Extrapulmonary Tuberculosis

外科實習醫師Ri 林耿立91-7-29

TuberculosisAn ancient infectionTubercle bacillus discovered in 1882WHO: 8,000,000 active cases in 1990Developing countries (95%)Developed countries: HIV infection

Tuberculosis Pathogenesis

Chronic necrotizing bacterial infectionTubercle 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 TuberculosisProportion in all TB in USA :

7% (1963) to 18% (1987) to 20% (now)Increase maybe due to HIV infectionMore 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 EPTBPeak age: children shift to 20-40 y/oHigh risk: Asians, female (2x to male), HIVHilar, paratracheal and neck lymphnodesSelf-limited (>90%), a little with pulmonary calcification

Tuberculosis Lymphadenitis (2) Differential Diagnosis

Nontuberculous mycobacteria (young age, unilateral and normal CXR)Virus or fungus infectionNeoplasmTuberculin skin test, history and CXRTotal 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 indirectCartilage preservationCold abscess and sinus tract formationFibrosis and ankylosis, calcification

Bone and joint Tuberculosis (3) Clinical Presentation

Tuberculous spondylitisTuberculous osteomyelitisTuberculous arthritisTuberculous tensynovitisTuberculous myositis

Bone and joint Tuberculosis (4) Tuberculous spondylitis

Most commonly, especially in developing countriesBack pain and rigidityVertebral body involvement and diskitisKyphosis and paraplegia

Bone and joint Tuberculosis (5) Tuberculous osteomyelitis

Initial: painful mass attached to bone with soft tissue swellingPredilection to metaphysis of long bonesMay extend to a joint or tenosynoviumSingle in adults; multiple in children, elders, immunosuppressive and HIV infection

Bone and joint Tuberculosis (6) Tuberculous arthritis

Large weight-bearing joint like hip, kneePainful, ankylosed or swollen mono-arthropathy, limitation of motionRice bodies, pannus, granulation, necrosis, narrowing of the joint space

Bone and joint Tuberculosis (7) Tuberculous myositis

More in immunosuppressive and AIDSMost in psoas muscle involvementSwelling, 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; neoplasmMonoarthritis, chronic pain, minimal signTuberculin skin testPlain radiography, open biopsyCT, MRI, CT-guided fine-needle aspiration biopsy

Bone and joint Tuberculosis (9) Treatment

Early diagnosisAnti-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 commonmicroscopic hematuria: 50%Recurrent E. coli infectionUrine pus cell, suprapubic pain, hemospermia, painful testicular swelling: all rare

Genitourinary Tuberculosis (2) Diagnosis

Tuberculin skin testUrine examination and cultureElevated ESRPlain film, high-dose IV urography, percutaneous antegrade pyelographyLimited value: endoscopy, biopsy, ultrasonography and CT

Genitourinary Tuberculosis (3) Pathology

Kidney: chronic parenchymal abscess, large renal calcification; may spread to ureter, bladder, seminal visicleBladder: bullous granulation from ureteric orifice, obstruction; fistula to rectumEpididymis: 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 cultureELISA and PCRTx: 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: limitedMeningeal biopsy: may contaminatingCT and MRI: helpfulTx: chemotherapy, surgery and steroids

Miliary TuberculosisLympho-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 EPTBOtologic TuberculosisOcular TuberculosisCardiovascular TuberculosisTuberculous PeritonitisTuberculous EnteritisTuberculosis of the liver and biliary tract

HIV and EPTBImmunosuppression 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 EPTBDetection: 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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