1. Extrapulmonary tuberculosis and HIV Outi Vehviläinen, MD Ilembula Lutheran Hospital 7.2.2014 1

2. EPTB  What is EPTB  Pathogenesis  Clinical manifestations  Diagnostic evaluation  Statistical information from ILH  X-rays and pictures 2

3. WHAT IS EPTB: definition  Causative organism: Mycobacterium tuberculosis  Primary infection or reactivation of latent focus  EPTB occurs outside lungs  10% of cases EPTB is disseminated throughout the body in multiple organs: most often lungs, liver,spleen,kidneys and bone marrow  The term miliary is now used to denote all forms of progressive, widely disseminated, hematogenous TB 3

4. EPTB in HIV(+):  33% extrapulmonary alone  33% pulmonary alone  33% both pulmonary and extrapulmonary (many with negative CXRs)  in 10% of cases EPTB is disseminated 4

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9. Clinical manifestations of EPTB: 9  Pleural effusions  Lymphatic system: cervical, supraclavicular  Skeletal: vertebral column, most often lower thoracal/lumbar region  Joint: hip,knee  Cns: meningitis,intracraniel tuberculomas  Pericardial: pericardial fluid with tamponade  Genitourinary tract: dysuria, hematuria  Disseminated: throughout the body, multiple organs, mostly: lungs (called miliary findings) liver,spleen,kidneys, bone marrow

10. Extrapulmonary TB Symptoms  Can have the same constitutional symptoms as people with pulmonary TB:  Fever, night sweats, fatigue, loss of appetite, weight loss.  In addition, patients often develop complaints specific to the body site infected with TB. examples:  Enlarged lymphnodes  Headache/confusion, neck stiffness,altered mental status  Skeletal pain: gradual onset  Joint pain, swelling  Abdominal pain  Urinary symptoms 10

11. DIAGNOSIS  Chest x-ray: can be typical/atypical or normal  Sputum for AFB :can be negative  Tuberculin skin test (TST)  Biopsy samples taken from the appropriate anatomic sites 11

12. DIAGNOSIS EPTB in HIV positive patients DIAGNOSIS is proven by:  One specimen from extra-pulmonary site culture positive for Mycobacterium tuberculosis  OR sputum positive for AFB  OR strong clinical evidence for extrapulmonary TB  AND laboratory confirmation of HIV infection  AND decision by clinician to treat with a full course of anti- tuberculosis chemotherapy 12

13. Diagnostic Challenges  Often more difficult to diagnose extrapulmonary TB  Because EPTB is less common, doctors often first think of other causes for the patient’s symptoms (e.g., pain in the right ankle more likely a sprained ankle than TB of the joint)  Secondly, EPTB often occurs in body sites that are difficult to access (e.g., the liver, which cannot be touched, or examined easily).  Hiv patients have higher rates of sputum negative disease  Chest radiographs may appear normal in up to 21% 13

14. EPTB/ILEMBULA LUTHERAN HOSPITAL 200820092010201120122013 Sputum + 8170766169 41 Sputum - 8047708386 63 Miliary 737116 34 Meningitis 01201 5 Spinal 97147 6 Effusion 1718203039 37 EP- children 912211520 30 Adenitis 0810712 14 Ohters 23360 1 Relapsy 00100 0 14 EPTB 44 52 6 573 85 127

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23. Conclusion  Common in HIV-infected persons  Difficult to diagnose because can mimic many diseases  Sputum for AFB often negative  CXR can be normal  Always get HIV test in patients with EPTB. 23

24. 24 ASANTE