Pulmonary tuberculosis: Difference between revisions
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== Background == |
== Background == |
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=== Microbiology === |
=== Microbiology === |
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− | * |
+ | * See [[Mycobacterium tuberculosis]] |
− | == Clinical |
+ | == Clinical Manifestations == |
+ | * Presents as reactivation of latent infection months or years after [[Mycobacterium tuberculosis#Primary tuberculosis|primary tuberculosis]] |
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* Subacute or [[chronic cough]] (at least 2 to 3 weeks) eventually becoming productive and occasionally involving [[hemoptysis]] |
* Subacute or [[chronic cough]] (at least 2 to 3 weeks) eventually becoming productive and occasionally involving [[hemoptysis]] |
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** Should be suspected in any patient with '''cough and [[HIV]] infection''' |
** Should be suspected in any patient with '''cough and [[HIV]] infection''' |
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* May transiently improve with partially-active antibiotics such as [[fluoroquinolones]] |
* May transiently improve with partially-active antibiotics such as [[fluoroquinolones]] |
||
− | == |
+ | == Diagnosis == |
+ | * '''At least three consecutive sputum specimens''', collected q8-24h, with at least one being an early morning specimen |
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− | * Spontaneous sputum, induced sputum, or bronchoalveolar lavage specimens |
+ | * Spontaneous sputum, induced sputum, or bronchoalveolar lavage specimens |
− | ** Acid-fast staining of a smear |
||
+ | * Can be sent for either acid-fast staining of a smear and culture, or for PCR (e.g. GeneXpert) |
||
− | ** Culture |
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+ | * Chest x-ray may show signs of prior tuberculosis, including dense pulmonary nodules (with or without calcification) which can be hilar or upper lobe; small nodules with or without scarring/fibrosis in the upper lobes; upper lobe volume loss or bronchiectasis; pleural scarring |
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− | ** PCR |
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== Management == |
== Management == |
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− | * |
+ | * Empiric treatment for suspected drug-susceptible tuberculosis is RIPE x2mo then RI x4mo |
− | ** Isoniazid 5mg/kg/d, max 300mg daily |
+ | ** [[Is treated by::Isoniazid]] 5mg/kg/d, max 300mg daily, with pyridoxine 25 mg po daily |
− | ** Rifampin 10mg/kg/d |
+ | ** [[Is treated by::Rifampin]] 10mg/kg/d |
− | ** Pyrazinamide 25mg/kg/d, max 2g daily |
+ | ** [[Is treated by::Pyrazinamide]] 25mg/kg/d, max 2g daily |
− | ** Ethambutol 20mg/kg/d, max 1.2g daily |
+ | ** [[Is treated by::Ethambutol]] 20mg/kg/d, max 1.2g daily, which can be dropped once susceptibility testing shows that it is pan-susceptible |
⚫ | |||
− | ** Pyridoxine 25 mg po daily |
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+ | * Treatment for multidrug-resistant tuberculosis is discussed [[Drug-resistant tuberculosis#Management|separately]] |
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⚫ | |||
+ | |||
+ | === Special Populations === |
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+ | * For the '''elderly''', or those at elevated '''risk of hepatotoxicity''': can do induction phase ''without'' [[pyrazinamide]] and extend continuation phase to 7 months (from 4) |
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+ | * For '''pregnant women''': can consider dropping [[pyrazinamide]] and extending the course by 3 months, but if there is severe disease then likely should follow standard treatment |
||
+ | * For '''high risk of relapse''', including extensive or cavitary disease in the first 2 months of treatment, culture-positivity after 2 months of treatment, or cavitary disease on CXR at end of treatment: the consolidation phase should be extended by 3 months (to 9 months total treatment) |
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+ | * For '''severe liver disease''': |
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+ | ** Avoid [[rifampin]], [[isoniazid]], and [[pyrazinamide]] |
||
+ | ** Recommend a fluoroquinolone, [[ethambutol]], and [[amikacin]] for 2 months followed by fluroquinolone and ethambutol for 18 months |
||
+ | ** Can consider adding [[rifampin]] if they are monitored closely |
||
+ | |||
+ | === Adjunctive Therapies === |
||
+ | |||
+ | * The addition of [[metformin]] to the induction regimen has been shown to speed resolution of radiographic findings, such as cavitations<ref>Chandrasekaran Padmapriydarsini, Megha Mamulwar, Anant Mohan, Prema Shanmugam, N S Gomathy, Aarti Mane, Urvashi B Singh, Nathella Pavankumar, Abhijeet Kadam, Hemanth Kumar, Chandra Suresh, Devaraju Reddy, Poornaganga Devi, P M Ramesh, Lakshmanan Sekar, Shaheed Jawahar, R K Shandil, Manjula Singh, Jaykumar Menon, Randeep Guleria, the METRIF Team, Randomized Trial of Metformin With Anti-Tuberculosis Drugs for Early Sputum Conversion in Adults With Pulmonary Tuberculosis, ''Clinical Infectious Diseases'', Volume 75, Issue 3, 1 August 2022, Pages 425–434, https://doi.org/10.1093/cid/ciab964</ref> |
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+ | ** [[Metformin]] 500 mg p.o. daily for 1 week then 1000 mg p.o. daily for 7 weeks |
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+ | ** No difference in conversion of sputum culture |
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+ | |||
+ | === Infection Control === |
||
* Airborne precautions until: |
* Airborne precautions until: |
||
− | ** Treated for at least 2 weeks |
+ | ** Treated for at least 2 weeks and symptoms are clearly improving |
− | ** 3x negative sputum smears |
+ | ** 3x negative sputum smears |
+ | ** They can be discharged home when clinical improvement, drug-resistant TB is not suspected and there is no contraindication for home isolation |
||
− | ** Improvement in symptoms |
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[[Category:Respiratory infections]] |
[[Category:Respiratory infections]] |
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− | [[Category: |
+ | [[Category:Tuberculosis]] |
− | [[Category:Mycobacteria]] |
Latest revision as of 11:48, 6 March 2023
Background
Microbiology
Clinical Manifestations
- Presents as reactivation of latent infection months or years after primary tuberculosis
- Subacute or chronic cough (at least 2 to 3 weeks) eventually becoming productive and occasionally involving hemoptysis
- Should be suspected in any patient with cough and HIV infection
- Constitutional symptoms, with fevers, night sweats, and unexplained weight loss
- Usually from reactivation of latent tuberculosis infection, and usually reactivates in lung apices
- May transiently improve with partially-active antibiotics such as fluoroquinolones
Diagnosis
- At least three consecutive sputum specimens, collected q8-24h, with at least one being an early morning specimen
- Spontaneous sputum, induced sputum, or bronchoalveolar lavage specimens
- Can be sent for either acid-fast staining of a smear and culture, or for PCR (e.g. GeneXpert)
- Chest x-ray may show signs of prior tuberculosis, including dense pulmonary nodules (with or without calcification) which can be hilar or upper lobe; small nodules with or without scarring/fibrosis in the upper lobes; upper lobe volume loss or bronchiectasis; pleural scarring
Management
- Empiric treatment for suspected drug-susceptible tuberculosis is RIPE x2mo then RI x4mo
- Isoniazid 5mg/kg/d, max 300mg daily, with pyridoxine 25 mg po daily
- Rifampin 10mg/kg/d
- Pyrazinamide 25mg/kg/d, max 2g daily
- Ethambutol 20mg/kg/d, max 1.2g daily, which can be dropped once susceptibility testing shows that it is pan-susceptible
- Standard duration for uncomplicated disease is 6 months total, though it is extended if high risk of relapse (see Special Populations, below)
- Treatment for multidrug-resistant tuberculosis is discussed separately
Special Populations
- For the elderly, or those at elevated risk of hepatotoxicity: can do induction phase without pyrazinamide and extend continuation phase to 7 months (from 4)
- For pregnant women: can consider dropping pyrazinamide and extending the course by 3 months, but if there is severe disease then likely should follow standard treatment
- For high risk of relapse, including extensive or cavitary disease in the first 2 months of treatment, culture-positivity after 2 months of treatment, or cavitary disease on CXR at end of treatment: the consolidation phase should be extended by 3 months (to 9 months total treatment)
- For severe liver disease:
- Avoid rifampin, isoniazid, and pyrazinamide
- Recommend a fluoroquinolone, ethambutol, and amikacin for 2 months followed by fluroquinolone and ethambutol for 18 months
- Can consider adding rifampin if they are monitored closely
Adjunctive Therapies
- The addition of metformin to the induction regimen has been shown to speed resolution of radiographic findings, such as cavitations[1]
- Metformin 500 mg p.o. daily for 1 week then 1000 mg p.o. daily for 7 weeks
- No difference in conversion of sputum culture
Infection Control
- Airborne precautions until:
- Treated for at least 2 weeks and symptoms are clearly improving
- 3x negative sputum smears
- They can be discharged home when clinical improvement, drug-resistant TB is not suspected and there is no contraindication for home isolation
- ↑ Chandrasekaran Padmapriydarsini, Megha Mamulwar, Anant Mohan, Prema Shanmugam, N S Gomathy, Aarti Mane, Urvashi B Singh, Nathella Pavankumar, Abhijeet Kadam, Hemanth Kumar, Chandra Suresh, Devaraju Reddy, Poornaganga Devi, P M Ramesh, Lakshmanan Sekar, Shaheed Jawahar, R K Shandil, Manjula Singh, Jaykumar Menon, Randeep Guleria, the METRIF Team, Randomized Trial of Metformin With Anti-Tuberculosis Drugs for Early Sputum Conversion in Adults With Pulmonary Tuberculosis, Clinical Infectious Diseases, Volume 75, Issue 3, 1 August 2022, Pages 425–434, https://doi.org/10.1093/cid/ciab964