Extrapulmonary Tuberculosis
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Transcript of Extrapulmonary Tuberculosis
Extrapulmonary Tuberculosis
外科實習醫師Ri 林耿立91-7-29
TuberculosisAn ancient infectionTubercle bacillus discovered in 1882WHO: 8,000,000 active cases in 1990Developing countries (95%)Developed countries: HIV infection
Tuberculosis Pathogenesis
Chronic necrotizing bacterial infectionTubercle bacilli: Mycobacterium tuberculosis (MTB)Optimal growth: PO2—140mmHg
Hematogenous dissemination and lymphatic spread
Modified form of tuberculosis (AIDS)
Tuberculosis Clinical stages
Stage 1: Onset (macrophage inhalation)Stage 2: SymbiosisStage 3: Early caseous necrosisStage 4a & 4b: Interplay of cell-mediated immunity and tissue-damaging delayed-type hypersensitivityStage 5: Liquefaction and cavity formation
Extrapulmonary TuberculosisProportion in all TB in USA :
7% (1963) to 18% (1987) to 20% (now)Increase maybe due to HIV infectionMore in minorities and foreign-bornsLymphatic TB (30%) > Pleural TB (24%) > Bone and joint TB (10%) > Genitourinary TB (9%) > Miliary TB (8%) > Meningeal TB (6%) (New York, 1995)
Tuberculosis Lymphadenitis (1)Most common form of EPTBPeak age: children shift to 20-40 y/oHigh risk: Asians, female (2x to male), HIVHilar, paratracheal and neck lymphnodesSelf-limited (>90%), a little with pulmonary calcification
Tuberculosis Lymphadenitis (2) Differential Diagnosis
Nontuberculous mycobacteria (young age, unilateral and normal CXR)Virus or fungus infectionNeoplasmTuberculin skin test, history and CXRTotal excision biopsy and culture
Tuberculosis Lymphadenitis (3) Treatment
Anti-tuberculous chemotherapy for 6 months course (1st line: pyrazinamide, isoniazid, rifampin, streptomycin)Surgical intervention (drainage and incision aren’t suggested)
Bone and joint Tuberculosis (1)Pott’s diseaseIncreasing since 1980s13-25%: HIV positive in several trialsLocation: lumbar spine (29.5%) > thoracic spine (20.5%) > knee (13.2%) > hip (8.2%) > soft tissue or muscle (4.5%) (Los Angeles, 1990-1995)
Hematogenous dissemination
Bone and joint Tuberculosis (2) Pathophysiology
Invasion of joint space: direct or indirectCartilage preservationCold abscess and sinus tract formationFibrosis and ankylosis, calcification
Bone and joint Tuberculosis (3) Clinical Presentation
Tuberculous spondylitisTuberculous osteomyelitisTuberculous arthritisTuberculous tensynovitisTuberculous myositis
Bone and joint Tuberculosis (4) Tuberculous spondylitis
Most commonly, especially in developing countriesBack pain and rigidityVertebral body involvement and diskitisKyphosis and paraplegia
Bone and joint Tuberculosis (5) Tuberculous osteomyelitis
Initial: painful mass attached to bone with soft tissue swellingPredilection to metaphysis of long bonesMay extend to a joint or tenosynoviumSingle in adults; multiple in children, elders, immunosuppressive and HIV infection
Bone and joint Tuberculosis (6) Tuberculous arthritis
Large weight-bearing joint like hip, kneePainful, ankylosed or swollen mono-arthropathy, limitation of motionRice bodies, pannus, granulation, necrosis, narrowing of the joint space
Bone and joint Tuberculosis (7) Tuberculous myositis
More in immunosuppressive and AIDSMost in psoas muscle involvementSwelling, less pain; a solitary nodule with cold abscess, limitation of muscle function; iliac fossa pain or tenderness in some case
Bone and joint Tuberculosis (8) Diagnosis and DDx
DDx: sarcoid arthritis and pyogenic arthritis; fungus infection; neoplasmMonoarthritis, chronic pain, minimal signTuberculin skin testPlain radiography, open biopsyCT, MRI, CT-guided fine-needle aspiration biopsy
Bone and joint Tuberculosis (9) Treatment
Early diagnosisAnti-tuberculosis drugs with minimal operative intervention for abscess drainage (86% complete recovery)Operative decompression (laminectomy should be avoided)Arthroplasty
Genitourinary Tuberculosis (1)Developing >> developed countries (400:13)Male/female=2:1, most 20-40y/o (45-55y/o)Vague urinary tract symptoms: painless frequent micturition is commonmicroscopic hematuria: 50%Recurrent E. coli infectionUrine pus cell, suprapubic pain, hemospermia, painful testicular swelling: all rare
Genitourinary Tuberculosis (2) Diagnosis
Tuberculin skin testUrine examination and cultureElevated ESRPlain film, high-dose IV urography, percutaneous antegrade pyelographyLimited value: endoscopy, biopsy, ultrasonography and CT
Genitourinary Tuberculosis (3) Pathology
Kidney: chronic parenchymal abscess, large renal calcification; may spread to ureter, bladder, seminal visicleBladder: bullous granulation from ureteric orifice, obstruction; fistula to rectumEpididymis: bloodstream spread, present with discharging sinus; may spread to testis
Genitourinary Tuberculosis (4) Treatment
Anti-tuberculous chemotherapy (effective)Surgery (>80%): nephrectomy, nephro-ureterectomy, epididymectomy and reconstructive surgery
Cutaneous Tuberculosis (1)Uncommon (<1% in the west) but increase very rapidly in recent yearsMay contagious spreadExogenous source: Tuberculous chancre and prosector’s wartEndogenous source: scrofulodermaHematogenous source: Lupus vulgaris (apple jelly nodules) and multiple soft tissue cold abscess (most in AIDS)Tuberculous masitis: most in 20-50 y/o female
Cutaneous Tuberculosis (2) Diagnosis and Therapy
Excisional biopsy for AFB stain and cultureELISA and PCRTx: chemotherapy (isoniazid is first) and surgery (excisional biopsy and debridement)
CNS Tuberculosis (1) Pathogenesis and clinical presentation
Tuberculous meningitis (TBM)May produce damage to vessels, infarction of brain, edema, fibrosisPredilection: base of brainIn AIDS: cerebral abscess or tuberculomasSpace-occupying sign: headache, seizure, paralysis, personality change, CN defects, neck stiffness, papilledema
CNS Tuberculosis (2) Diagnosis and Treatment
CSF: clear or slightly opalescent; elevated protein and low glucose (virus: high)AFB and culture: limitedMeningeal biopsy: may contaminatingCT and MRI: helpfulTx: chemotherapy, surgery and steroids
Miliary TuberculosisLympho-hematogenous disseminationInfants and children: primaryElders or HIV infection: reactivationFever, weakness, anorexia, Wt loss, coughDx: CXR, HRCTTx: Chemotherapy for 9-12 months (HIV at least 12 months) or steroids (controversial, prevent reactivation and infection)
Other EPTBOtologic TuberculosisOcular TuberculosisCardiovascular TuberculosisTuberculous PeritonitisTuberculous EnteritisTuberculosis of the liver and biliary tract
HIV and EPTBImmunosuppression increases infection and makes its symptoms become atypicalTB: most cause of death in 24-44 y/o AIDSEPTB occur in 40-80% in HIV(+). Lymph node involvement is the most, but miliary, CNS or cutaneous TB are more than HIV(-)Prudent chemotherapy, TST for prevetion (if > 5mm, then INH chemoprophylaxis)Multipledrug-resistent TB
Molecular methods and EPTBDetection: Nucleic acid amplication test (MTD test and AMT test), show high sensitivity (95-96%) in AFB(+) but low sensitivity (45-53%) in AFB(-)MTD2 test (sensitivity 100%, specificity 99.6%)Mycobacterium tuberculosis direct testAmplicor mycobacterium tuberculosis test
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