Pulmonary Tuberculosis – Overview and Key Points

Pulmonary Tuberculosis – Overview and Key Points

I. Types of Pulmonary Tuberculosis:

• Acute Pulmonary Tuberculosis: Rare, includes:

• Miliary tuberculosis

• Primary pulmonary tuberculosis

• Tuberculous pleurisy

• Initial Stage of Pulmonary Tuberculosis:

• Systemic: Fever, fatigue, headache

• Functional: Persistent cough with phlegm > 2 weeks, hemoptysis (small amount, late stage of hemoptysis), chest pain, dyspnea

• Physical Examination: Diminished breath sounds, crackles at the apex of the lung

• Acute Pulmonary Tuberculosis: High fever, cough, chest pain, dyspnea.

• Full-blown Stage of Pulmonary Tuberculosis:

• Systemic: Anemia, persistent afternoon fever, exhaustion

• Functional: Increased cough, continuous chest pain, dyspnea at rest

• Physical Examination: Concave chest, crackles, rales, cavernous breathing, X-ray: displacement of the cardiac shadow

• Failed Pulmonary Tuberculosis: Tuberculosis bacteria still present after 5 months (culture).

• Recurrent Tuberculosis: Previously cured, now AFB+ (smear).

• Chronic Tuberculosis: Tuberculosis bacteria still present after retreatment with close supervision.

• Classification of Pulmonary Tuberculosis by Lesion Progression: Primary pulmonary tuberculosis, tuberculoma, tuberculous pleurisy, miliary tuberculosis.

• What type of tuberculosis is common in adolescents? Miliary tuberculosis/primary pulmonary tuberculosis.

• What type of tuberculosis is less common in middle-aged adults? Primary pulmonary tuberculosis.

• How to manage pulmonary tuberculosis with conflicting history and physical examination findings? Tuberculous pleurisy, requires definitive diagnosis.

II. Classification of Pulmonary Tuberculosis:

• 5 ways to classify pulmonary tuberculosis:

• CTCLQG (Classification of Tuberculosis in Children and Adults)

• Age

• Lesion progression, disease characteristics

• X-ray

• Previous treatment history

III. When to Diagnose Pulmonary Tuberculosis with Negative AFB (Acid-fast Bacilli):

• One of two scenarios:

• High suspicion based on lab results (Expert… – )

• History + X-ray + insufficient conditions for broad-spectrum testing/ HIV (+)

IV. Diagnosis of Pulmonary Hemoptysis:

• Differential Diagnosis of Hemoptysis, Hematemesis:

• Upper respiratory tract bleeding: Blood appears in the nose/mouth and flows out.

• Hematemesis: Blood appears in the mouth, may be accompanied by vomiting.

• Basis for differential diagnosis of hemoptysis, hematemesis:

• Medical history

• Symptoms:

• Blood characteristics: Frothy/not frothy

• Color:

• What is it mixed with?

• History

• Definitive Diagnosis: Hemosiderin in sputum/low-grade fever

• Causes of Hemoptysis:

• Pulmonary: Tuberculosis > bronchiectasis > pulmonary tumor > pneumonia from other causes > pulmonary embolism.

• Systemic: Rheumatic heart disease, Goodpasture’s syndrome, collagen vascular disease, foreign body.

• Cardiovascular:

• Complications of Hemoptysis: Death, acute respiratory failure, pneumonia, lung collapse, pulmonary embolism.

• Principles of Management:

• Immobilization

• Sedation

• Hemostasis

• Address the underlying cause

V. Pleural Effusion (PE):

• Tuberculous PE: Seen in children, acute course.

• X-ray of PE:

• Homogeneous opacity

• Small: Blunted costophrenic angle

• Moderate: 2/3 of the lung field, Damoiseau’s curve, widened costophrenic sulcus

• Large: Mediastinal shift, air-fluid level

• Tuberculous PE:

• WBC: > 2000, increased lymphocytes, sometimes 90%

• Protein: Low protein, decreased sodium, protein > 30mg/dl, LDH > 0.6

• If there’s a decrease in all 3 protein levels, consider: Pleural thickening, large abscess not yet ruptured, extensive lung collapse.

• Light’s Criteria for Diagnosis of Exudative, Transudative PE: One of the following 3:

• LDH > 2/3 * 180(165) blood LDH

• Protein >0.5 * 7,5

• LDH: Serum >=0.6

• Causes of Transudative PE: Hepatic, renal, cardiac failure, malnutrition.

• Causes of Exudative PE:

• Pulmonary: Tuberculosis, pulmonary tumor, pneumonia

• Non-pulmonary: Acute pancreatitis, etc.

• Definitive Diagnosis of Tuberculous PE: Biopsy.

• Treatment of Exudative PE:

• SHH: Oxygen therapy, thoracentesis, breathing exercises

• UT: Pleurodesis

• Thoracentesis for Tuberculous PE: Early, thorough, avoid multiple aspirations, <1l, at least 24h apart.

• Complications of Thoracentesis: Pulmonary edema (nausea, dizziness, fainting), pneumothorax (rapid aspiration), pleural puncture, needle puncture.

VI. Some Important Information:

• Normal WBC count: 4.5-5 T/l

• Normal Hb level: > 120

• WBC differential:

• Lymphocytes: 35%

• Neutrophils: 60%

• Eosinophils: +-8%

• Basophils: 3.2 +-2

• Differentiating PE from Pleural Thickening:

• History: Previous pleural disease.

• No pleural pain.

• Lung collapse, localized costophrenic sulcus narrowing.

• Differentiating PE from Lung Collapse: Lung collapse.

Note: This article is for informational purposes only. For accurate diagnosis and treatment, consult a specialist physician.