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8/13/2012
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TB IntensiveSan Antonio, TexasAugust 7-10, 2012
Extrapulmonary TBLinda Dooley, MD
August 9, 2012
Linda Dooley, MD has the following disclosures to make:
• No conflict of interests
• No relevant financial relationships with any commercial companies pertaining to this educational activity
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Extrapulmonary Tuberculosis
Linda Dooley, MD, FACP
August 9, 2012
Thanks to Dr. Robert Longfield for all the picture slides and
several other slides
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Generalizations about Extrapulmonary TB
• Treated the same as pulmonary TB
• May be harder to diagnose
• Can be (almost ) anywhere
• More common in immune supressed patients (HIV, TNF blockers)
• More common in Asian patients
Pulmonary vs Extrapulmonary
PulmonaryExtrapulmonary
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Distribution of Extrapulmonary TB
LymphaticPleuralMeningitisGIBone and jointMiliaryGenitourinaryOther
DISTRIBUTION
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Patient with extrapulmonary TB may also have pulmonary involvement, even with a normal chest x‐ray
ALWAYS GET SPUTUM FOR AFB EVEN IF THE CHEST X‐RAY IS NORMAL
Pleural Tuberculosis
• 2nd most common form of extra‐pulmonary TB
• In most of the world, TB is the most common cause of pleural effusions
• Higher incidence in HIV+ patients
• Commonly a manifestation of primary TB
• May progress from an exudative effusion to an empyema or bronchopleural fistula
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Diagnosis
• Thoracentesis with pleural biopsy
• 30% yield for MTB from pleural fluid
• Exudative fluid with lymphocyte predominance, protein
• Pleural biopsy and culture may double yield of + culture; protein more than 4 g/dl; glucose varies
Tuberculous pleural effusions often resolve without treatment but high risk for later pulmonary
disease: treat anyway
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TB Empyema
Treatment
•Same as pulmonary TB
•6 months adequate if no drug resistance or immune problems
•Drop PZA at 2 months and leave EMB in regimen if cultures negative
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Lymphatic TB
• Most common form of extra-pulmonary TB (30-40%)• Most common sites are cervical (scrofula), mediastinal but can affect any node
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Diagnosis and Treatment
• Fine needle aspirate or open biopsy
• Culture for AFB
• Don’t forget CXR and sputum
• More common in women, Asianpopulation, immune suppression (HIV, TNF blockers)
• Treat like pulmonary TB
• Immune reconstitution may occur even with HIV negative patients
TB Meningitis
• 300‐400 cases annually in US
• 1% of TB disease
• Even with effective treatment, case fatality high: 15‐40%
• Early diagnosis both difficult and critical
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Pathogenesis
• TB granuloma spills into subarachnoid space producing inflammation, proliferative arachnoiditis, vasculitis and communicating hydrocephalus
• Localized initially to base of brain
Necrotizing granulomatous changes in arachnoid and blood vessels
Basilar meningitis
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Diagnosis
• Presentation may mimic bacterial meningitis: acute, rapidly progressive
• May be a slowly progressive dementia over months with personality change, social withdrawal or memory deficits
• Lumbar puncture: AFB stain and culture, PCR, NAAT, low CSF glucose, high protein, lymphocyte predominance
• Negative results do NOT exclude the diagnosis
CSF examination
• Serial examination of the CSF by AFB stain and culture is the best diagnostic approach
• Typically elevated protein, low glucose, and lymphocyte predominance
• Early CSF may be relatively acellular or PMN predominant
• Smears and cultures may yield positive results days to weeks after therapy has been initiated or may be negative
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CSF
• May improve AFB yield by using last fluid removed on LP
• Removing a large volume (10‐15 cc) of CSF for AFB culture
• Centrifuged specimen
• Consider repeat LP: serial studies can be helpful and improve yield
Nov
CT and MRI helpful in diagnosis
Multiple tuberculomas along enhanced dural reflections
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Basilar enhancement and hydrocephalus
Treatment
• Treat if meningitis suspected
• Early treatment essential
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Treatment
• 12 months for drug sensitive disease
• 18 months if no PZA
• Extend to 18‐24 months for severe illness, slow clinical response, or immune suppression
• No guidelines for length of treatment for MDR or XDR TB
CSF Penetration of TB Meds
GOOD FAIR POOR
Isoniazid * Rifampin * Streptomycin *
Pyrizimamide Ethambutol Capreomycin *
Ethionamide Quinolones * Amikacin *
Cycloserine Kanamycin *
Linezolid *
* Can Be Given IV
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Steroids
• Adjunctive corticosteroids may be beneficial and are recommended for all children and adults being treated for TB meningitis
• Doses– Children: 2‐4 mg/kg prednisone tapered over 4 weeks
– Adults: 60 mg/d prednisone tapered oever 6 weeks or .4 mg/kg/day dexamethasone IV tapered to .1 mg/kg/day
Surgery
• Hydrocephalus may require urgent shunting.
• Serial LP and steroid therapy may suffice for Stage I pts awaiting response to antibiotics.
• Shunting should not be delayed in patients with stupor, coma or progressive neurologic signs.
Nov 2009
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Pericardial TB
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Pericardial TB
• Uncommon and difficult diagnosis
• Presents with acute or insidious onset; nonspecific symptoms
• Ultrasound helpful; acid fast studies may not be positive
• Surgery for progressive tamponnade or recurrent effusions on TB Rx
• Steroids reduce mortality and need for surgery or repeat pericardiocentesis: start at 60 mg/d 1st month and reduce over 11 weeks
Bone and Joint TB
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Skeletal TB
• Spinal TB (Pott’s disease) most common location: 40%
• Next most common: hip (40%) and knee (10%)
• Can be anywhere
• Frequently delayed diagnosis
• X‐ray not helpful in distinguishing other infectious destructive etiology
Diagnosis
• Joint aspiration: WBC may be PMN or lymphocytes
• WBC count varies widely
• Protein 4‐6 g/dl; glucose may be low
• Acid fast culture yield high (up to 80%)
• Presence of positive smear much lower (20%)
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Treatment
• Standard TB therapy but extend treatment
• 12 months usual but extend for slow or uncertain response
• Surgery if needed to protect spinal cord (for instability or cord compression) or to remove prosthetic joint
• Effective drug treatment may preclude need for surgery
Soft Tissue TB
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Soft Tissue TB
• Often adjacent to bony and may be direct spread from bony structure or may erode into bone
• If not sure, treat like skeletal TB (longer duration)
• I&D of abscess will only be diagnostic if acid fast cultures done
Gastrointestinal and Peritoneal TB
• Peritoneal TB 10% extra‐pulmonary
• GI tract: any site possible but more common terminal ileum and cecum then rest of colon
• Often delayed diagnosis
• TB bacilli may be ingested rather than inspired: consider early if patient drank or ate unpasteurized milk products
• Acid fast cultures frequently negative: pathology caseating necrotizing granulomas
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Peritoneal TB
Laparoscopic view of peritoneal granulomas
Peritoneal TB: laparoscopic view of spiderweb adhesions
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Treatment
• If cultures negative or pending, assume PZA resistance
Esophageal TB Duodenal TB
Consider the age of your patient and possible childhood exposure to M. bovis
84 yo man with normal CXR
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Urogenital TB
Genitourinary TB
• 10‐15% extrapulmonary TB
• Often insidious onset, subtle nonspecific symptoms, delay in diagnosis
• Hematogenous spead from primary site, often years after infection
• Any part of GU tract may be affected
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Ureteral abnormalities (multiple “beading” strictures) may be virtually diagnostic of renal TB
Renal TB
• May have pyuria or hematuria or both
• Acid fast cultures of urine for sterile pyuria
• May need more than 3 specimens of first morning urine collection
• Urine AFB studies not always positive
• NAAT testing may be helpful but negative result does not preclude diagnosis
• Surgery or stenting for obstruction
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Prostatic TB
Testicular TB
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Uterine TB
Female Genital TB
• With Fallopian tube involvement, unlikely that preservation of fertility possible since usual scarring
• Often diagnosed by pathology after hysterectomy: treat even if involved organ removed
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Other TB
Laryngeal TB
Tuberculous Otitis Media
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XXXXXXXXXXTB Mastoiditis
Adrenal TB
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Adrenal insufficiency and TB
• May have unsuspected adrenal involvement alone or with disseminated TB
• Assessment of adrenal function if slow response or hypokalemia, hyponatremia, hypotension
• Don’t forget adrenal insufficiency possiblity if steroids were stopped after long use
Ocular TB
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Ocular TB
• Diagnosis made by ophthalmologist
• Diagnosis of exclusion
• No cultures available
• Treat same as pulmonary TB
TB of the Skin
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Dermatologic TB
• May be hematogenous or direct spread
• May be injection: accidents in pathology or microbiology lab
• Treatment same as pulmonary TB
What’s left??
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TB Everywhere
Miliary or Disseminated TB
• Tiny lesions spread throughout the body
• Distinctive pattern on CXR or CT
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Miliary TB• Pulmonary involvement may not be present
• Frequently subacute presentation with fever and weight loss
• More rarely can be fulminant sepsis‐like presentation with acute onset and rapid deterioration (usually fatal)
• Liver biopsy may be helpful
• Blood cultures may be positive if acid fast studies done
Treatment of Disseminated TB
• Prolonged treatment needed: 12 months
• Cultures may be negative: paucibacillary disease
• Don’t let negative cultures or normal CXR tempt you to shorten therapy
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Thank you
And thanks again to Dr. Longfield for his slides
Don’t forget to get sputum AFB even if you think only extrapulmonary TB
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