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Diagnosis of TB

Learning Objectives
List the 4 principle components of a TB
evaluation
Describe the criteria which differentiate
PTB+ from PTB Describe the 3 major indications for culture
and DST

Common Sites of TB Disease


Lungs
Pleura
Central nervous system
Lymphatic system
Genitourinary systems
Bones and joints
Disseminated (miliary TB)

Systemic Symptoms of TB
Fever
Chills
Night sweats
Appetite loss
Weight loss
Fatigue

Evaluation for TB
1.HIV test
2.Medical history
3.Physical examination
4.Bacteriologic or histologic
exam
(Chest radiograph if
indicated)

Medical History
HIV status
Symptoms of disease
History of TB exposure, infection, or disease
Past TB treatment
Demographic risk factors for TB
Other medical conditions that increase risk for TB
disease (e.g., diabetes)

Symptoms of Pulmonary TB
Productive, prolonged cough
(duration of 2-3 weeks)
Chest pain
Hemoptysis (bloody sputum)
Signs may vary based on HIV status

Specimen Collection Procedure


Obtain 3 sputum specimens for smear
examination
and culture

Spot, first morning, spot


Follow infection control precautions during
specimen collection

Sputum Smear Examination

Specimens should be sent to the lab immediately


to preserve the quality of the specimens
Always aim for three specimens at each exam
Always store at a cool temperature and away
from sunlight to preserve the quality of specimens
3 respiratory specimens will detect 90% of
smear-positive cases

AFB smear-microscopy

Acid-fast bacilli (AFB) (shown in red) are tubercle bac

Acid fast smear showing TB bacilli

Smear-positive PTB vs.


Smear-negative PTB PTB+ (Pulmonary TB smear-positive)
One AFB-positive smear; i.e. any patient with at
least one positive smear result (irrespective of
quantity of AFBs seen on microscopy)

Recommendations to improve the diagnosis of smear negative pulmonary and


extrapulmonary TB among adults in HIV prevalent and resource constrained settings.
Draft for discussion by Strategic and Technical Advisory Group of Stop TB Department of
WHOJune 2006

Smear-positive PTB vs.


Smear-negative PTB PTB- (smear-negative)
Any pulmonary TB case that does not meet the definition
of being smear-positive. This includes:
1. Patients with three negative smear results and
radiological findings and doctors decision to treat for TB
2. Patients with negative smear results and a positive
culture result for M. tuberculosis
3. Patients who are unable to produce sputum and with
highly suspicious radiological and clinical findings and
doctor's decision to treat for TB

Other Acid Fast Bacilli


Mycobacteria other than those comprising the M.
tuberculosis complex are called Non-Tuberculous
Mycobacteria (NTM) or Mycobacteria Other Than
Tuberculosis (MOTT).
These mycobacteria may cause pulmonary disease
resembling TB. Increasingly, cases from these organisms
are being reported in patients with weakened immune
systems, especially due to HIV.
It is important to note that infection with MOTT also may
produce AFB-positive sputum smear results and positive
Mantoux skin test readings mimicking M. tuberculosis.
Culture can distinguish between M. tuberculosis and MOTT.
Disease due to MOTT is usually unresponsive to first-line
anti-TB drugs.

Chest Radiograph
Diagnosis of PTB solely on basis of
CXR not encouraged
May have unusual appearance in
HIV-positive persons
CXR is helpful in HIV+, smearnegative patients
Cannot confirm diagnosis of TB

Arrow points to cavity i


patient's right upper lob

Cultures
Should be requested for ALL
retreatment patients
Relapse
Failure
Return after default

Culture is indicated for


New and retreatment PTB cases
still smear- positive at end of
intensive phase
Symptomatic contacts of known
MDR cases

Colonies of M.
tuberculosis
growing on media

Diagnosis in Children
1. Patient history
Contact to PTB+
Symptoms consistent with TB

HIV test
2. Clinical Exam
3. TST
4. Bacteriological confirmation
5. Investigations for PTB and EPTB
Guidance of National Tb Programmes for the Management of TB in Children
WHO/HTM/TB/2006.371

Key Risk Factors in Children


Risk Factors For Children Include:

Household contact with a newly diagnosed


smear-positive case
Age less than 5 years
HIV infection
Severe malnutrition.

Key Features of TB in Children


The presence of three or more of the following should strongly suggest a
diagnosis of TB:
Chronic symptoms suggestive of TB
Physical signs highly of suggestive of TB
A positive tuberculin skin test
Chest X-ray suggestive of TB
(The presentation in infants may be more acute, resembling acute severe
pneumonia and should be suspected when there is a poor response to
antibiotics. In such situations, there is often an identifiable source case,
usually the mother.)