Which clinical manifestations are associated with a diagnosis of tuberculosis?
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In the early 20th century in the United States, when tuberculosis was more prevalent, the risk of becoming infected with M. tuberculosis was high across the entire population. Currently, tuberculosis has retreated into fairly well-defined pockets of high-risk individuals, such as foreign-born persons from high-prevalence countries, persons who travel to high-prevalence countries, inmates of correctional institutions, illicit drug users, unprotected health care workers who care for high-risk patients, migrant families, homeless persons, and anyone likely to encounter people with contagious tuberculosis. One must distinguish the risk factors for becoming infected with M. tuberculosis from factors that increase the likelihood that an infected individual will develop disease. Age, immunocompromised status, and recent infection with M. tuberculosis are the major risk factors for progression of infection to disease. Show
Although tuberculosis occurs throughout the United States, cases are disproportionately reported from large urban areas. Cities with populations exceeding 250,000 account for only 18% of the U.S. population, but almost 50% of tuberculosis cases in the United States. Among U.S.-born persons, tuberculosis disproportionately affects African Americans, whose rates of tuberculosis disease remain 8.5 times the rates seen in whites born in the United States [31,32]. The number of tuberculosis cases in the United States is increasing among foreign-born persons from countries with a high prevalence of tuberculosis. The percentage of total cases of tuberculosis in the United States that occurs in foreign-born individuals increased from 22% in 1986 to 59% in 2007, and foreign-born individuals have a 9.7 times higher rate of tuberculosis than individuals born in the United States [31]. In addition, 85% of cases of multidrug-resistant (MDR) tuberculosis are seen in foreign-born individuals [31]. In previous estimates, two thirds of foreign-born individuals with tuberculosis were younger than 35 years when entering the United States, and in many cases, their disease could have been prevented if they had been identified as infected after immigration and given appropriate treatment for M. tuberculosis infection. Until very recently, new immigrants to the United States older than 15 years of age were required to have a chest radiograph but no tuberculin skin test to detect asymptomatic infection; children younger than 15 years old received no tuberculosis testing as part of immigration [33]. This policy ignored a huge reservoir of future tuberculosis cases. Studies have estimated that 30% to 50% of the almost 1 million annual new immigrants to the United States are infected with M. tuberculosis [29]. Foreign-born women and adolescents of childbearing age should be one group targeted for appropriate tuberculosis screening and prevention [34]. There are data suggesting that the current U.S. Centers for Disease Control and Prevention (CDC) and American Thoracic Society (ATS) policies on targeted screening of immigrants [35] would fail to prevent most cases [36]. A more effective strategy to decrease tuberculosis in the United States may be to expand treatment programs in countries from which immigrants originate [37]. Another factor that has had a great impact on tuberculosis case rates in the United States has been the epidemic of HIV infection [27]. The proportion of women with HIV infection is increasing; the population demographic in which HIV is most rapidly spreading is persons of reproductive age (13 to 44 years old), who accounted for 73% of newly diagnosed cases in 2006 [38]. Because the risk factors for HIV infection intersect with risk factors for tuberculosis, the number of coinfected women is expected to increase [39–41]. Approximately 16% of tuberculosis patients 25 to 44 years old in the United States are also HIV-seropositive [42]. In most locales experiencing increases in tuberculosis cases, the demographic groups with the greatest tuberculosis morbidity rates are the same as those with high morbidity rates from HIV infection. HIV-infected persons with a reactive tuberculin skin test develop tuberculosis at a rate of 5% to 10% per year compared with a historical average of 5% to 10% for the lifetime of an immunocompetent adult. There is controversy concerning the infectiousness of adults with HIV-associated pulmonary tuberculosis. Although some studies have indicated dually infected adults are as likely as non–HIV-infected adults with tuberculosis to infect others, some studies have shown less transmission from HIV-infected adults [43]. The current epidemiology of tuberculosis in pregnancy is unknown. From 1966-1972, the incidence of tuberculosis during pregnancy at New York Lying-In Hospital ranged from 0.6% to 1% [44]. During this time, 3.2% of the patients with culture-proven pulmonary tuberculosis were first diagnosed during pregnancy, a rate equal to that of nonpregnant women of comparable age. Only two series of pregnant women with tuberculosis have been reported from the United States in the past 2 decades [45,46], and two series have been reported from the United Kingdom [47,48]. In the latter two series, diagnosis was delayed in many women with extrapulmonary manifestations of tuberculosis. Increased risk of tuberculosis is most striking for foreign-born women, who have high rates of tuberculosis infection, and poor minority women. In the United States, almost 40% of tuberculosis cases in minority women occur in women younger than 35 years. Approximately 80% of cases of tuberculosis infection and disease among children in the United States occur in minority populations [25,49]. Most of these cases occur after exposure to an ill family member. In all populations, whether the disease incidence is high or low, tuberculosis infection and disease tend to occur in clusters, often centered on the close or extended family, meaning that minority newborns are at greatly increased risk of congenital and postnatally acquired tuberculosis infection and disease. View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9781416064008000183 Tuberculosis : Clinical Manifestations and DiagnosisV. Courtney Broaddus MD, in Murray & Nadel's Textbook of Respiratory Medicine, 2022 Radiographic FeaturesRadiographic examination of the chest is commonly the first diagnostic study undertaken, after the history and physical examination.16,17 However, in resource-limited settings, a chest radiograph is not necessarily included as part of the routine evaluation because of cost, complexity, and nonspecificity of the findings.18 Pulmonary TB nearly always causes detectable abnormalities on the chest radiograph, although, in patients with HIV infection, a chest radiograph may be normal in up to 11% of patients with positive sputum cultures, and the chest radiograph may be normal in laryngeal TB. Inprimary TB, resulting from recent infection, the process is generally seen as a middle or lower lung zone opacity, often associated with ipsilateral hilar adenopathy (Fig. 53.1). Atelectasis may result from compression of airways by enlarged lymph nodes. If the primary process persists beyond the time when specific cell-mediated immunity develops, cavities may form (so-called progressive primary TB). Inreactivation TB, developing at a time remote from the original infection, one sees involvement of the upper lobes of one or both lungs. Cavitation is common in this form of TB. The most frequent sites are the apical and posterior segments of the right upper lobe (Fig. 53.2) and the apical-posterior segment of the left upper lobe. Healing of the tuberculous lesions usually results in development of a fibrotic scar with shrinkage of the lung parenchyma and, often, calcification. Involvement of the anterior segments alone is unusual. In the immunocompetent adult with TB, intrathoracic adenopathy is uncommon. When the disease progresses, infected material may be spread via the airways (i.e., “bronchogenic” spread) into the lower portions of the involved lung or to the other lung. Erosion of a parenchymal focus of TB into a blood or lymph vessel may result in dissemination of the organism and a miliary pattern on chest imaging (Fig. 53.3; seeFig. 20.21). Radiographic findings in HIV-infected patients are affected by the degree of immunosuppression. As further explained and illustrated inChapter 123, TB early in the course of HIV infection—before profound depletion of CD4 T cells—tends to produce typical radiographic findings with predominantly upper lobe infiltration and cavitation.20 With more advanced HIV disease and CD4 T-cell deficiency, the radiographic findings become more “atypical”: cavitation is uncommon, and lower lung zone or diffuse opacities and intrathoracic adenopathy are frequent (Fig. 53.4). Surprisingly, a substantial number of HIV-infected patients with pulmonary TB have normal radiographs at the end of their course of treatment.21 View chapter on ClinicalKey TuberculosisGeetha Ramachandran, Soumya Swaminathan, in Handbook of Pharmacogenomics and Stratified Medicine, 2014 36.2 TB Etiology and Natural HistoryTuberculosis is caused by the bacillus Mycobacterium tuberculosis (Figure 36.1) [3]. It typically affects the lungs (pulmonary TB) but can affect other sites as well (extrapulmonary TB). The disease is spread in the air when people who are sick with pulmonary TB expel bacteria, for example by coughing. In general, a relatively small proportion of people infected with Mycobacterium tuberculosis will develop TB disease; however, the probability of developing TB is much higher among people infected with HIV. TB is also more common among men than women and affects mostly adults in economically productive age groups.  Figure 36.1. Causative organism for TB. High-power micrograph of acid-fast bacilli in the sputum of a patient with tuberculosis, shown by Ziehl-Neelsen staining (×1000). Source: Reproduced with permission from Lawn and Zumla [3].The natural history of TB is influenced by several factors, the course being determined by the balance between host immunity and virulence of the TB bacillus. This understanding facilitates identification of areas where interventional strategies can be identified for TB control [4–6]. View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780123868824000360 TuberculosisJavad Parvizi MD, FRCS, ... Associate Editor, in High Yield Orthopaedics, 2010 Definition:Tuberculosis (TB) is an inhaled infectious disease that primarily affects the lungs; however, it may also affect the central nervous system, lymphatic and circulatory systems, bones, and tissues. TB was the cause of the “white plague” in the seventeenth and eighteenth centuries in Europe. Incidence:Eight million people globally develop TB and 3 million die from the disease. In 1998, there were about 18,000 new cases in the United States. Age and Gender:TB is not age or gender specific. Etiology and Pathophysiology:Tuberculosis is caused by an acid-fast, aerobic bacilli bacterium—Mycobacterium tuberculosis. The disease is initiated when the bacilli reach the pulmonary alveoli after inhalation. TB is a granulomatous inflammatory condition causing periods of tissue destruction and necrosis followed by healing and fibrosis. Associations and Predispositions:Infection with human immunodeficiency virus, acquired immunodeficiency syndrome, poor nutrition and environmental conditions, intravenous drug use, and alcoholism. Fig. 226-1. Magnetic resonance imaging study showing extensive destruction of L1 and L2 vertebral bodies and the intervening disk with posterior extension in a Pakistani man with Pott’s disease. (From Mandell GL, Bennett JE, Dolin R [eds.]: Principles and Practice of Infectious Diseases, 6th ed. Philadelphia, Saunders, 2005.)Signs and Symptoms:Signs and symptoms include a persistent dry cough, significant weight loss, a decrease in energy, fever, and night sweats. For advanced stage tuberculosis, symptoms include chest pain and difficulty breathing. Diagnostic Studies:Diagnostic tests include chest x-ray examination, computed tomography scan, sputum cultures, tuberculin skin test, bronchoscopy, interferon (IFN)-gamma blood test, and QuantiFERON-TB Gold, which has more recently been used instead of the tuberculin skin test. Macropathology:An individual with stage IV TB disease presents with either exudative lesions resulting from polymorphonuclear leukocytes around M.tuberculosis or granulomatous lesions due to hypersensitivity of the host to tuberculoproteins. These lesions appear in the well-aerated upper lobes of the lungs because M. tuberculosis is an obligate aerobe. Micropathology:Once M. tuberculosis is inhaled, activated macrophages surround tubercles; this complex often serves as a breeding ground, hence promoting growth of M. tuberculosis. Treatment:If active TB is diagnosed or strongly suspected, treatment is initiated with isoniazid, rifampin, pyrazinamide, and ethambutol. Dosage and drug of choice are altered per case, gender, and age. Second-line drugs include cycloserine, ethionamide, streptomycin, and levofloxacin. View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B978141600236900239X TuberculosisAnn M. Loeffler MD, in Pediatric Clinical Advisor (Second Edition), 2007 Basic InformationDefinitionTuberculosis (TB) is a disease characterized by active replication of Mycobacterium tuberculosis complex. Children with pulmonary TB have chest radiographic changes and may or may not have clinical symptoms or physical examination abnormalities. Latent TB infection (LTBI) is an infection with M. tuberculosis, but the organism is in a latent or dormant state. The patient has a skin test result that is positive for TB but a normal chest radiograph and no signs or symptoms of tuberculosis. SynonymsConsumption LTBI Scrofula (i.e., mycobacterial disease in a peripheral lymph node) TB ICD‐9‐CM Codes010.01 Primary tuberculosis (often used to code for LTBI) 011.6 Tuberculosis pneumonia (any form) 012.1 Tuberculosis of intrathoracic lymph nodes 017.2 Peripheral scrofula 795.5 Positive tuberculosis TB skin test (TST) without active tuberculosis (nonspecific) V01.1 Exposure to active tuberculosis Epidemiology & Demographics•One third of the world's population is infected with M. tuberculosis. ○Incidence is highest in Asia, Africa, Eastern Europe, and Latin America. ○Prevalence of infection increases incrementally with age (i.e., with accumulated risk of exposure). •Active tuberculosis after infection is highest in the first year of life. ○Children younger than 1 year old have a 40% risk of developing active disease if infected. ○This is in contrast to the population as a whole, who have only a 10% lifetime risk of reactivation to active disease. •Other populations at increased risk of activation after infection: ○Adolescents (especially girls) ○Recently exposed or infected individuals (50% of the risk of activation is in the first 2 years of infection) ○Recent immigrants (<5 years in the United States) ○Those with various immunocompromising medical conditions (e.g., human immunodeficiency virus [HIV] infection, cancer, chronic immunosuppressive therapy, diabetes mellitus, renal failure) •In the United States, most children with TB are foreign born, children of immigrant families, and other minorities. •Of 922 U.S. children younger than 15 years and diagnosed with TB in 2003, 432 (47%) were Hispanic, 118 (13%) were Asian, and 261 (28%) were black. Clinical Presentation•More than 50% of U.S. children diagnosed with active TB are asymptomatic. Most are identified because they were evaluated after known exposure to a contagious adolescent or adult with active pulmonary or laryngeal TB. •Symptomatic children may have sluggish weight gain or weight loss, cough, fever, malaise, bone or joint pain, or symptoms of meningitis. •Physical examination abnormalities are scant in children with pulmonary TB. Even children with impressive radiographic changes may have only modest lung findings on examination. ○Infants are more likely to have fever, rales, and increased work of breathing. Adolescents have disease more typical of an adult presentation, with fever, cough, weight loss, night sweats, and rales with decreased breath sounds, dullness to percussion, or egophony. •Lymphadenopathy is the most common extrapulmonary finding. ○Intrathoracic lymphadenopathy is common and is symptomatic only if there is significant compression on a bronchus or erosion through the bronchial wall (i.e., endobronchial TB). ○Scrofula (i.e., peripheral mycobacterial lymphadenopathy) caused by TB is more often found in older children. It most typically occurs in the cervical node chains and is characterized by gradual lymph node enlargement, skin discoloration, skin thinning, and eventual skin breakdown. •Meningitis and military TB are the next most common sites of extrapulmonary TB and are more often associated with fever and systemic symptoms. Meningitis caused by TB is more indolent than that caused by other bacteria and viruses. •TB can occur in other body parts, including bone, joints, skin, and kidneys. Etiology•Inhalation of M. tuberculosis causes most TB cases. •Much less commonly, ingestion of unpasteurized milk products containing M. bovis causes TB (with a propensity to cause lymphatic disease). •Rarely, newborns may be infected congenitally or during the birth process. View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323035064103396 TuberculosisJohn W. Ogle MD, in Berman's Pediatric Decision Making (Fifth Edition), 2011 Tuberculosis (TB) is a disease caused by Mycobacterium tuberculosis and other closely related mycobacterial species (M. bovis, M. africanum). M. tuberculosis produces either latent infection or active tuberculous disease. Latent infection is the presence of a positive skin test with no sign or symptom of active TB and a normal chest radiograph. Active TB can involve almost any organ system but most commonly infects the lungs, pleura, central nervous system, lymphatic system, kidneys, bladder, bones, and joints. A.Ask about exposures to active TB and any risk factors for development of active TB. In childhood TB, the disease is usually contracted from an adult with active TB. Detail any close contact with persons at high risk for TB, including foreign-born persons from high-prevalence areas, the homeless, the incarcerated, human immunodeficiency virus (HIV)–positive individuals, intravenous drug users, nursing home residents, and the medically underserved. Risk factors for progression of infection to active TB include young age (<4 years), recent infection with TB (<2 years), HIV infection, diabetes mellitus, prolonged corticosteroid therapy, other immunosuppressive therapy, leukemia, lymphoma, other cancers, end-stage renal disease, chronic malabsorption syndromes, and low body weight (10% or more less than ideal). Symptoms of pulmonary TB include a prolonged or productive cough, hemoptysis, and chest pain. Symptoms of TB meningitis include changes in mental status, irritability, difficulty feeding, decreased responsiveness, and seizures. Systemic symptoms of active TB include fever, chills, night sweats, weight loss, and easy fatigability. Many children with active TB have subtle symptoms or are asymptomatic. B.TB is often a slowly progressive disease, and many children with active TB have normal examinations. On physical examination, look, listen, and feel for findings that suggest meningitis (irritability, lethargy, unresponsiveness, full fontanelle, nuchal rigidity, presence of Kernig and Brudzinski signs) or pneumonia (tachypnea, retractions, nasal flaring, crackles). Examine for signs of adenitis or soft-tissue abscess (swelling, redness, or induration) or bone or joint infection (refusal to use limb, swollen joint, limitation of joint motion). C.The Mantoux method of tuberculin skin testing (referred to as PPD or TST) is the preferred method of testing for TB infection in children. A PPD test can be performed during the same visit that immunizations are given, and a previous immunization with bacille Calmette–Guérin (BCG) is not a contraindication to placement of a PPD. The test involves the intradermal administration of 0.1 ml of 5 tuberculin units of purified protein derivative on the volar surface of the forearm to produce a wheal 6 to 10 mm in diameter. The test should be read at 48 to 72 hours, measuring only the induration in millimeters. Measure with a ruler perpendicular to the long axis of the arm. A skin test response is typically positive 2 to 12 weeks after infection. Table 1 details interpretation of the skin test. Results are interpreted regardless of prior BCG vaccination. Measurement of γ-interferon released from white blood cells stimulated by M. tuberculosis antigens forms the basis of a new diagnostic test for TB. In adult patients, these tests have equal sensitivity and greater specificity than Mantoux testing. These tests are not yet FDA approved in children. D.Children who are PPD positive with a normal chest radiograph, with no symptoms or signs of active TB, have latent TB infection. Treat with isoniazid, 10 to 15 mg/kg/day, for 9 months. Breast-fed and malnourished children warrant supplemental vitamin B6 (Pyridoxine) therapy, 1 to 2 mg/kg/day (25 mg maximum), to prevent peripheral neuropathy. Treat children younger than 4 years with close exposure to a case of active TB with isoniazid, even if the child is PPD negative and the chest radiograph is normal, for 10 to 12 weeks after the last exposure; then repeat the PPD test. A newborn exposed to TB should have a chest radiograph, a PPD test; consider a lumbar puncture. If findings of TB are not present, treat with isoniazid for 3 to 4 months; then repeat the PPD test. Some experts treat these neonates with 9 months of isoniazid. If the contact case has isoniazid-resistant, rifampin-sensitive TB, treat with rifampin. Treatment of latent TB infection provides substantial protection against development of subsequent active TB. E.The diagnostic tests for active TB are directed at confirming the diagnosis, obtaining a specimen for culture and sensitivities, and detailing the extent of disease. Always obtain a chest radiograph, even in those without pulmonary symptoms. A culture is important to confirm the diagnosis of TB and to guide TB therapy. Specimens can be obtained from sputum, early-morning gastric aspirates (useful in infants and young children who cannot produce sputum), bronchoalveolar lavage fluid, pleural fluid, pus, urine, cerebrospinal fluid, or a biopsy specimen. TB in children can be confirmed microbiologically in only 30% to 40% of cases. The decision to hospitalize a child for diagnostic testing balances the risks and costs of obtaining specimens along with the seriousness of the disease and the likelihood of alternate diagnoses. F.The treatment of active TB is complicated by the long duration of therapy, difficulties with compliance of patients, emergence of multidrug resistance, and coexisting diseases such as HIV infection. Therapy of active TB is directly observed therapy with isoniazid, rifampin, and pyrazinamide. Those patients with both HIV infection and TB should ideally be treated by experts in both HIV and TB care. For all patients, if the TB strain is resistant to any of the first-line TB drugs, or if the patient remains symptomatic after 3 months, consult a TB medical expert. Because we cannot test visual acuity in young children, ethambutol has been avoided in the past. Because there is no evidence that ethambutol in the doses used causes visual problems in young children, many experts use ethambutol in young children when four-drug therapy is indicated. Children with latent TB and most children with active TB are not contagious. Children with cavitary TB, laryngeal TB, intubated patients, patients with positive smears for acid fast bacilli, and some immune-suppressed patients may pose contagious risk. G.Consider the use of corticosteroids for 6 to 8 weeks when there is severe morbidity from inflammation. Corticosteroids are indicated for children with tuberculous meningitis because steroids have been shown to lower mortality and long-term neurologic sequelae. Indications in addition to meningitis may include pleural and pericardial effusions, severe miliary disease, and intrinsic or extrinsic bronchial obstruction and atelectasis. H.Tuberculous meningitis has a high mortality rate and is associated with severe neurologic sequelae in survivors. Increased intracranial pressure must be carefully managed, and the use of corticosteroids is indicated. Initial antibiotic therapy should include four drugs. Rifampin, streptomycin, and ethambutol penetrate into cerebrospinal fluid well only when meninges are inflamed. Isoniazid and pyrazinamide have good cerebrospinal fluid penetration. What are clinical manifestations of tuberculosis?Active TB .
Coughing for three or more weeks. Coughing up blood or mucus. Chest pain, or pain with breathing or coughing. Unintentional weight loss.
What is the clinical diagnosis of tuberculosis?The most commonly used diagnostic tool for tuberculosis is a skin test, though blood tests are becoming more commonplace. A small amount of a substance called tuberculin is injected just below the skin on the inside of your forearm. You should feel only a slight needle prick.
What are the 4 cardinal clinical signs and symptoms of tuberculosis?What Are the Symptoms of TB? The general symptoms of TB disease include feelings of sickness or weakness, weight loss, fever, and night sweats. The symptoms of TB disease of the lungs also include coughing, chest pain, and the coughing up of blood.
Which of the following signs and symptoms is common in clients with active TB?TB bacteria usually grow in the lungs and symptoms can include: bad cough that last 3 weeks or longer, pain in the chest, coughing up blood or sputum, weakness/fatigue, weight loss, chills, fever and night sweats.
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