inpatient / infectious disease
Tuberculosis (TB)
# Tuberculosis
Assessment:
-- History: *** exposures, travel, homeless, incarceration, IVDU, healthcare work, HIV, immunosuppressed
-- Clinical/Exam: *** fever, cough, sOB, hemoptysis, night sweats, weight loss, arthralgia
-- Data: *** CXR, AFB stains and cultures
-- Etiology/DDx: ***
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
Plan:
Workup
-- Isolate if ** cough, dyspnea, hemoptysis and 1+ RF (and if CXR equivocal but immunosuppressed) - d/c if AFB smear neg x3 or on TB tx for 2 weeks and AFB smear neg x3 with clinical improvement
-- f/u IGRA, AFB cultures from sputum x3 if c/f pulmonary TB; bronch can increase yield
-- Before treating - LFTs, BMP (Cr), HIV, Hep A/B/C, DM, EtOH use, pregnancy test
Treatment
-- Active TB - isoniazid, rifampin, pyrazinamide, ethambutol for 2 months followed by INH+RIF for 4 months
-- Latent TB - INH, rifapentine weekly for 12 weeks or RIF for 4 weeks
PDF coming soon!
If You Remember Nothing Else
While common and a leading cause of death worldwide, tuberculosis is rare in the United States. Initial infections are usually kept at bay by the immune system leading to a latent infection. Reactivation can happen if the immune system is weakened. Active infection leads to symptoms including cough, hemoptysis, fevers, night sweats, weight loss. TB can spread to any organ, but widely disseminated disease is usually limited to those with profound immunosuppression. Treatment is with atypical antibiotics (RIPE) and for prolonged periods. Latent TB is screened for via PPD testing or interferon-gamma release assay (IGRA), commonly known as quant-GOLD.
Clinical Pearls
- Testing is based on story and likelihood of progression to active disease - if positive and no true RFs, repeat testing. If positive in someone with high risk, proceed to treatment
- Only 5-10% of utreated cases will progress to active TB if untreated
- Tests like IGRA are less sensitive in patients with immunocompromise
- In primary TB, CXR is often normal or only shows hilar lymphadenopathy; in reactivation of TB, will see cavitation in ⅓ of patients in apical sections of the lungs
- Cultures have poor sensitivity but are clearly helpful if positive
- Medication side effects - hepatotoxicity, EMB causes optic neuritis, INH causes peripheral neuropathy (give B6), RIF causes body fluids to turn orange
- In disseminated TB, commonly involved organs include spleen, liver, lymph nodes, adrenals, meninges, vertebra (Pott Disease), and joints
Trials and Literature
- Tuberculosis Review (NEJM, 2013)
Other Resources
