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