Clinical Presentation of Mycobacterium Tuberculosis

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Clinical Presentation of Mycobacterium
Tuberculosis

• By Dr.Sujith S.

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Introduction

• Tuberculosis, one of the oldest diseases known to
  affect humans, is a major cause of death
  worldwide.
• This disease, which is caused by bacteria of the
  Mycobacterium tuberculosis complex? affects the
  lungs
• Other organs are involved in up to one-third of
  cases

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• If untreated, the disease may be fatal within 5
  years in 5065 of cases.
• Transmission usually takes place through the
  airborne spread of droplet nuclei produced by
  patients with infectious pulmonary tuberculosis.

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• M. bovis (the bovine tubercle bacillus)
• M. caprae (related to M. bovis)
• M. africanum (isolated from cases in West,
  Central, and East Africa)
• M. microti (the "vole" bacillus, a less virulent
  and rarely encountered organism)
• M. pinnipedii (a bacillus infecting seals and sea
  lions in the southern hemisphere and recently
  isolated from humans)
• M. canettii

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Etiological Agent

• M. tuberculosis is a rod-shaped,
  non-spore-forming, thin aerobic bacterium
  measuring 0.5 um by 3 um the bacilli cannot be
  decolorized by acid alcohol this characteristic
  justifies their classification as acid-fast
  bacilli.
• Acid fastness is due mainly to the organisms'
  high content of mycolic acids, long-chain
  cross-linked fatty acids, and other cell-wall
  lipids

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History

• Fever
• Fatigue
• Cough
• Weight loss
• Dyspnoea
• Chest Pain
• Retrosternal interscapular dull
  pain,worsened by swallowing

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Cont.d

• Cough -initially mild,non-productive / productive
  of only scanty sputum.
• May be present only in the morning, when
  accumulated secretions are expectorated.
• Progressive,?cough becomes more continuous and
  productive of yellow or yellow-green sputum,
  rarely foul-smelling.
• Frank hemoptysis, due to caseous sloughing or
  endobronchial erosion?present later in the
  disease.

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• Dyspnoea-occurs when
• extensive parenchymal involvement/ pleural
  effusions, /pneumothorax.
• Pleuritic chest pain -when present, signifies
  inflammation abutting or invading the pleura,
  with or without an effusion.
• Rarely progresses to frank empyema
• Patients may present with painful ulcers of the
  mouth, tongue, larynx or GI tract .

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Elderly

• Fever, sweats and hemoptysis were less common in
  the elderly.
• These patients were less likely to have cavitary
  disease / positive purified protein derivative
  (PPD) skin test.

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Cont.d

• Painless swelling of the lymph nodes, most
  commonly at posterior cervical and
  supraclavicular sites.
• Increase in urinary frequency
• Dysuria
• Nocturia
• Hematuria
• Flank or abdominal pain

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• Pain swelling in the weight-bearing joints
• (the spine in 40 of cases, the hips in 13, and
  the knees in 10).

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• Initially as headache and slight mental changes.
  May evolve acutely with severe headache,
  confusion, lethargy, altered sensorium, and neck
  rigidity.
• Paresis of cranial nerves
• Involvement of cerebral arteries may produce
  focal ischemia.
• Coma, with hydrocephalus and intracranial
  hypertension

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• Abdominal pain and swelling
• Obstruction
• Hematochezia
• Palpable mass in the abdomen

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• Diffuse abdominal pain/ pain localizing to the
  right upper quadrant, nausea, vomiting and
  diarrhea. Hepatomegaly .
• Liver function test abnormalities are common,
  including elevated alkaline phosphatase and
  transaminases.
• Cholestatic jaundice is also well-documented in
  miliary TB.
• Ascites may be detected in occasional patients.
  Miliary TB may also present as pancreatitis /
  cholecystitis .

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Physical Examination

• Not specific and usually are absent in mild or
  moderate disease.
• Dullness with decreased fremitus resonance may
  indicate pleural thickening or effusion.
• Rales may be present throughout inspiration, or
  may be heard only after a short cough
  (post-tussive rales).

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• When large areas of the lung are involved, signs
  of consolidation associated with open bronchi?
  whispered pectoriloquy/tubular breath sounds.
• Distant hollow breath sounds over cavities are
  called amphoric,after the sound made by blowing
  across the mouth of jars used in antiquity
  (amphora).

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• Pulmonary Tuberculosis

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Primary Disease

• Primary pulmonary tuberculosis occurs soon after
  the initial infection with tubercle bacilli.
• Inspired air is distributed to the middle and
  lower lung zones-most commonly involved in
  primary tuberculosis.
• The lesion -accompanied in more than half of
  cases by hilar or paratracheal lymphadenopathy.
• The lesion heals spontaneously ,later be evident
  as a small calcified nodule (Ghon lesion).

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Post Primary disease

• Chronic TB
• Postprimary disease
• Recrudescent TB
• Endogenous reinfection
• Adult type progressive TB

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• Reactivation of a previously dormant focus seeded
  at the time of the primary infection.
• The apical posterior segments of the lung are
  frequently involved.
• The original site of spread may have been
  previously visible as a small scar called a Simon
  focus

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• Localized to the apical and posterior segments of
  the upper lobes- higher mean oxygen tension
  (compared with that in the lower zones) favors
  mycobacterial growth.
• The superior segments of the lower lobes are
  frequently involved.
• Small infiltrates to extensive cavitary disease..

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• Liquefied necrotic contents - discharged into the
  airways? satellite lesions within the lungs that
  may in turn undergo cavitation
• Massive involvement of pulmonary segments or
  lobes, with coalescence of lesions, produces
  tuberculous pneumonia.
• Some pulmonary lesions become fibrotic and may
  later calcify, but cavities persist in other
  parts of the lungs

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• Endobronchial TB
• Direct extension to the bronchi from an adjacent
  parenchymal focus, usually a cavity.
• Spread of organisms to the bronchi via infected
  sputum from a distant site.

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• Clinical Presentation
• Bronchorrhea, which is production of more than
  500 mL per day of sputum .
• Caseous material from endobronchial lesions /
  calcific material from extension of calcific
  nodes into the bronchi can be expectorated, which
  is known as lithoptysis.

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• Wheezing and hemoptysis may also be seen.
• Lymph node rupture can be associated with chest
  pain.
• Dyspnea may signal obstruction or atelectasis
• Physical findings
• Diminished breath sounds, rhonchi or wheezing may
  be heard.
• The wheeze is described as low-pitched, constant
  and always heard over the same area on the chest
  wall.

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•  Lower lung field TB
• Disease located below a line traced across the
  hila, including the perihilar regions, on a
  standard PA and lateral chest x-ray.
• Risk factors
• Elderly patients
• Diabetes
• Renal/ hepatic disease
• Those receiving corticosteroids
• Underlying silicosis appear most at risk for
  lower lobe

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• Complications of Pulmonary TB
• Hemoptysis
• Pneumothorax
• Bronchiectasis
• Extensive pulmonary destruction

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• Hemoptysis
• Active disease(smear positive)
• "Rasmussen's aneurysm" causes massive hemoptysis
  when TB extends into the adventitia and media of
  bronchial arteries, resulting in inflammation and
  thinning of the vessel wall.
• Subsequently rupturing into the cavity,
  producing hemoptysis.

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• Other causes
• residual bronchiectasis
• an aspergilloma/ other fungus ball invading an
  old healed cavity,
• a ruptured broncholith that erodes through a
  bronchial artery
• a carcinoma
• another infectious or inflammatory process.

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• CNS Tuberculosis

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• Meningitis
• Intracranial tuberculoma
• Spinal tuberculous arachnoiditis

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Pathogenesis

• Scattered tuberculous foci (tubercles) are
  established in the brain, meninges, or adjacent
  bone during the bacillemia.
• The chance occurrence of a subependymal tubercle,
  with progression and rupture into the
  subarachnoid space.

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• The spillage of tubercular protein into the
  subarachnoid space produces an intense
  hypersensitivity reaction.

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• Proliferative arachnoiditis, most marked at the
  base of the brain, produces a fibrous mass
  involving cranial nerves and penetrating vessels.
• Communicating hydrocephalus results from
  extension of the inflammatory process to the
  basilar cisterns and impedance of CSF circulation
  and resorption.

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• Vasculitis with resultant thrombosis and
  infarction involves vessels that traverse the
  basilar/ spinal/ are located within the brain
  substance.

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• Meningitis
• ?The prodromal phase(2 to 3 weeks)
• fever,malaise,lassitude
• ?The meningitic phase-
• meningismus, protracted headache, vomiting,
  lethargy, confusion, and varying degrees of
  cranial nerve and long-tract signs

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• The paralytic phase
• ?delirium, stupor, coma, seizures, multiple
  cranial nerve palsies,or dense hemiplegia.

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• About one-third of patients on presentation
  ?generalized (miliary) tuberculosis
• Careful fundoscopic examination often shows
  choroidal tubercles .
• These are multiple, ill-defined, raised
  yellow-white nodules (granulomas) of varying size
  near the optic disk.

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• Tuberculoma
• Tuberculomas are conglomerate caseous foci within
  the substance of the brain ? from deep-seated
  tubercles acquired during a recent or remote
  hematogenous bacillemia.

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• Radiologically
• clinically silent
• single / multiple enhancing nodular lesions , on
  CT scanning of patients with meningitis or
  miliary TB without meningitis.

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• Tuberculoma is also a distinct clinical syndrome
  manifested by focal neurologic symptoms and signs
  of an intracranial mass lesion.

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• Tuberculosis Lymphadenitis

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Pathogenesis

• Isolated peripheral tuberculous lymphadenopathy
  ?reactivation of disease at a site seeded
  hematogenously during primary TB infection.

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Clinical Presentation

• The most common presentation is isolated chronic,
  nontender, lymphadenopathy. The mass may be
  present for up to 12 months before diagnosis
• A firm discrete mass or matted nodes fixed to
  surrounding structures the overlying skin may be
  indurated. Uncommon findings include fluctuance,
  draining sinus/ erythema nodosum

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• Cervical lymphadenopathy is the most common
  manifestation of TB lymphadenitis.
• A unilateral mass appears in the anterior or
  posterior cervical triangles submandibular and
  supraclavicular lymph node involvement also
  occurs.
• Bilateral disease is uncommon.
• Multiple nodes may be involved at that site.

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• The axillary, inguinal, mesenteric, mediastinal,
  and intramammary lymph nodes.
• Mediastinal lymphadenopathy
• Dysphagia
• Esophageal perforation
• Vocal cord paralysis due to recurrent laryngeal
  nerve involvement
• Pulmonary artery occlusion mimicking pulmonary
  embolism.

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• Tuberculous peritoneal lymphadenopathy
  ?i)periportal region
• ?ii)peripancreatic
• ?iii)mesenteric lymph nodes.
• ?iv)Hepatic lymph node involvement can lead
  to jaundice, portal vein thrombosis, and portal
  hypertension.
• Extrinsic compression of renal arteries due to
  tuberculous abdominal lymphadenopathy can result
  in renovascular hypertension

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• Skeletal Tuberculosis

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• Spinal TB (Pott's disease) most often affects the
  lumbar and lower thoracic region. Tuberculous
  abscess ? frequently bilateral.
• Tuberculous arthritis tends to occur in the
  weight-bearing joints, the hip and the knee, and
  is usually monoarticular.

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Pathogenesis

• The bacillemia
• Seeds organisms
• Bone and synovium

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• Spinal TB
• Infection - in the anteroinferior aspect of the
  cancellous vertebral body, inflammatory bone
  destruction and caseating necrosis.
• Active infection spreads down behind the anterior
  ligament , involves the adjacent vertebral body.
• Local destruction - collapse of bony structures,
  herniation of the disk into the vertebral bodies.

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• A tuberculous abscess - impinge on local
  structures.
• An epidural abscess -produce pressure on the
  cord.
• An extraspinal soft tissue mass - erodes ribs and
  adjacent structures
• Psoas abscess - track down to the groin

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• Vertebral collapse
• spinal instability with gibbous deformity
• distort the anatomy of the canal to the point of
  spinal cord compression.
• Granulomatous changes ?synovial proliferation in
  tuberculous arthritis with joint effusion and
  erosion of cartilage.
• Slowly progressive destruction, disorganization
  of joint architecture, and potential deformity.

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Clinical Presentation

• Local pain-associated with muscle spasm and
  rigidity.
• Description of the patient with spinal TB reads
  "The muscle spasm, which extends beyond the
  diseased area, sometimes produces the well-known
  erect posture and 'aldermanic' gait.
• The patient walks with short deliberate steps to
  avoid any jarring of the spine.

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• ii)Cord compression during the active phase of
  the infection resulting in paraplegia (Pott's
  paraplegia)
• Late-onset paraplegia ?osteophytes and other
  chronic degenerative changes at a site of
  previous infection.
• TB of the pedicles and other posterior spinal
  elements is well-described.

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• Renal Tuberculosis

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Spinal TB
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TB Arthritis of Hip
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• Two major mechanism
• i)Direct infection of the kidney and lower
  urinary tract
• ii)Secondary amyloidosis.
• iii)Nephrotoxicity induced by antimicrobial
  agents
• iv)Hyponatremia due to the syndrome of
  inappropriate ADH secretion because of pulmonary
  involvement /miliary disease.

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Pathogenesis

• Hematogenous seeding either at the time of
  primary pulmonary infection.
• The net effect is the formation of granulomatous
  lesions in the glomeruli ? heal without producing
  any renal disease.
• The granulomas may caseate and rupture into the
  tubular lumen as late as 30 years after the
  initial infection.
• Tubercle bacilli can enter the medullary
  interstitium, eventually leading to granuloma
  formation and progressive medullary injury.
• Similar lesions can occur in the ureters,
  bladder, and, in males, the prostate and
  epididymis.

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• Dysuria and gross hematuria being the most common
  symptoms .
• Renal colic ? uncommon manifestation with active
  extrarenal disease (fever, weight loss, cough,
  hemoptysis).
• Rupture of the glomerular granulomas is a random
  event, independent of disease elsewhere
• .

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• Incidentally found to have pyuria and/or
  microscopic hematuria.
• Heavy proteinuria and cellular casts.
• Plasma creatinine concentration is usually normal
  or near normal.
• Ureteral strictures may cause obstructive
  uropathy-gt severe cases, renal loss .

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• Signs of extrarenal disease include ureteral
  strictures (single or multiple)
• A contracted bladder
• Calcifications in the vas deferens, seminal
  vesicles, or prostate.

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• Refractory hypertension ? complication of renal
  tuberculosis.
• The elevation in blood pressure ? is angiotensin
  II-mediated-from intimal proliferation of vessels
  in or near areas of inflammation, leading to
  segmental ischemia and renin release.

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• Drug induced Nephritis
• Renal glucosuria
• Hyperuricosuria
• polyuria due to nephrogenic diabetes insipidus
• increased urinary excretion of polyclonal light
  chains.

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• Mild hyponatremia (plasma sodium concentration
  usually between 125 and 135 meq/L) .
• Most patients appear to have the syndrome of
  inappropriate ADH secretion.

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• Tuberculosis
  Peritonitis

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• Risk factors
• Cirrhosis
• HIV infection
• Diabetes mellitus
• Underlying malignancy?treatment with anti-tumor
  necrosis factor (TNF) agents
• Patients undergoing continuous ambulatory
  peritoneal dialysis

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• Reactivation of latent tuberculous foci in the
  peritoneum ? hematogenous spread from a primary
  lung focus.
• As the disease progresses-? the visceral and
  parietal peritoneum become increasingly studded
  with tubercles.
• Ascites develops secondary to "exudation" of
  proteinaceous fluid from the tubercles.

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Clinical Presentation

• Ascites (93 percent), abdominal pain (73
  percent), and fever (58 percent).
• Many patients had a diffusely distended tender
  abdomen.
• The classic doughy abdomen is associated with
  the fibroadhesive form of tuberculous
  peritonitis.

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• The salient clinical findings
• Abdominal tenderness
• Hepatomegaly
• Ascites

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• Genital
  Tuberculosis

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• Tuberculosis - affect the upper female
  reproductive tract (fallopian tube, endometrium,
  ovaries)
• i)Extension from an intraabdominal focus,
  hematogenous seeding
• ii)Ascending from lower genital tract (cervix,
  vagina, vulva) infection.
• The fallopian tube and endometrium are most
  commonly involved.

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• The finding of endometrial tuberculosis always
  means that the tubes are infected
• Tuberculous salpingitis can exist without
  associated endometritis.
• Pelvic mass, infertility, abnormal uterine
  bleeding, and pelvic pain
• Epididymo-orchitis in males

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• Tuberculosis
  Pericarditis

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• Stage of infection
• The degree of pericardial involvement
• The degree of extrapericardial tuberculous disease

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• Physical Findings
• Fever
• Tachycardia
• Increased jugular venous pressure
• Hepatomegaly
• Ascites
• Peripheral edema
• Pericardial rub and distant heart sounds

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• Constructive Pericarditis
• Kussmaul's sign (the lack of an inspiratory
  decline in jugular venous pressure).
• Elevated and distended jugular veins with a
  prominent Y descent (the second inward deflection
  of the internal jugular pulse due to diastolic
  inflow of blood into the right ventricle)
• In constriction, the inspiratory decline in
  pressure is not transmitted to the right heart
  chambers.

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• Cardiac Tamponade
• Hypotension with a narrow pulse pressure,
  reflecting the limited stroke volume.
• Sinus tachycardia
• Elevated jugular venous pressure
• Pulsus paradoxus, defined as an abnormally large
  decrease in systolic blood pressure (gt10 mmHg) on
  inspiration.

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• Ascites .
• The main clue? elevation of jugular venous
  pressure.

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• Tuberculosis
  Enteritis

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Pathogenesis

• Swallowing of infected sputum
• Hematogenous spread from active pulmonary or
  miliary TB
• Ingestion of contaminated milk or food, a rarity
  in the Western world
• Contiguous spread from adjacent organs

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• Most common siteileocecal region
• Cause
• Relative stasis and abundant lymphoid tissue.
  The organism penetrates the mucosa and localizes
  in the submucosal lymphoid tissue, where it
  initiates an inflammatory reaction with
  subsequent lymphangitis, endarteritis, granuloma
  formation, caseation necrosis, mucosal
  ulceration, and scarring.

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• Ulcerative (60 percent)?multiple superficial
  ulcers.
• Hypertrophic (10 percent)? scarring, fibrosis,
  and pseudotumor lesions.
• Ulcerohypertrophic (30 percent)? inflammatory
  mass centering around the ileocecal valve with
  thickened and ulcerated intestinal walls.

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Clinical Presentation

• Nonspecific chronic abdominal pain
• Anorexia, fatigue, fever, night sweats, weight
  loss, diarrhea, constipation, or blood in the
  stool may be present.
• A palpable right lower quadrant abdominal mass
  is present in 25 to 50 percent of patients.
• Small bowel obstruction / colonic perforation .
  The presence of ascites may help to distinguish
  ileocecal TB from Crohn's disease.

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• Tb Pleural
  Effusion

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Pathogenesis

• Tuberculous pleural effusions ? a delayed
  hypersensitivity reaction to mycobacterial
  antigens in the pleural space.
• These antigens probably enter the pleural space
  after rupture of a subpleural focus of disease or
  leakage from these lesions.

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Clinical Presentation

• Tuberculous pleural effusion ? acute febrile
  illness causing a i) nonproductive cough (94
  percent) ii) pleuritic chest pain
  (78 percent) without an elevation in the
  peripheral white blood cell (WBC) count.
• Night sweats, chills, weakness, dyspnea, and
  weight loss.

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• TB Adrenalitis

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• Tuberculous adrenalitis results from hematogenous
  spread from active infection elsewhere in the
  body .
• Extraadrenal tuberculosis is usually evident, but
  may be clinically latent

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• Miliary
  Tuberculosis

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Clinical Presentation

• During primary infection, the disease has a more
  acute onset and more rapid clinical course.
• Acute disease may be fulminant,
• i) multiorgan system failure
• ii)a syndrome of septic shock
• iii) acute respiratory distress syndrome, ARDS

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• Late miliary tuberculosis can be acute, but is
  more likely to be subacute or chronic.
• Reinfection may have a role in highly endemic
  areas.
• At the chronic end of the spectrum, patients may
  present with failure to thrive without fever,
  with fever of unknown origin, or with dysfunction
  of one organ system

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• Thankyou

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