Extrapulmonary Tuberculosis

外科實習醫師Ri 林耿立91-7-29

Tuberculosis

An ancient infection

Tubercle bacillus discovered in 1882

WHO: 8,000,000 active cases in 1990

Developing countries (95%)

Developed countries: HIV infection

Tuberculosis Pathogenesis

Chronic necrotizing bacterial infection

Tubercle 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 Tuberculosis

Proportion in all TB in USA :

7% (1963) to 18% (1987) to 20% (now)

Increase maybe due to HIV infection

More 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 EPTB

Peak age: children shift to 20-40 y/o

High risk: Asians, female (2x to male), HIV

Hilar, paratracheal and neck lymphnodes

Self-limited (>90%), a little with pulmonary calcification

Tuberculosis Lymphadenitis (2) Differential Diagnosis

Nontuberculous mycobacteria (young age, unilateral and normal CXR)

Virus or fungus infection

Neoplasm

Tuberculin skin test, history and CXR

Total 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 indirect

Cartilage preservation

Cold abscess and sinus tract formation

Fibrosis and ankylosis, calcification

Bone and joint Tuberculosis (3) Clinical Presentation

Tuberculous spondylitis

Tuberculous osteomyelitis

Tuberculous arthritis

Tuberculous tensynovitis

Tuberculous myositis

Bone and joint Tuberculosis (4) Tuberculous spondylitis

Most commonly, especially in developing countries

Back pain and rigidity

Vertebral body involvement and diskitis

Kyphosis and paraplegia

Bone and joint Tuberculosis (5) Tuberculous osteomyelitis

Initial: painful mass attached to bone with soft tissue swelling

Predilection to metaphysis of long bones

May extend to a joint or tenosynovium

Single in adults; multiple in children, elders, immunosuppressive and HIV infection

Bone and joint Tuberculosis (6) Tuberculous arthritis

Large weight-bearing joint like hip, knee

Painful, ankylosed or swollen mono-arthropathy, limitation of motion

Rice bodies, pannus, granulation, necrosis, narrowing of the joint space

Bone and joint Tuberculosis (7) Tuberculous myositis

More in immunosuppressive and AIDS

Most in psoas muscle involvement

Swelling, 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; neoplasm

Monoarthritis, chronic pain, minimal sign

Tuberculin skin test

Plain radiography, open biopsy

CT, MRI, CT-guided fine-needle aspiration biopsy

Bone and joint Tuberculosis (9) Treatment

Early diagnosis

Anti-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 common

microscopic hematuria: 50%

Recurrent E. coli infection

Urine pus cell, suprapubic pain, hemospermia, painful testicular swelling: all rare

Genitourinary Tuberculosis (2) Diagnosis

Tuberculin skin test

Urine examination and culture

Elevated ESR

Plain film, high-dose IV urography, percutaneous antegrade pyelography

Limited value: endoscopy, biopsy, ultrasonography and CT

Genitourinary Tuberculosis (3) Pathology

Kidney: chronic parenchymal abscess, large renal calcification; may spread to ureter, bladder, seminal visicle

Bladder: bullous granulation from ureteric orifice, obstruction; fistula to rectum

Epididymis: 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 culture

ELISA and PCR

Tx: 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: limited

Meningeal biopsy: may contaminating

CT and MRI: helpful

Tx: chemotherapy, surgery and steroids

Miliary Tuberculosis

Lympho-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 EPTB

Otologic Tuberculosis

Ocular Tuberculosis

Cardiovascular Tuberculosis

Tuberculous Peritonitis

Tuberculous Enteritis

Tuberculosis of the liver and biliary tract

HIV and EPTB

Immunosuppression 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 EPTB

Detection: 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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