Treatment of Drug-Susceptible Tuberculosis in Association with HIV Infection

Initiation of Antiretroviral Therapy in the Setting of Tuberculosis Associated with HIV Infection (see Human Immunodeficiency Virus)

Immune Reconstitution Inflammatory Syndrome (IRIS) (see Immune Reconstitution Inflammatory Syndrome)

Treatment of Drug-Resistant Tuberculosis in Association with HIV Infection


Treatment of Tuberculosis in Association with Pregnancy (see Pregnancy) (Per CDC Recommendations, Accessed 9/16) [LINK]

General Comments

Contraindicated Anti-Tuberculous Drugs During Pregnancy

Preferred Regimen (Total = 9 mo Course)


Prognosis

Role of Tobacco Use (see xxxx)


References

General

Diagnosis

Clinical

Treatment of Latent Tuberculosis

Treatment of Tuberculosis Disease