extra pulmonary tuberculosis
TRANSCRIPT
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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