Extrapulmonary Tuberculosis

1. Extrapulmonary Tuberculosis ?????? Ri ??? 91-7-29

2. Tuberculosis An ancient infection Tubercle bacillus discovered in 1882 WHO: 8,000,000 active cases in 1990 Developing countries (95%) Developed countries: HIV infection

3. 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)

4. Tuberculosis Clinical stages Stage 1: Onset (macrophage inhalation) Stage 2: Symbiosis Stage 3: Early caseous necrosis Stage 4a & 4b: Interplay of cell-mediated immunity and tissue-damaging delayed-type hypersensitivity Stage 5: Liquefaction and cavity formation

5. 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-borns Lymphatic TB (30%) > Pleural TB (24%) > Bone and joint TB (10%) > Genitourinary TB (9%) > Miliary TB (8%) > Meningeal TB (6%) (New York, 1995)

6. 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

7. 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

8. 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)

9. Bone and joint Tuberculosis (1) Pott�s disease Increasing since 1980s 13-25%: HIV positive in several trials Location: 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

10. 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

11. Bone and joint Tuberculosis (3) Clinical Presentation Tuberculous spondylitis Tuberculous osteomyelitis Tuberculous arthritis Tuberculous tensynovitis Tuberculous myositis

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. Genitourinary Tuberculosis (4) Treatment Anti-tuberculous chemotherapy (effective) Surgery (>80%): nephrectomy, nephro-ureterectomy, epididymectomy and reconstructive surgery

22. Cutaneous Tuberculosis (1) Uncommon (<1% in the west) but increase very rapidly in recent years May contagious spread Exogenous source: Tuberculous chancre and prosector�s wart Endogenous source: scrofuloderma Hematogenous source: Lupus vulgaris (apple jelly nodules) and multiple soft tissue cold abscess (most in AIDS) Tuberculous masitis: most in 20-50 y/o female

23. 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)

24. CNS Tuberculosis (1) Pathogenesis and clinical presentation Tuberculous meningitis (TBM) May produce damage to vessels, infarction of brain, edema, fibrosis Predilection: base of brain In AIDS: cerebral abscess or tuberculomas Space-occupying sign: headache, seizure, paralysis, personality change, CN defects, neck stiffness, papilledema

25. 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

26. Miliary Tuberculosis Lympho-hematogenous dissemination Infants and children: primary Elders or HIV infection: reactivation Fever, weakness, anorexia, Wt loss, cough Dx: CXR, HRCT Tx: Chemotherapy for 9-12 months (HIV at least 12 months) or steroids (controversial, prevent reactivation and infection)

27. Other EPTB Otologic Tuberculosis Ocular Tuberculosis Cardiovascular Tuberculosis Tuberculous Peritonitis Tuberculous Enteritis Tuberculosis of the liver and biliary tract

28. HIV and EPTB Immunosuppression increases infection and makes its symptoms become atypical TB: most cause of death in 24-44 y/o AIDS EPTB 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

29. 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 test Amplicor mycobacterium tuberculosis test

30. Thank you for your Attetion! May Fortune be with You�