LYMPH NODE TUBERCULOSIS (TUBERCULOUS LYMPHADENITIS) Epidemiology:

o >40% of cases in United Stateso Children and woman (particularly non-Caucasians) seem to be especially susceptibleo Particularly frequent among HIV-infected patientso 70% of patients with nodal disease have cervical node involvement alone, 7% inguinal

involvement, 7% axillary involvement, 16% multiple nodes involved simultaneously, and 5-10% of patients have active pulmonary TB concomitantly

Etiology: M. bovis M. tuberculosis (now) Clinical Feature:

o Painless swelling of the lymph nodes (enlarged single node or several notes matted together), most commonly at posterior cervical and supraclavicular sites (a condition historically referred to as scrofula), frequently nodes flocculent or have draining sinuses

o Usually discrete and non tender in early disease but may be inflamed and have a fistulous tract draining caseous material

o Systemic symptoms limited to HIV-infected patients Diagnosis:

o Established by fine needle aspiration (83% of cases) or surgical biopsy

o Acid fast bacilli: 50% of caseso Cultures: positive in 70-80%o Histologic examination shows granulomatous tissueo PPD positive: 74-96% of cases

Differential Diagnosis: variety of infectious conditions, neoplastic diseases such as lymphomas or metastatic carcinomas, and rare disorders like Kikuchi Disease (necrotizing histiocytic lymphadenitis), Kimura’s disease, and Castleman’s disease

Treatment: o Antituberculous therapyo Surgical intervention: when excision necessary/to remove nodes that remain enlarged after

therapy

PLEURAL TUBERCULOSIS Epidemiology:

o ~20% of extrapulmonary cases in the United Stateso Common in primary tuberculosis

Etiology:

o Contiguous spread of parenchymal inflammation

o Pleurisy accompanying postprimary disease (penetration by tubercle bacilli into pleural space) effusion depending on extent of reactivity: small, remain unnoticed and resolve spontaneously, and sufficiently large

Clinical features:o Fever, pleuritic chest pain, dyspnea ( if effusion sufficiently large)o Physical findings: dullness to percussion and absence of breath sounds

Diagnosis:o Thoracentesis

to ascertain the nature of effusion and to differentiate from other etiologies Fluid: straw-colored and at times hemorrhagic An exudates (pleural fluid protein greater than 4g/dL) with a protein concentration, a pH of

~7.3 (occasionally <7.2), detectable white blood cells (usually 500-6000/uL) Neutrophil dominate in early mononuclear cells Mesothelial cells generally rare/absent

o Chest radiograph: effusion and in 1/3 cases shows parenchymal lesiono Acid fast bacilli: seen in only 10-25% of caseso Cultures: may be positive for M. tuberculosis in 25-75% of caseso Pleural concentration of adenosine deaminase (ADA)

Useful screening test Tuberculosis excluded if value very low

o Needle biopsy Required for diagnosis and reveals granulomas and/or yields a positive culture in up to 80%

of cases Treatment:

o Chemotherapy: responds well and may resolve spontaneouslyTUBERCULOUS EMPYEMA Epidemiology: less common complication of pulmonary tuberculosis Etiology: rupture of cavity with spillage of a large number of organisms into pleural space, in severe

pleural fibrosis and restrictive lung disease Clinical feature:

o Bronchopleural fistula with evident air in pleural space Diagnosis:

o Pleural fluid: purulent, thick, contain large numbers of lymphocyteo Chest radiograph: hydropneumothorax with an air-fluid level

o Acid fast smears and mycobacterial culture: positive Treatment:

o Surgical drainageo Chemotherapyo Removal of thickened visceral pleura (decortications): to improve lung function

UPPER AIRWAY TUBERCULOSIS Epidemiology: nearly always a complication of advanced cavitary pulmonary tuberculosis,

tuberculosis of the upper airways may involve the larynx, pharynx, and epiglottis Clinical Feature:

o Hoarseness, dysphonia, dysphagia, and chronic productive cougho Findings depend on the site of involvemento Laryngoscopy: ulcerations Carcinoma of larynx: similar feature but painless

Diagnosis:o Acid-fast smear sputum: often positiveo Biopsy: may be necessary in some cases to establish diagnosis

GENITOURINARY TUBERCULOSIS Epidemiology:

o ~15% of all extrapulmonary cases in the United States, may involve any portion of genitourinary tract

o 1/3 of patients may concomitantly have pulmonary disease Clinical Feature:

o Urinary frequency, dysuria, nocturia, hematuria, and flank or abdominal paino Patients may be asymptomatic and discovered after severe destruction lesions of the kidneys

Diagnosis:o Culture-negative pyuria in acidic urine: raises suspicion of tuberculosiso Intravenous pyelography, abdominal CT, or MRI: shows deformities, obstruction, and

calcifications and ureteral structures severe lead to hydronephrosis and renal damageo Culture of 3 morning urine specimens: definitive diagnosis in nearly 90% of cases

GENITAL TUBERCULOSIS Epidemiology:

o Diagnosed more commonly in female than in male patientso Almost half of cases of genitourinary tuberculosis, urinary tract disease is also present

Clinical Feature:o Infertility, pelvic pain, and menstrual abnormalities (affects fallopian tubes and endometrium)o Slightly tender mass that may drain externally through fistulous tract (affects epididymis) +

orchitis and prostatitis Diagnosis:

o Biopsy or culture of specimens (by dilatation and curettage) Treatment:

o Chemotherapy: respond well

SKELETAL TUBERCULOSIS Epidemiology:

o ~10% of extrapulmonary cases Pathogenesis:

Reactivation of hematogenous foci or to spread from adjacent paravertebral lymph nodes Clinical features:

o Weight-bearing joints affected (spine (40% of cases), hips (13% of cases), knees (10% of cases)) Diagnosis:

o Examination of synovial fluid: thick in appearance, with a high protein concentration, and a variable cell count

o Synovial biopsy and tissue culture: to establish diagnosis Complication: joint may be destroyed Treatment:

o Chemotherapyo Surgery (severe cases)

SPINAL TUBERCULOSIS (POTT’S DISEASE OR TUBERCULOUS SPONDYLITIS) Epidemiology: upper thoracic spine mostly in children, lower thoracic and upper lumbar vertebrae

mostly in adults Pathogenesis: anterior superior or inferior angle of the vertebral body

↓lesion slowly reaches adjacent body

↓ affecting intervetebral disk

↓ collapse of vertebral bodies

↓kyphosis (gibbus) and paravertebral “cold” abscess ↓ ↓

In upper spine In lower spineabscess track & penetrate chest wall reach inguinal ligaments/presents psoas abscess

↓ soft tissue mass

Clinical Featureso Involves 2/more adjacent vertebral

bodies o CT or MRI reveals characteristic lesion

and suggest etiology Diagnosis

o Apiration of the abscess or bone biopsy confirms the tuberculous etiology

o Cultures usually positive and histologic findings highly typical

Differential Diagnosiso Tumorso Other infections

Complication: paraplegia due to abscess or a lesion compressing spinal cordPYOGENIC BACTERIAL OSTEOMYELITIS Involves disk very early

Produce rapid sclerosisPARAPARESIS: partial paralysis of the lower extremities Due to large abscess is a medical

emergency Requires rapid drainageTUBERCULOSIS OF HIP JOINTS Involving head of femur Causes painTUBERCULOSIS OF KNEE Produce pain and swelling