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 bacilli

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 doctor’s 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+, smear-

negative patients Arrow points to cavity in
patient's right upper lobe.

• Cannot confirm diagnosis of TB

 Cultures

• Should be requested for ALL

retreatment patients
– Relapse
– Failure
– Return after default
Colonies of M. tuberculosis
• Culture is indicated for growing on media
– New and retreatment PTB cases
still smear- positive at end of
intensive phase
– Symptomatic contacts of known
MDR cases
 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.)