DIAGNOSIS OF TUBERCULOSIS

9.

Diagnosis
1.

In order to diagnose tuberculosis (TB), you must:

1.
2.
3.

2.

When should TB be suspected?

1.
2.

3.

Suspect TB
Screen for TB
Confirm TB

Anyone who breathes is susceptible to TB infection and disease, but is

the person at high risk?
In the U.S., TB is more common among certain groups and in
certain settings
1) close contacts of a person with active TB
2) foreign-born persons from countries where TB is very common
3) high-risk groups
1.
the homeless
2.
inmates of jails and prisons
3.
residents of long term care facilities (for example,
nursing homes)
4.
previously-infected persons of all ages (PPD reactors)
5.
some ethnic groups, notably African American and Native
Americans have higher rates
6.
HIV-infected and other immune compromised persons
7.
substance use (alcohol abuse, injection drug use, other drug
abuse)

Screening for TB
1.

The skin test

1) PPD (Mantoux) is the only acceptable tuberculin skin test for
screening
2) the skin test cannot distinguish between TB infection and TB
disease
3) most people who have active TB have a positive skin test, but
some, as many as 25% of patients, will have a false
negative result
4) multiple puncture tests or tine tests have no place in
the evaluation of TB
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the PPD is useful in indicating if TB germs are present, especially

in TB outside of the lungs when recovery of specimens is not
always possible
How else can we screen for TB disease?
1) symptoms of the patient
2) lab results
3) x-ray results
4) response to treatment
5)

2.

All of the above play a role in helping to make the TB diagnosis

35.

Symptoms of tuberculosis
10-20% of patients may have no symptoms, at least in the early stages.
1.

Chest symptoms
1.
2.
3.
4.

2.

General symptoms and signs

1.
2.
3.
4.

3.

Cough, prolonged for three or more weeks (present in 40-80%)

Sputum production (represents lung damage)
Chest pain (maybe pleural TB)
Coughing any blood or blood-tinged sputum

Fever, present in 65-80% of patients

Chills/night sweats
Fatigue and weakness
Loss of appetite and weight loss

Chest x-ray
1.
2.
3.
4.

Location of an infiltrate (the area of disease) will be in the upper

lobe more often, in both adults and children
Cavities are sometimes seen at top of one or both lungs
Other patterns typical for TB are hollow areas and/or fluid in the lung
Generally a normal x-ray means no infectious TB, but there are
exceptions (CXR of HIV+ patients may present unusual patterns or
be normal)

Chest x-ray reports will note abnormalities by describing infiltrates,

densities, markings, thickening, and fibronodular scarring. Any abnormal
findings in the presence of symptoms require lab studies.

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Physicians vary on the frequency of chest x-rays after the initial abnormal
one. Usually, a chest x-ray is repeated after two or three months of
medication to look for improvement.
TERMS USED ON X-RAY REPORTS
Infiltrate, shadow, opacity, density
1 Abnormal collection of material within the lung.
2 "Infiltrate" presumes that cells, fluid, etc., have "infiltrated" or invaded;
a pathologic description.
3 The other terms indicate what can be seen on the x-ray itself, without
interpretation; the normal lucency of part of the lung is not present.
Atelectasis
1 Airlessness and collapse of an anatomic division of the lung, implying
bronchial occlusion.
Consolidation
1 Complete filling of an anatomic division of the lung, as by exudate.
Hilar adenopathy
1 Enlargement of the lymph glands located centrally where the
bronchi and major pulmonary blood vessels enter the lung.
Blunting of the costophrenic angle
1 Loss of sharp angle formed by the diaphragm and the rib cage. This is
a nonspecific change and can be produced by a variety of processes.
61.

Confirming tuberculosis: lab confirmation

A. Sputum collection
1.
2.
3.
4.
5.
6.
7.

Collection of sputum specimens is essential to confirm that TB disease

is present
Sputum is the mucus from deep within the lung and not saliva. The
health worker must assure that mucus is present in the collection tube
Ideally three sputum specimens will be collected by the patient on
three successive days, usually right after getting up in the morning
There must be a sufficient quantity in each tube
The specimen needs to be kept refrigerated until transported to the
lab, as soon as possible after the collection
Inducing sputum specimens by breathing a saline mist is not
preferred, but acceptable when the patient is unable to produce
spontaneously. Induced specimens are usually very watery
Teach the patient that this is where the TB germ hides

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2.

The AFB smear

1.
2.
3.
4.
5.
6.

3.

Culture
1.

4.

The sputum specimen is spun in a centrifuge and a small amount

of the concentrate is smeared on a glass slide
The slide is stained and then washed with acid solution
The acid (acid test) does not destroy TB bacilli
The slide is examined under the microscope to see if any germs
are visible. If so, they are counted
Smears are rapid tests, usually within 1 day
Results:
1) positive smear means that there were so many bacilli that
they could be seen under the microscope
1.
at least 10,000 bacilli per ml are needed
2.
smears will be positive in about half of TB patients (in
California, it is 40%)
3.
other mycobacteria can cause a positive TB smear
4.
provides a measure of infectiousness: smear positive
means very infectious
2) negative smear means that there were too few bacilli to be
seen directly under a microscope
1.
Negative smears means less infectious

A culture means that a sputum specimen has been placed on some

kind of medium (like jelly or broth), either in a plate or tube, which
favors the growth of TB bacilli. The medium is then placed in an
incubator (an oven kept at body temperature) for some weeks
1) culture confirmation is essential to the diagnosis of TB
2) culture results take 3 to 6 weeks as TB grows slowly. At 3 weeks,
the culture plate is examined for colonies of growth typical of TB
3) the number of colonies found in positive TB culture is another
indication of the stage of the patients disease and degree of
infectiousness

Other techniques for confirming TB

1.

2.

BACTEC is a technique developed to speed up confirmation of

TB bacilli in a specimen
1) requires that sputum be placed in a soup-like broth to which
radioactive ingredients have been added. If TB is present, the
bacilli release radioactive gas into the small broth bottle and
the BACTEC machine reads the amount of this gas, if present
2) can confirm the presence of TB within one week
Other more sophisticated tests involve amplifying DNA of any TB
germs present and also identifying genes of TB in the lab specimen
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IV.

Susceptibility testing
1.

After a specimen is confirmed to contain Mycobacterium tuberculosis,

another test is done to see if the patients particular TB is susceptible or
able to be killed by the first-line TB medications
1.
2.
3.

2.

Ways in which drug resistance may become apparent

1.
2.
3.

3.

The patients symptoms improve but more slowly than expected

Sputum cultures within 3 months of taking adequate medication
are still positive
The lab reports resistance to one or more TB drugs

Certain patients are more likely to have drug-resistant TB

1.
2.

4.

Susceptibility tests again take 3-6 weeks to determine if the TB bacilli

can grow in the presence of any TB drugs
Drug resistance is a problem in many other countries and within
certain areas and population groups within the U.S.
It is critical to identify TB disease which is resistant to any TB drug and
to treat that individual patient with medications that will work

Patients who have previously been inadequately treated for TB

People who develop TB who were contacts to a drug-resistant case

Extrapulmonary TB (TB outside of the lungs)

1.
2.
3.
4.

15-20% of TB disease occurs in other sites in the body

Up to 40% of TB in children is extrapulmonary
A large percentage of HIV+ people with TB have extrapulmonary
disease or TB in both the lungs and another site in the body
Common sites of body where TB can occur
1) miliary TB in the blood and multiple sites
2) lymph node (scrofula)
3) urinary tract
4) brain/nervous system
5) bones (especially in the spine Potts disease)

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Differences Between Sputum Smears and Cultures

Feature
Equipment needed

Smears
Microscope, glass slides,
special dyes

Time needed to make report

Basis of procedure

1 day
Looking for AFB on slide
under microscope

Significance of a negative
report

Patient is less likely to be

infectious
Does not rule out TB disease
(culture may be positive)

Significance of a positive
report

Patient is more likely to

infectious (if AFB are tubercle
bacilli

Cultures
Incubators, safety cabinet,
culture plates or tubes, culture
media, biochemicals for test
2 to 8 weeks
Growth of tubercle bacilli or
other mycobacteria on culture
media in incubator
No liver tubercle bacilli found
in the specimen
Does not rule out TB disease
(live tubercle may be in other
specimens and/or in the
patient)
Confirms diagnosis of TB
disease

AFB could be non-tuberculous

mycobacteria

Smear Classifications and Results

Classification of Smear
4+
3+
2+
1+
Actual number of AFB seen
(no plus sign)
No AFB seen

Smear Result
Strongly positive
Strongly positive
Moderately positive
Moderately positive
Weakly positive

Infectiousness of Patient
Probably very infectious
Probably very infectious
Probably infectious
Probably infectious
Probably infectious

Negative

May not be infectious

May vary with laboratory testing and reporting

Source:
Center for Disease Control and Prevention. (1995). Self-Study Module for Tuberculosis:
Diagnosis of Tuberculosis Infection and Disease, Atlanta: Author.

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