Extrapulmonary tuberculosis and HIV Outi Vehviläinen, MD Ilembula Lutheran Hospital
EPTB What is EPTB Pathogenesis Clinical manifestations Diagnostic evaluation Statistical information from ILH X-rays and pictures 2
WHAT IS EPTB: definition Causative organism: Mycobacterium tuberculosis Primary infection or reactivation of latent focus EPTB occurs outside lungs 10% 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 3
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 4
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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 lymphnodes Headache/confusion, neck stiffness,altered mental status Skeletal pain: gradual onset Joint pain, swelling Abdominal pain Urinary symptoms 10
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 11
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 12
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% 13
EPTB/ILEMBULA LUTHERAN HOSPITAL Sputum Sputum Miliary Meningitis Spinal Effusion EP- children Adenitis Ohters Relapsy EPTB
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Conclusion Common in HIV-infected persons Difficult to diagnose because can mimic many diseases Sputum for AFB often negative CXR can be normal Always get HIV test in patients with EPTB. 23
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