LYMPH NODE TUBERCULOSIS (TUBERCULOUS LYMPHADENITIS)

Epidemiology:
o >40% of cases in United States
o Children and woman (particularly non-Caucasians) seem to be especially susceptible
o Particularly frequent among HIV-infected patients
o 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 cases
o Cultures: positive in 70-80%
o Histologic examination shows granulomatous tissue
o 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), Kimuras disease, and Castlemans disease
Treatment:
o Antituberculous therapy
o Surgical intervention: when excision necessary/to remove nodes that remain enlarged after
therapy


PLEURAL TUBERCULOSIS
Epidemiology:
o ~20% of extrapulmonary cases in the United States
o 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 lesion
o Acid fast bacilli: seen in only 10-25% of cases
o Cultures: may be positive for M. tuberculosis in 25-75% of cases
o 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 spontaneously
TUBERCULOUS 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 lymphocyte
o Chest radiograph: hydropneumothorax with an air-fluid level
o Acid fast smears and mycobacterial culture: positive
Treatment:
o Surgical drainage
o Chemotherapy
o 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 cough
o Findings depend on the site of involvement
o Laryngoscopy: ulcerations
Carcinoma of larynx: similar feature but painless
Diagnosis:
o Acid-fast smear sputum: often positive
o 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 pain
o Patients may be asymptomatic and discovered after severe destruction lesions of the kidneys
Diagnosis:
o Culture-negative pyuria in acidic urine: raises suspicion of tuberculosis
o Intravenous pyelography, abdominal CT, or MRI: shows deformities, obstruction, and
calcifications and ureteral structures severe lead to hydronephrosis and renal damage
o 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 patients
o 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 Chemotherapy
o Surgery (severe cases)
SPINAL TUBERCULOSIS (POTTS 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 spine
abscess track & penetrate chest wall reach inguinal ligaments/presents psoas abscess

soft tissue mass
Clinical Features
o 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 Diagnosis
o Tumors
o Other infections
Complication: paraplegia due to abscess or a lesion compressing spinal cord
PYOGENIC BACTERIAL OSTEOMYELITIS
Involves disk very early
Produce rapid sclerosis
PARAPARESIS: partial paralysis of the lower
extremities
Due to large abscess is a medical
emergency
Requires rapid drainage
TUBERCULOSIS OF HIP JOINTS
Involving head of femur
Causes pain
TUBERCULOSIS OF KNEE
Produce pain and swelling