Extrapulmonary tuberculosis and HIV

Outi Vehviläinen, MD

Ilembula Lutheran Hospital 7.2.2014

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EPTB

What is EPTB Pathogenesis Clinical manifestations Diagnostic evaluation Statistical information from ILH X-rays and pictures

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WHAT IS EPTB: definitionCausative organism: Mycobacterium tuberculosisPrimary infection or reactivation of latent focusEPTB occurs outside lungs10% of cases EPTB is disseminated throughout the body

in multiple organs: most often lungs, liver,spleen,kidneys and bone marrow

The term miliary is now used to denote all forms of progressive, widely disseminated, hematogenous TB

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EPTB

in HIV(+): 33% extrapulmonary alone

33% pulmonary alone

33% both pulmonary and extrapulmonary (many with negative CXRs)

in 10% of cases EPTB is disseminated

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Clinical manifestations of EPTB:9

Pleural effusions

Lymphatic system: cervical, supraclavicular

Skeletal: vertebral column, most often lower thoracal/lumbar region

Joint: hip,knee

Cns: meningitis,intracraniel tuberculomas

Pericardial: pericardial fluid with tamponade

Genitourinary tract: dysuria, hematuria

Disseminated: throughout the body, multiple organs, mostly: lungs (called miliary findings) liver,spleen,kidneys, bone marrow

Extrapulmonary TB Symptoms Can have the same constitutional symptoms as people with pulmonary TB:

Fever, night sweats, fatigue, loss of appetite, weight loss.

In addition, patients often develop complaints specific to the body site infected with TB. examples:Enlarged lymphnodesHeadache/confusion, neck stiffness ,altered mental statusSkeletal pain: gradual onsetJoint pain, swellingAbdominal painUrinary symptoms

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DIAGNOSIS

Chest x-ray: can be typical/atypical or normal

Sputum for AFB :can be negative Tuberculin skin test (TST) Biopsy samples taken from the appropriate

anatomic sites

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DIAGNOSIS EPTB in HIV positive patients

DIAGNOSIS is proven by:

One specimen from extra-pulmonary site culture positive for Mycobacterium tuberculosis

OR sputum positive for AFB

OR strong clinical evidence for extrapulmonary TB

AND laboratory confirmation of HIV infection

AND decision by clinician to treat with a full course of anti- tuberculosis chemotherapy

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Diagnostic Challenges

Often more difficult to diagnose extrapulmonary TB Because EPTB is less common, doctors often first think of other causes

for the patient’s symptoms (e.g., pain in the right ankle more likely a sprained ankle than TB of the joint)

Secondly, EPTB often occurs in body sites that are difficult to access (e.g., the liver, which cannot be touched, or examined easily).

Hiv patients have higher rates of sputum negative disease Chest radiographs may appear normal in up to 21%

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EPTB/ILEMBULA LUTHERAN HOSPITAL

2008 2009 2010 2011 2012 2013Sputum +

81 70 76 61 69 41

Sputum - 80 47 70 83 86 63Miliary 7 3 7 11 6 34Meningitis

0 1 2 0 1 5

Spinal 9 7 1 4 7 6Effusion 17 18 20 30 39 37EP-children

9 12 21 15 20 30

Adenitis 0 8 10 7 12 14Ohters 2 3 3 6 0 1Relapsy 0 0 1 0 0 0

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EPTB 44 52 65 73 85 127

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Ilembula

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Conclusion

Common in HIV-infected personsDifficult to diagnose because can mimic many

diseasesSputum for AFB often negativeCXR can be normalAlways get HIV test in patients with EPTB.

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ASANTE