Tuberculosis (TB) is divided into two categories: pulmonary and extrapulmonary.
Treatment of active TB is complex and is becoming even more complex with the emergence of multidrug-resistant tuberculosis and HIV infection. Hospital admission is recommended for severe cases.
Standard therapy for pulmonary TB includes isoniazid and rifampin for 6 months along with pyrazidamide for the first 2 months (isoniazid and rifampin without pyrazidamide may be used for 9 months, if necessary). Treatment consists of three drugs that are effective against the organism.
If the incidence of drug-resistant TB in a community is greater than 4%, ethambutol or streptomycin is added until sensitivities are known. (All strains of bacteria are tested to determine the sensitivity to the antibiotics used.) Sputum should be negative after 3 months of therapy. If not, treatment is reevaluated. If a patient is unable to tolerate isoniazid, or if isoniazid-resistant TB is present, rifampin, ethambutol, and pyrazidamide are usually used for 18 months. If rifampin-resistant TB is present, the regimen usually consists of isonizaid, ethambutol, and pyrazidamide for 18 months. If there is resistance to both isoniazid and rifampin, the disease is very difficult to treat.
Antibiotic Side effects
Isoniazid Hepatitis, peripheral neuropathy, central nervous system effects including seizures, psychosis, encephalopathy
Pyrazinamide Arthralgia, hyperuricemia, hepatitis, photosensitivity, gastric irritation; contraindicated in pregnant patients
Rifampin Drug interactions; gastric irritation; colitis; fever; puritis; anaphylaxis; thrombocytopenia; leukopenia; hemolytic anemia; elevated LFT (liver function test); flu-like symptoms; colors body fluids orange; may permanently discolor contact lenses
Streptomycin Ototoxicity, paresthesia, dizziness, nausea, tinnitus, nephrotoxicity, peripheral neuropathy, allergic skin rash
Ethambutol Optic neuritis, peripheral neuropathy, headache, rashes, arthralgias, hyperuricemia, anaphylaxis (rare)
Standard therapy for extrapulmonary TB
Therapy for extrapulmonary TB uses the same drugs but may last longer. Steroid therapy may be useful in pericardial disease and is indicated in children with meningitis.
Surgery
With multidrug-resistant TB that does not respond to antibiotics, the infected portion(s) of the lung may be removed surgically. The prognosis for these patients is extremely poor. Tuberculosis empyema (pus in pleural fluid) may require chesttube drainage of the pleural space.
Treating pregnant patients
Pregnant patients with TB usually receive isonizaid and rifampin with ethambutol. These drugs have not been found to be harmful to the fetus. Streptomycin is contraindicated because it causes deafness in the fetus. Pyrazinamide is also contraindicated in pregnant patients.
With good compliance, relapse is rare. Long term effects and complications due to scarring may occur. For those with extensive disease, the prognosis is poor.
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Pulmonary Tuberculosis Types
Primary Tuberculosis Pneumonia
Tuberculosis Pleurisy
Cavitary Tuberculosis
Miliary TB
Laryngeal Tuberculosis
Primary tuberculosis pneumonia
This uncommon type of TB presents as pneumonia and is very infectious. Patients have a high fever and productive cough. It occurs most often in extremely young children and the elderly. It is also seen in patients with immunosuppression, such as HIV-infected and AIDS patients, and in patients on long term corticosteroid therapy.
Tuberculosis pleurisy
This usually develops soon after initial infection. A granuloma located at the edge of the lung ruptures into the pleural space, the space between the lungs and the chest wall. Usually, a couple of tablespoons of fluid can be found in the pleural space. Once the bacteria invade the space, the amount of fluid increases dramatically and compresses the lung, causing shortness of breath (dyspnea) and sharp chest pain that worsens with a deep breath (pleurisy). A chest x-ray shows significant amounts of fluid. Mild- or low-grade fever commonly is present. Tuberculosis pleurisy generally resolves without treatment; however, two-thirds of patients with tuberculosis pleurisy develop active pulmonary TB within 5 years.
Cavitary TB
Cavitary TB involves the upper lobes of the lung. The bacteria cause progressive lung destruction by forming cavities, or enlarged air spaces. This type of TB occurs in reactivation disease. The upper lobes of the lung are affected because they are highly oxygenated (an environment in which M. tuberculosis thrives). Cavitary TB can, rarely, occur soon after primary infection.
Symptoms include productive cough, night sweats, fever, weight loss, and weakness. There may be hemoptysis (coughing up blood). Patients with cavitary TB are highly contagious. Occasionally, disease spreads into the pleural space and causes TB empyema (pus in the pleural fluid).
Miliary TB
Miliary TB is disseminated TB. "Miliary" describes the appearance on chest x-ray of very small nodules throughout the lungs that look like millet seeds. Miliary TB can occur shortly after primary infection. The patient becomes acutely ill with high fever and is in danger of dying. The disease also may lead to chronic illness and slow decline.
Symptoms may include fever, night sweats, and weight loss. It can be difficult to diagnose because the initial chest x-ray may be normal. Patients who are immunosuppressed and children who have been exposed to the bacteria are at high risk for developing miliary TB.
Laryngeal TB
TB can infect the larynx, or the vocal chord area. It is extremely infectious.
Extrapulmonary Tuberculosis
This type of tuberculosis occurs primarily in immunocompromised patients.
Lymph Node Disease
Tuberculosis Peritonitis
Tuberculosis Pericarditis
Osteal Tuberculosis
Renal Tuberculosis
Adrenal Tuberculosis
Tuberculosis Meningitis
Lymph node disease
Lymph nodes contain macrophages that capture the bacteria. Any lymph node can harbor uncontrolled replication of bacteria, causing the lymph node to become enlarged. The infection can develop a fistula (passageway) from the lymph node to the skin.
Tuberculosis peritonitis
M. tuberculosis can involve the outer linings of the intestines and the linings inside the abdominal wall, producing increased fluid, as in tuberculosis pleuritis. Increased fluid leads to abdominal distention and pain. Patients are moderately ill and have fever.
Tuberculosis pericarditis
The membrane surrounding the heart (the pericardium) is affected in this condition. This causes the space between the pericardium and the heart to fill with fluid, impeding the heart's ability to fill with blood and beat efficiently.
Osteal tuberculosis
Infection of any bone can occur, but one of the most common sites is the spine. Spinal infection can lead to compression fractures and deformity of the back.
Renal tuberculosis
This can cause asymptomatic pyuria (white blood cells in the urine) and can spread to the reproductive organs and affect reproduction. In men, epididymitis (inflammation of the epididymis) may occur.
Adrenal tuberculosis
TB of the adrenal glands can lead to adrenal insufficiency. Adrenal insufficiency is the inability to increase steroid production in times of stress, causing weakness and collapse.
TB meningitis
M. tuberculosis can infect the meninges (the main membrane surrounding the brain and spinal cord). This can be devastating, leading to permanent impairment and death. TB can be difficult to discern from a brain tumor because it may present as a focal mass in the brain with focal neurological signs.
Headache, sleepiness, and coma are typical symptoms. The patient may appear to have had a stroke.
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Treatment of active TB is complex and is becoming even more complex with the emergence of multidrug-resistant tuberculosis and HIV infection. Hospital admission is recommended for severe cases.
Standard therapy for pulmonary TB includes isoniazid and rifampin for 6 months along with pyrazidamide for the first 2 months (isoniazid and rifampin without pyrazidamide may be used for 9 months, if necessary). Treatment consists of three drugs that are effective against the organism.
If the incidence of drug-resistant TB in a community is greater than 4%, ethambutol or streptomycin is added until sensitivities are known. (All strains of bacteria are tested to determine the sensitivity to the antibiotics used.) Sputum should be negative after 3 months of therapy. If not, treatment is reevaluated. If a patient is unable to tolerate isoniazid, or if isoniazid-resistant TB is present, rifampin, ethambutol, and pyrazidamide are usually used for 18 months. If rifampin-resistant TB is present, the regimen usually consists of isonizaid, ethambutol, and pyrazidamide for 18 months. If there is resistance to both isoniazid and rifampin, the disease is very difficult to treat.
Antibiotic Side effects
Isoniazid Hepatitis, peripheral neuropathy, central nervous system effects including seizures, psychosis, encephalopathy
Pyrazinamide Arthralgia, hyperuricemia, hepatitis, photosensitivity, gastric irritation; contraindicated in pregnant patients
Rifampin Drug interactions; gastric irritation; colitis; fever; puritis; anaphylaxis; thrombocytopenia; leukopenia; hemolytic anemia; elevated LFT (liver function test); flu-like symptoms; colors body fluids orange; may permanently discolor contact lenses
Streptomycin Ototoxicity, paresthesia, dizziness, nausea, tinnitus, nephrotoxicity, peripheral neuropathy, allergic skin rash
Ethambutol Optic neuritis, peripheral neuropathy, headache, rashes, arthralgias, hyperuricemia, anaphylaxis (rare)
Standard therapy for extrapulmonary TB
Therapy for extrapulmonary TB uses the same drugs but may last longer. Steroid therapy may be useful in pericardial disease and is indicated in children with meningitis.
Surgery
With multidrug-resistant TB that does not respond to antibiotics, the infected portion(s) of the lung may be removed surgically. The prognosis for these patients is extremely poor. Tuberculosis empyema (pus in pleural fluid) may require chesttube drainage of the pleural space.
Treating pregnant patients
Pregnant patients with TB usually receive isonizaid and rifampin with ethambutol. These drugs have not been found to be harmful to the fetus. Streptomycin is contraindicated because it causes deafness in the fetus. Pyrazinamide is also contraindicated in pregnant patients.
With good compliance, relapse is rare. Long term effects and complications due to scarring may occur. For those with extensive disease, the prognosis is poor.
http://www.pulmonologychannel.com/tuberculosis/treatment.shtml
Pulmonary Tuberculosis Types
Primary Tuberculosis Pneumonia
Tuberculosis Pleurisy
Cavitary Tuberculosis
Miliary TB
Laryngeal Tuberculosis
Primary tuberculosis pneumonia
This uncommon type of TB presents as pneumonia and is very infectious. Patients have a high fever and productive cough. It occurs most often in extremely young children and the elderly. It is also seen in patients with immunosuppression, such as HIV-infected and AIDS patients, and in patients on long term corticosteroid therapy.
Tuberculosis pleurisy
This usually develops soon after initial infection. A granuloma located at the edge of the lung ruptures into the pleural space, the space between the lungs and the chest wall. Usually, a couple of tablespoons of fluid can be found in the pleural space. Once the bacteria invade the space, the amount of fluid increases dramatically and compresses the lung, causing shortness of breath (dyspnea) and sharp chest pain that worsens with a deep breath (pleurisy). A chest x-ray shows significant amounts of fluid. Mild- or low-grade fever commonly is present. Tuberculosis pleurisy generally resolves without treatment; however, two-thirds of patients with tuberculosis pleurisy develop active pulmonary TB within 5 years.
Cavitary TB
Cavitary TB involves the upper lobes of the lung. The bacteria cause progressive lung destruction by forming cavities, or enlarged air spaces. This type of TB occurs in reactivation disease. The upper lobes of the lung are affected because they are highly oxygenated (an environment in which M. tuberculosis thrives). Cavitary TB can, rarely, occur soon after primary infection.
Symptoms include productive cough, night sweats, fever, weight loss, and weakness. There may be hemoptysis (coughing up blood). Patients with cavitary TB are highly contagious. Occasionally, disease spreads into the pleural space and causes TB empyema (pus in the pleural fluid).
Miliary TB
Miliary TB is disseminated TB. "Miliary" describes the appearance on chest x-ray of very small nodules throughout the lungs that look like millet seeds. Miliary TB can occur shortly after primary infection. The patient becomes acutely ill with high fever and is in danger of dying. The disease also may lead to chronic illness and slow decline.
Symptoms may include fever, night sweats, and weight loss. It can be difficult to diagnose because the initial chest x-ray may be normal. Patients who are immunosuppressed and children who have been exposed to the bacteria are at high risk for developing miliary TB.
Laryngeal TB
TB can infect the larynx, or the vocal chord area. It is extremely infectious.
Extrapulmonary Tuberculosis
This type of tuberculosis occurs primarily in immunocompromised patients.
Lymph Node Disease
Tuberculosis Peritonitis
Tuberculosis Pericarditis
Osteal Tuberculosis
Renal Tuberculosis
Adrenal Tuberculosis
Tuberculosis Meningitis
Lymph node disease
Lymph nodes contain macrophages that capture the bacteria. Any lymph node can harbor uncontrolled replication of bacteria, causing the lymph node to become enlarged. The infection can develop a fistula (passageway) from the lymph node to the skin.
Tuberculosis peritonitis
M. tuberculosis can involve the outer linings of the intestines and the linings inside the abdominal wall, producing increased fluid, as in tuberculosis pleuritis. Increased fluid leads to abdominal distention and pain. Patients are moderately ill and have fever.
Tuberculosis pericarditis
The membrane surrounding the heart (the pericardium) is affected in this condition. This causes the space between the pericardium and the heart to fill with fluid, impeding the heart's ability to fill with blood and beat efficiently.
Osteal tuberculosis
Infection of any bone can occur, but one of the most common sites is the spine. Spinal infection can lead to compression fractures and deformity of the back.
Renal tuberculosis
This can cause asymptomatic pyuria (white blood cells in the urine) and can spread to the reproductive organs and affect reproduction. In men, epididymitis (inflammation of the epididymis) may occur.
Adrenal tuberculosis
TB of the adrenal glands can lead to adrenal insufficiency. Adrenal insufficiency is the inability to increase steroid production in times of stress, causing weakness and collapse.
TB meningitis
M. tuberculosis can infect the meninges (the main membrane surrounding the brain and spinal cord). This can be devastating, leading to permanent impairment and death. TB can be difficult to discern from a brain tumor because it may present as a focal mass in the brain with focal neurological signs.
Headache, sleepiness, and coma are typical symptoms. The patient may appear to have had a stroke.
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