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CLINICAL OVERVIEW
Tuberculosis
Updated September 13, 2018. Copyright Elsevier BV. All rights reserved.
Urgent Action
Report all suspected cases (while awaiting culture results) and confirmed cases of tuberculosis to local
and state health departments as required by law
Synopsis
Key Points
Persons at higher risk for infection or at higher risk of progression to active disease if infected should be
screened for latent tuberculosis with a tuberculin skin test or interferon-γ release assay
In the primary or reactivation stages, patients may present with pulmonary involvement,
extrapulmonary involvement (more rarely), or both. Presentation depends on stage of disease and
underlying health of affected person
The diagnostic approach to active pulmonary tuberculosis includes 3 sequential sputum samples for
acid-fast bacilli smears, nucleic acid amplification testing, and sputum culture for Mycobacterium
tuberculosis
Drug-susceptible pulmonary tuberculosis is treated with a 6-month multidrug regimen, which includes
isoniazid, rifampin, ethambutol, and pyrazinamide
Multidrug-resistant tuberculosis infection is present when a strain is resistant to at least the first line
drugs isoniazid and rifampin
Extensively drug-resistant tuberculosis is present when strains are resistant to at least the first line drugs
of isoniazid and rifampin, a fluoroquinolone, and an aminoglycoside
Therapy for multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis requires second
line drugs to be continued for 18 to 24 months
Pitfalls
Reactivation tuberculosis may mimic community-acquired pneumonia and should always be considered,
at least initially, in the differential diagnosis
Patients with multidrug-resistant tuberculosis are at high risk for treatment failure and additional drug
resistance
When treatment failure is diagnosed, never add a single drug to a failed treatment regimen. Drugs
should always be added in groups of 2 or 3 to prevent further acquired resistance 1
Terminology
Clinical Clarification
Classification 2
Occult bacterial dissemination occurs until innate immunity stops the process (majority of cases)
Primary progressive tuberculosis occurs in a small percentage of cases within 2 years of infection
(occurring more frequently among patients at the extremes of age and among debilitated or
immunosuppressed patients)
After primary tuberculosis infection in a patient with intact immune system, most cases remain latent
and inactive
Develops after latent tuberculosis infection in 5% to 10% (historically), but risk may be much greater in
high-risk groups 3
Reactivation tuberculosis is typically pulmonary and occurs more than 2 years after primary infection
Diagnosis
Clinical Presentation
History
Patients with latent tuberculous infection are asymptomatic but may have a history of exposure
Dyspnea
Nonproductive cough
Reactivation tuberculosis
Fever
Night sweats
Weight loss
Productive cough with purulent or bloody sputum for longer than 3 weeks
Extrapulmonary tuberculosis (accounts for 15% of cases in immunocompetent patients, 50% to 70% of
cases in immunocompromised patients) 4
Fever
Miliary (widely disseminated hematogenous tuberculosis; seen in 1%-2% of all tuberculosis cases) 5
Fever
Night sweats
Weight loss
Tuberculosis meningitis
Headache
Stiff neck
Confusion or somnolence