Diagnosis of Tuberculosis Dr. John Watson Leeds General Infirmary doc

DiagnosisofTuber culos is
Dr.JohnWatson
Dr.JohnWatson
LeedsGeneralInfirmary
LeedsGeneralInfirmary
Somedefi nitions
u
u
PulmonaryTB
PulmonaryTB


activeTBdiseaseinthelung
activeTBdiseaseinthelung
u
u
ExtrapulmonaryTB
ExtrapulmonaryTB


diseaseanywhereelse
diseaseanywhereelse
(includingpleura,intra
(includingpleura,intra


thoracicnodes)
thoracicnodes)
u
u

LatentTBinfection(LTBI)
LatentTBinfection(LTBI)


somebacilliinthe
somebacilliinthe
body,notactivedisease
body,notactivedisease
DelaysinTBDiagnosis
u
u
Delayfromonsetofsymptomstostartof
Delayfromonsetofsymptomstostartof
treatmentmedian68days
treatmentmedian68days
–
–
2003,Yorkshireand HumberRegion
2003,Yorkshireand HumberRegion
u
u
TBDeaths
TBDeaths
–
–
delayfromonsetofsymptoms
delayfromonsetofsymptoms
todiagnosis116days
todiagnosis116days
–

–
1992
1992
–
–
2002,Leeds
2002,Leeds
ConsiderthePo ssibi lity
u
u
Beawareofepidemiologicalriskfactors
Beawareofepidemiologicalriskfactors
–
–
KnownTBcontact
KnownTBcontact
–
–
Ethnicgroup
Ethnicgroup
–
–
Countryofbirth
Countryofbirth
–
–
HIV
HIV
–
–

Otherimmunecompromise
Otherimmunecompromise
–
–
Deprivation
Deprivation
u
u
RememberTBcanaffectanyone
RememberTBcanaffectanyone
Takeahis tory
u
u
Historyofriskfactors
Historyofriskfactors
u
u
Constitutionalsymptoms
Constitutionalsymptoms
u
u
Pulmonarysymptoms
Pulmonarysymptoms
u
u
Otherorgansymptoms
Otherorgansymptoms
u
u
PrevioushistoryofTBdiagnosis/treatment

PrevioushistoryofTBdiagnosis/treatment
Symptomsconstitutional
u
u
Fever
Fever
–
–
Persistingmorethan2weeks
Persistingmorethan2weeks
u
u
Chills
Chills
u
u
NightSweats
NightSweats
u
u
Anorexia
Anorexia
u
u
Weightloss
Weightloss
u
u
Fatigue
Fatigue

SymptomsPulmonary
u
u
Cough
Cough
u
u
Sputum
Sputum
u
u
+/
+/


Haemoptysis
Haemoptysis
u
u
Mayalsohave
Mayalsohave
–
–
Chestpain(
Chestpain(
pleuritic
pleuritic
)
)
–

–
Breathlessness
Breathlessness
Symptoms
extrapul monary
•
•
Backpain
Backpain
•
•
Convulsions
Convulsions
•
•
Dysuria
Dysuria
•
•
Abdominalpain
Abdominalpain
•
•
Redeye
Redeye
•
•
Swollenfoot
Swollenfoot
•

•
Dizziness
Dizziness
•
•
Necklumps
Necklumps
•
•
J ointpain
J ointpain
•
•
Paraesthesiae
Paraesthesiae
•
•
Alteredbowelhabit
Alteredbowelhabit
•
•
In fertility
In fertility
•
•
Dysphagia
Dysphagia
•
•
Skinulcer

Skinulcer
u
u
Almostanychronicsymptom
Almostanychronicsymptom
u
u
considerTBespeciallyifconstitutionalsymptoms
considerTBespeciallyifconstitutionalsymptoms
Symptoms– 
LatentTBInfection
None
None
Symptomsinterpretation
u
u
Symptomsnotspecific
Symptomsnotspecific
u
u
Symptomsnotsensitive
Symptomsnotsensitive
–
–
Eg
Eg
inaLosAngelesstudy
inaLosAngelesstudy
–
–

Cough
Cough
72%
72%
–
–
Cough>2/52
Cough>2/52
48%
48%
–
–
Pulmonar yTB,cough>2/52
Pulmonar yTB,cough>2/52
52%
52%
–
–
Fever
Fever
52%
52%
–
–
Fever>2/52
Fever>2/52
29%
29%
Examine thepatient
u

u
Pulmonary
Pulmonary
–
–
Dependsonsiteandextentofdisease
Dependsonsiteandextentofdisease
–
–
Chestexaminationoftennormalunlessadvanced
Chestexaminationoftennormalunlessadvanced
disease
disease
u
u
Extra
Extra


pulmonary
pulmonary
–
–
Almostan ysign,anywhere
Almostan ysign,anywhere
u
u
LatentTBInfection
LatentTBInfection
–

–
Normal
Normal
ChestXray
u
u
Abnormalitiesmostcommoninupperlobesor
Abnormalitiesmostcommoninupperlobesor
apicalsegmentoflowerlobes
apicalsegmentoflowerlobes
–
–
Infiltrates
Infiltrates
–
–
Nod ules
Nod ules
–
–
Consolidation
Consolidation
–
–
Cavities
Cavities
–
–
Fibrosis
Fibrosis

u
u
Atypicalin
Atypicalin
immunosuppressed
immunosuppressed
(includingHIV)
(includingHIV)
u
u
Cannotconfirmdiagnosis
Cannotconfirmdiagnosis
u
u
Cannotdistinguishactiveandolddisease
Cannotdistinguishactiveandolddisease
Infiltrationwith
Infiltrationwith
cavityandvolumeloss
cavityandvolumeloss
inLeft
inLeft
upperlobe
upperlobe
Infiltratesinright
Infiltratesinright
upperlobe
upperlobe
Extensivebilateral
Extensivebilateral

disease
disease
40yearold
40yearold
White,UKborn,
White,UKborn,
Employed,
Employed,
HIVnegative
HIVnegative
After
After
completing
completing
treatment
treatment
Opacity
Opacity
Apicalsegment
Apicalsegment
Rightlowerlobe
Rightlowerlobe
Rightlowerlobe
Rightlowerlobe
consolidation
consolidation
Oldchangesleft
Oldchangesleft
apex
apex

Pleuraleffusion
Pleuraleffusion
Differe ntialdiagnosis
u
u
Unilateralinfiltrate
Unilateralinfiltrate
–
–
Pneumonia,carcinoma
Pneumonia,carcinoma
u
u
Bilateralinfiltrates
Bilateralinfiltrates
–
–
Sarcoid
Sarcoid
u
u
Upperzonefibrosis
Upperzonefibrosis
–
–
Sarcoid
Sarcoid
,Extrinsicallergic
,Extrinsicallergic
alveolitis

alveolitis
,ABP A
,ABP A
u
u
Solitarycavity
Solitarycavity
–
–
Carcinoma,Abscess,Rheumatoid
Carcinoma,Abscess,Rheumatoid
u
u
Multiplecavities
Multiplecavities
–
–
Wegener
Wegener
’
’
s
s
granulomatosis
granulomatosis
,
,
Staph
Staph
.Pneumo nia,PMF

.Pneumo nia,PMF
u
u
Hilar
Hilar
/
/
Mediastinal
Mediastinal
LymphNodes
LymphNodes
–
–
Sarcoid
Sarcoid
,Lymphoma
,Lymphoma
Differe ntialdiagnosis
SomeTBwhichwere
SomeTBwhichwere
missed
missed
–
–
originally
originally
thoughttobe:
thoughttobe:
u
u

Lymphoma
Lymphoma
u
u
Pneumonia
Pneumonia
u
u
BronchialCarcinoma
BronchialCarcinoma
u
u
Cacolon
Cacolon
u
u
Emp yema
Emp yema
u
u
Rightheartfailure
Rightheartfailure
u
u
Osteoarthritis
Osteoarthritis
SomeIthoughtwere
SomeIthoughtwere
TBbutwerenot
TBbutwerenot

–
–
turnedouttobe:
turnedouttobe:
u
u
Lymphoma
Lymphoma
u
u
Pneumonia
Pneumonia
u
u
Wegeners
Wegeners
granulomatosis
granulomatosis
u
u
Sarcoidosis
Sarcoidosis
u
u
PCP 
PCP 
u
u
Mesothelioma
Mesothelioma

Sputumexamina tion
u
u
Sputumsmear+
Sputumsmear+
ve
ve
:
:
–
–
Somanybacilliinthe
Somanybacilliinthe
sputumyoucanseethem 
sputumyoucanseethem 
underamicroscope
underamicroscope
–
–
Mostinfectious
Mostinfectious
u
u
SputumSmear
SputumSmear


ve
ve
–

–
–
–
notenoughbugsinthe
notenoughbugsinthe
sputumtosee
sputumtosee
–
–
need3 morning
need3 morning
specimenstobesure
specimenstobesure
–
–
maystillbeculture+
maystillbeculture+
ve
ve
–
–
infectiousnessapprox
infectiousnessapprox
25%ofsmear+
25%ofsmear+
ve
ve
AAFB (showninred)aretuberclebacilli
Culture 
u

u
Goldstandardfor
Goldstandardfor
diagnosis
diagnosis
u
u
Resultsin2
Resultsin2


3weekswith
3weekswith
liquidmedia
liquidmedia
u
u
Enablessensitivitytesting
Enablessensitivitytesting
u
u
Distinguishesnon
Distinguishesnon
tuberculous
tuberculous
mycobacteria
mycobacteria
u
u
Cultureallspecimens

Cultureallspecimens
–
–
Sputum,biopsyspecimens,
Sputum,biopsyspecimens,
BAL,aspirates
BAL,aspirates
u
u
Remember
Remember


Formalinkills!
Formalinkills!
ColoniesofM.tuberculosis
growingonsolidmedia
What,nosputum?
Culturesomethingelse!
u
u
Gastricaspirates
Gastricaspirates
u
u
Inducedsputum
Inducedsputum
–
–
Nebulised

Nebulised
hypertonicsaline
hypertonicsaline
u
u
Bronchoscopy
Bronchoscopy
with
with
lavage
lavage
u
u
Extra
Extra


pulmonary
pulmonary
–
–
aspirate/biopsy
aspirate/biopsy
–
–
Pleuralbiopsymoresensit ivethanpleuralfluid
Pleuralbiopsymoresensit ivethanpleuralfluid