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12/10/2009
Objectives
1. To recognize how TB presents differently:
Clinical Presentation of TB (a) among HIV-infected and -uninfected patients.
(b) among infants, children, adolescents and adults.
in HIV-infected Adults & Children
2. To describe the clinical manifestations of
Celine Gounder, MD, ScM
Johns Hopkins University
various forms of TB.
Division of Infectious Diseases and
Center for Tuberculosis Research
Risk of developing TB disease Presentation of TB by CD4 count
• Risk of LTBI TB disease • At CD4+ T-cell counts > 350 cells/mm3
– Pulmonary TB is most common form of disease.
– HIV-uninfected persons: ~10% lifetime risk – Extrapulmonary is more common than in HIV-
– HIV-infected persons: ~10% annual risk uninfected persons.
• The risk of TB disease increases even before • With lower CD4+ T-cell counts:
– Extrapulmonary TB and disseminated TB is more
CD4+ T-cell counts decrease. common.
• Reference: Sonnenberg P, et al. J Infect Dis. – Clinical, radiologic, histopathologic and microbiologic
2005;191:150-58. features may be absent.
– Features may not emerge until immune reconstitution
with ART.
Pulmonary TB “Tree-in-bud sign”
• Indicates airway plugging with mucus, pus or
• Symptoms: fluid
– Infants: fever, cough, dyspnea • Branching course of peripheral airways can be
– Children: cough seen
– Adolescents/adults: fever, cough, sputum
• Associated with infection that is spread
production, anorexia, weight loss, night sweats,
hemoptysis endobronchially
• Signs:
– Crackles, wheezing, decreased breath sounds
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Cavitation
Cavitary lesions with hemorrhage Intrathoracic lymphadenopathy
• Symptoms:
– Usually none
– Rarely causes symptoms associated with extrinsic
airway compression or trachea-esophageal fistula
formation
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Pleural TB
• Symptoms:
– Chest pain, cough, dyspnea, fatigue, anorexia,
weight loss, night sweats
• Signs:
– Decreased breath sounds, dullness to percussion,
asymmetric chest movement, pleural rub,
decreased vocal resonance and fremitus,
bronchial breathing and egophony above the
effusion
Pleural effusions
Tuberculous
pleurisy
TB empyema with pleural thickening Subpleural tuberculoma
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Superficial lymphadenitis
• Symptoms:
– Painless, slowly enlarging lymph nodes over weeks
to months without erythema or warmth, fever,
weight loss, fatigue, night sweats
Inguinal
Axillary
Disseminated (Miliary) TB Disseminated TB
• Disseminated or miliary: hematogenous or • Symptoms:
lymphatic spread from the lungs to other – Fever, cough, dyspnea, weight loss, anorexia, night
parts of the body sweats, rigors
• Signs:
– Fever, cachexia, tachypnea, hypoxemia, abnormal
lung exam, hepatosplenomegaly,
lymphadenopathy, erythematous macular or
papular skin lesions, choroid tubercles
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Disseminated TB Disseminated TB
• Adult respiratory distress syndrome
• Noncardiogenic pulmonary edema
• Shock
• Fever of unknown origin
• Failure to thrive without fever
Disseminated TB Disseminated TB
Disseminated TB Disseminated TB
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TB pericarditis TB pericarditis
• Symptoms:
– Fever, chest pain, cough, dyspnea, orthopnea,
weight loss
• Signs:
– Hepatomegaly, jugular venous distension, pulsus
paradoxus, pericardial friction rub/knock, ascites,
pedal edema
TB Meningitis
• Symptoms:
– Adults: headache, fever, neck stiffness, lethargy
– Children: nausea, abdominal complaints, lethargy,
irritability
• Signs:
– Stage I (early): nonfocal signs
– Stage II (intermediate): Brudzinski's and Kernig's signs,
tripod phenomenon, cranial nerve palsies
– Stage III (advanced): hemiplegia or paraplegia,
hypertonia, hypertension, hemodynamic instability,
decerebrate posturing, seizures, coma
Basilar meninges
TB meningitis
Asterisks: ventricular dilatation
Black arrows: inflammatory exudate in the ambient cistern
White arrows: multiple foci of vasculitis-associated subacute,
ischemic necrosis
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Tuberculomas and
Enhancing meninges
Tuberculous brain abscess
• Frequency:
– TB meningitis > Tuberculoma > TB brain abscess
• TB brain abscesses more commonly associated
with tuberculous meningitis, and thus more
likely to see:
– Concomitant meningismus
– Lower glucose concentration
Tuberculomas and Tuberculomas and
Tuberculous brain abscess Tuberculous brain abscess
• Symptoms: • Tuberculomas
– Headache, fever, delirium – Subacute
• Signs: • Tuberculous brain abscces
– Focal neurological defects – Acute
– Evidence of intracranial hypertension – More toxic
– Cranial nerve palsies, papilledema, hemiparesis,
seizures
Tuberculous brain abscess TB of the CNS
• Early treatment reduces morbidity and
mortality
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Laryngeal TB Laryngeal TB
• Symptoms: http://www.youtube.com/watch?v=cAScqih4lTg
– Cough, hemoptysis, odynophagia, hoarseness,
pain or weakness with speaking, ear pain
• Signs:
– Laryngeal edema and/or hyperemia; nodular
swelling of interarytenoid space, aryepiglottic
folds and/or epiglottis; vocal cord paralysis;
laryngeal stenosis
Otologic TB Mastoiditis
• Symptoms:
– Painless otorrhea, hearing loss
• Signs:
– Tympanic perforations, thickened tympanic
membrane, facial nerve paralysis, bony
labyrinthitis
Pott’s Disease:
Pott’s Disease
Spinal TB
• Symptoms:
– Back and neck pain, weakness, numbness,
changes in gait
• Signs:
– Flank mass, paraparesis, paraplegia, spinal
deformity
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Pott’s Disease Psoas Abscess
Abdominal TB
Tuberculous ileitis
(enteritis, peritonitis)
• Symptoms:
– Abdominal pain, weight loss, fever, weakness,
nausea, vomiting, anorexia, abdominal distension,
night sweats, constipation, diarrhea
• Signs:
– Cachexia, abdominal mass, abdominal distension,
“doughy” abdomen, ascites, rebound tenderness
Obstruction
Obstruction
Abdominal lymphadenopathy
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Doughy abdomen Doughy abdomen
Peritonitis Hepatobiliary TB
• Symptoms:
– Abdominal pain, fever, malaise, fatigue, night
sweats, anorexia, weight loss
• Signs:
– Right upper quadrant tenderness,
hepatosplenomegaly, jaundice, ascites
TB of the kidneys, ureters and bladder
• Symptoms:
– Fever, night sweats, weight loss, dysuria, flank
pain, hematuria, urinary frequency/urgency,
nocturia
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Renal TB
TB of the fallopian tubes,
TB of the bladder
endometrium and ovaries
• Symptoms:
– Pelvic pain, infertility, amenorrhea,
dysmenorrheal, abnormal uterine bleeding, fever,
weight loss, fatigue
• Signs:
– Adnexal masses, uterine enlargement
TB of the fallopian tubes TB of the fallopian tubes
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TB of the endometrium TB of the ovaries
Pelvic adhesions TB of the epididymis and testes
• Symptoms:
– Painful scrotal swelling
• Signs:
– Scrotal mass, infertility
Epididymitis and Orchitis Testicular TB
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TB of the seminal vesicles TB of the prostate
• Symptoms:
– Dysuria, perineal pain
• Signs:
– Hard, irregular, nodular or granular prostate
– Soft fluctuant mass
– Hematuria, urethral discharge, infertility
– Draining perineal fistula
Addison’s disease:
TB of the prostate
TB of the adrenal gland
• Symptoms:
– Fatigue, anorexia, nausea, abdominal pain,
diarrhea, arthralgias, myalgias
• Signs:
– Orthostatic hypotension, hyperpigmentation
Adrenal TB TB Mastitits
• Symptoms:
– Unilateral breast lump/swelling
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Mastitis TB of the skin
• Tuberculosis cutis miliaris acuta generalisata
(acute miliary TB)
• Tuberculosis verrucosa cutis (warty TB)
• Lupus vulgaris
• Scrofuloderma
• Erythema nodosum
Tuberculosis cutis miliaris acuta
Skin ulcers
generalisata
Tuberculosis verrucosa cutis Lupus vulgaris
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Scrofuloderma Erythema nodosum
Key Take-home Point Presentation of TB in infants
• Tuberculosis can cause disease ANYWHERE in • Usually have signs and symptoms of TB
the body! • Higher risk for progressive primary TB disease
• Tuberculosis should be on the differential • Extrapulmonary TB is common
differential diagnosis of EVERY HIV-infected – Lymphadenitis
patient. – CNS disease
– Pleural disease
– Disseminated (miliary) disease
Presentation of TB in children Presentation of TB in adolescents
• More likely to have subclinical disease than • Usually have signs and symptoms of TB
infants or adolescents
• Similar risk to adults of LTBI active TB • Similar risk to adults of LTBI active TB
• Most develop pulmonary parenchymal disease
and/or intrathoracic lymphadenopathy
• Extrapulmonary TB is common
– Lymphadenitis
– CNS disease
– Pleural disease
– Disseminated (miliary) disease
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Reference
• Gounder CR, Chaisson RE. Tuberculosis and
Other Mycobacterial Infections in HIV-Infected
Patients. Clinical Care Options in Practice.
http://www.clinicaloptions.com/inPractice/HI
V/Management%20of%20Specific%20Disease
%20States/ch28_pt1. 1 Oct 2009.
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