1. Hannah Leaver hyl1g10@soton.ac.uk
Tuberculosis
Hannah Leaver

2. Definition
“a multisystem disease with countless presentations and manifestations. It is the most common cause of infectious disease- related mortality worldwide”

3. Aetiology Modifiable RFs: Alcoholism Silicosis
Malnutrition and low body weight
Smoking
IV drug abuse
Immunosuppressed – HIV, Head and Neck Cancer, Diabetes Mellitus
Immunosuppressive therapy – TNFα antagonists, steroids
Non-Modifiable RFs:
Age < 5 years
Elderly
Geographical - ↑ in tropical regions
Family history

4. Pathophysiology Healing scar Primary infection Primary complex
Ghon focus
Regional lymphadenopathy
Primary complex
Activation of cell-mediated immunity
Healing scar
Persistence of viable bacteria (latent)
Progressive disease
Miliary TB
Post primary TB
Death
New infection

5. Resolution
Infection
1° TB
Latent (90%)
2° infection

6. Primary Infection Childhood exposure in endemic areas
Elderly in western regions
Immune response limits damage to a localised mid-zone area of the lung (Ghon focus)
Hilar involvement
Develops within 4 weeks
Calcification on chest XR.

7. Post Primary Pulmonary TB
Often due to reactivation/ reinfection
Signs and Symptoms:
Persistent cough
Haemoptysis – occurs only in 1/3
Pleurisy
Tiredness, chronic ill health
Weight loss
Fever
Night sweats
Investigations:
Sputum Ziehl-Neelsen stain of AFB
Sputum culture (Takes up to 8 weeks) XR
Complications
Severe haemoptysis
Exudative Pleural effusion
Cavitation
TB empyema

8. Pleural Effusions Transudate Exudate Cause
↑ hydrostatic pressure, ↓ colloid osmotic pressure e.g. HF
Inflammation e.g. Pneumonia, Lung cancer, TB
Appearance
Clear
Cloudy
Protein (g/L)
<30
>30
Fluid protein: Serum protein ratio
<0.5
>0.5
LDH (IU/L)
<200
>200
Fluid LDH : Serum LDH ratio
<0.6
>0.6
Other
Often bilateral (larger on R side)
Unilateral

9. Chest X-rays Consolidation in the left upper lobe.
Two densely calcified granulomas are also present on the left, one near the hilum and the second in the left lower lobe.
No convincing lymph node enlargement. 

10. Multifocal patchy opacities in the right upper lobe with thickening
Upward shift of the minor fissure

11. Patchy opacities in the posterior segment of the upper right lobe, consistent with post- primary tuberculosis

12. Diffuse bilateral, largely upper lobe, consolidation and pulmonary infiltrates.  
Suggestion of small area of cavitation at the left lung apex.

13. Extrapulmonary TB Pleural TB
Cough, pleuritic pain, unilateral effusions
Lymph node TB
Cervical lymph nodes
Unilateral, painless, increased size and matted
TB Meningitis
Headache, fever, mental state changes (coma), neck stiffness, CN palsies
Bone/Joint TB
Potts disease of spine – back pain or stiffness
Monoarticular arthritis – hips and knees
GU TB
Flank pain, dysuria, ↑f
Men – painful scrotum, prostatitis, epididymitis
Women – mimics PID
GI TB
Ulcers of mouth and anus
Dysphagia
Abdominal pain
Malabsorption
Change in bowel habits

14. Appearance
Cells (/μL)
Protein (g/L)
Glucose (mmol/L)
NORMAL
Gin clear
0.4
Lymphocytes
2.7 – 4.4
BACTERIAL MENINGTIS
Cloudy/ purulent
1000 – 5000
Polymorphs
0.8 – 4.0
TB MENINGITIS
Clear/ slightly turbid. “Spider web”
50 – 5000
Polymorphs/ lymphocytes mixed
0.6 – 6.0
0 – 2.2
VIRAL MENINGITIS
Clear/ slight haze
10 – 2000
Normal
* Polymorph = polymorphonuclear leukocyte or granulocyte

15. Miliary TB SYSTEMIC DISSEMINATION
2 clinical syndromes occur, with malaise, weight loss and weakness
Young/HIV infected – rapid onset, high fever, very unwell
Elderly – insidious onset, chronic course and slow decline in health without fever
Diagnosis – Miliary pattern on CXR ( multiple, small nodules) and organisms may be found in sputum, bone marrow, liver and GU tract

17. Investigations Pulmonary TB Extrapulmonary Mantoux test
Ziehl-Neelsen stain
Sputum culture
Extrapulmonary
Histology – granulomata/ AFB
XR (Potts)
CSF TB meningitis – lymphocytes, ↑protein, ↓glucose
Mantoux test
Measures delayed hypersensitivity reaction to intradermal purified protein derivative
+ve = previous exposure or previous BCG vaccine

18. Management Conservative Isolate Contact trace
Inform local authority – TB is a notifiable disease
Medical 
Short form chemo
Rifampin
Isoniazid
Pyrazinamide
Ethambutol
All taken for 2 months. -Rifampin/Isoniazid taken for a further 4months. -If meninges involved, Rifampin/Isoniazid for 10 months + corticosteroid
S/Es - hepatotoxicity

19. Differentials
EXTENSIVE!! - Such a non specific disease

20. Prognosis
Poor prognostic markers include
Immunocompromised
older age
history of previous treatment