1. Diagnosis and Management of TB John Yates Consultant Infectious Diseases

2. 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

3. Sites of infection 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,

4. Diagnosis- pulmonary 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

5. Diagnosis - pulmonary 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

6. Early pulmonary disease Patch of nodules

7. Early pulmonary disease

8. Late pulmonary disease cavity

9. Lymphadenopathy Asymmetrical hilar enlargement

10. 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

11. Extra-pulmonary 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

12. Diagnosis –extra pulmonary Immunological tests – negative in 10% active disease for mantoux Targeted imaging – but disease often multi- focal e.g. peritoneum, lymph nodes, spine, chest simultaneously Biopsy for histology, smear and culture

13. Abdominal TB Ascites Lymph node mass

14. Spinal TB Increased soft tissue around L4/5

15. 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