TB 6-1

Unit 6: Diagnosing TB
Botswana National Tuberculosis Programme

Manual Training for Medical Officers
Objectives
At the end of this unit, participants will be able to:
Diagnose pulmonary tuberculosis disease
using sputum smears
Diagnose smear negative pulmonary TB
disease
Diagnose extra-pulmonary TB disease
Slide 6-2
Diagnosis of Tuberculosis
Priority is in diagnosing and curing infectious
cases
ALL persons with TB symptoms should also
be tested for HIV
Routine HIV testing in Botswana
Rapid HIV testing available in all public health
facilities
Slide 6-3
Common Sites of TB Disease

Lungs
Pleura
Central nervous
system
Lymphatic system
Genitourinary systems
Bones and joints
Disseminated (miliary
TB)
Pericardial disease
Source: CDC, 2001.
Slide 6-4
The Effect of HIV Infection on

Symptoms and Signs of TB
TB is more common in HIV infected persons,
systemic symptoms are very common
HIV-related immunosuppression doesnt
always allow the body to contain TB disease
to a single organ system
Must be looking for signs and symptoms of
both pulmonary and extrapulmonary TB
Slide 6-5
Case Finding (1)

Highest priority to find and cure infectious
cases: people with smear-positive PTB
Two ways of identifying TB cases:
Passive case finding: illness diagnosed
when patient presents for medical care at
health facility
Active case finding: health workers actively
search for patients with TB in the
community
Slide 6-6
Who is a TB Suspect?
Any person who presents with symptoms or
signs suggestive of TB, in particular cough of
long duration (more than 2 weeks).
Source: WHO, 2003

Slide 6-7
Case Finding (2)

Most common tools for case finding include:
History taking
Physical examination
Sputum examination
X-ray examination
Tuberculin skin testing
Slide 6-8
Active Case Finding

Contact investigation most common method in
Botswana
Other methods include special surveys based on:
Geography
Targeted testing of defined populations
(e.g., schools, prisons)
Slide 6-9
Clinical Presentation
Take a thorough history for each patient
Determine if signs and symptoms point to
pulmonary or extrapulmonary TB
Also obtain medical and social history
Do a general physical examination with

additional care to detect signs of
tuberculosis
Slide 6-10
Medical History
Have you had close contact with someone with TB?

Do you have a cough? How long, dry, productive, colour?
Is blood present in your sputum?
Do you have chest pain? When & where?
Do you have shortness of breath? How long?
Do you sweat profusely at night?
Have you lost weight?
When did you start losing weight?
When did you lose your appetite?
How long have you been feeling weak and tired?
Do you smoke?
Have you previously been tested for TB?
Do you know your HIV status?
Source: Chiang C-V et al., 2007.

Slide 6-11
Common Symptoms of
Adult Pulmonary TB (1)
Cough (prolonged) for two to three weeks
Any person with this symptom is classified as TB suspect
Sputum
Fever/ night sweats
Weight loss, wasting in advanced cases
Shortness of breath
Malaise
Slide 6-12
Common Symptoms of
Adult Pulmonary TB (2)
Haemoptysis
Chest pain
Tachypnoea (abnormally fast breathing)
Anaemia
Abnormal breath sounds
Loss of appetite
Slide 6-13
Pulmonary TB Diagnosis
How do you currently diagnose

pulmonary tuberculosis disease?
Slide 6-14
PTB types, BNTP 2005
Source: BNTP, 2005
Slide 6-15
Sputum Smears
Smear microscopy is widely available and
accessible for diagnosis in Botswana
When pulmonary TB is suspected, three
sputum specimens must be collected for
examination
Outpatient: spot-early morning-spot
Inpatient: three early morning specimens
over three consecutive days
Slide 6-16
Sputum Collection Techniques (1)

Sputum collection should be done outside or
in an empty room with very good ventilation
If above not possible, try for best possible
ventilation
Use sterile glass or plastic containers, 5-6 cm
deep, with screw cap
Slide 6-17
Sputum Collection Techniques (2)

The health worker should explain and demonstrate
procedure
The health worker should supervise,
but should NOT stand in front of the patient
Collect away from other people
Only sputum (2-5 ml) should be accepted as a good

specimen
Saliva (white, watery, frothy) should not be accepted
because it will yield useless and misleading results
Slide 6-18
Specimen Quality
Poor quality sputum

Source: CDC, 2007
Better quality
Slide 6-19
Patient Instructions:
Sputum Collection (1)
Explain clearly to patient:
Why sputum is needed
Three samples required
Spotmorning-spot
What a good sample is and how to obtain it
Opening and tight closing of containers
Not to soil the exterior of the container
Not to expose the sample to sunlight
Transport of sputum containers
The need to return to the clinic
Slide 6-20
Patient Instructions:
Sputum Collection (2)
Rinse mouth and throat with water two to three times,
and drink some water to wet throat (for easy spitting of
viscid sputum)
Inhale deeply 2-3 times, breathe out hard each time
Keep the body inclined to front
Cough deeply from the chest
Open the container and keep it near mouth and spit
sputum in
Close lid securely
Wash hands after handling sputum container
Bring container to HCW
Slide 6-21
Sputum Smear Examination

Specimens should be sent to lab as soon as
possible
Complete Mycobacteriology Request and
Report Form
Always aim for three specimens from each
suspect
Spot-early morning-spot specimen collection
will detect 90% of smear-positive cases
Slide 6-22
Acid-Fast Smear
Showing TB Bacilli
University of Alabama at Birmingham, Department of Pathology

Slide 6-23
Mycobacteriology
Request and Report Form
Must be completed by HCW for each specimen
submitted to lab, and must accompany it to the lab
Smear microscopy
TB culture
Drug sensitivity testing
Completed suspect register
Lab will:
Process specimen
Complete REPORT section on forms lower half
Return to requesting HCW or treatment unit
Slide 6-24
Sputum Results
Once Mycobacteriology Request and
Report form is received back in the clinic,
the receiving HCW should record the
results in:
TB Treatment card
The Suspect and Sputum Dispatch Register
Facility TB Register as appropriate
Slide 6-25
Recording Sputum
Smear Microscopy Results
Number of Acidfast Bacilli (AFB)
# of Oil Immersion
Fields Examine
Reported as:
No AFB
Per 100 fields
No AFB seen
(No AFB per 100 fields)
1-9 AFB
Per 100 fields
Scanty, record exact figure

(1-9 AFB per 100 fields)
10-99 AFB
Per 100 fields
1+ (10-99 AFB per 100 fields)
1-10 AFB
Per field
2+ (1-10 AFB per field in 50

fields)
More than 10 AFB
Per field
3+ (>10 AFB per field in 20

fields)
Slide 6-26
Why the Emphasis

on Sputum Smears?
ITECH, 2006
University of Alabama at Birmingham, Department of Pathology
Direct Microscopy is the most reliable and cost effective way to

identify persons who are most likely to transmit TB to others
Slide 6-27
What does a Positive

Sputum Smear Mean?
Positive smear predicts higher
contagiousness to others
Smears may be positive and not mean TB
Due to laboratory error or MOTT
Sensitivity and specificity of a positive smear

depends on prevalence of MOTT and HIV in a
population
Slide 6-28
NTRL Culture Performance:

2004-2006
Proportion N (%)
RESULT
2004
2005
2006
Smear+ / Culture-
60 (6.48)
81 (5.40)
69 (5.12)
Smear- / Culture+
44 (4.75)
62 (4.14)
103 (7.64)
Smear+ / Culture+
147 (15.87)
135 (9.00)
181 (13.43)
Smear- / Culture-
596 (64.36)
1148 (76.58)
853 (63.28)
Sub-total
847 (91.47)
1426 (95.12)
1206 (79.47)
Contamination
79 (8.53)
73 (4.87)
142 (10.53)
Total
926
1499
1348
Data for analysis granted by NTRL and BOTUSA

Slide 6-29
Botswana Laboratory Network:

Referral System
Mobile Stops
Health Posts
5 Clinic Laboratories
(Council)
16 Primary Hospital Laboratories
6 District Hospital
Laboratories
3 Mine
Hospital
Laboratories
2 Referral Hospital
Laboratories
3 Reference
Laboratories
Unit 6: Diagnosing
TB
BNTRL
Slide 6-30
Primary and District Lab

Services in TB control (Level 1)
Receipt of specimens: from clinics

Preparation and staining of smears
ZN microscopy /recording
Reporting of results
Maintenance of lab register
Management of reagents and supplies
Internal Quality Control (QC)
Collect specimen for culture and DST, send to NTRL
Participation in EQA
Slide 6-31
Nyangagbwe Referral lab (Level 2)

Activities: receive specimen for AFB and
culture
Services to clinics: FM/ZN smear microscopy
(smear microscopy and send results)
Support activities: (supply of reagents/
materials, training; EQA for smear microscopy
including supervision)
Inoculate specimen and refer to NTRL for
incubation and DST
Slide 6-32
Role of NTRL in TB Control
Identify mycobacterium other than MTB

DST of M. Tuberculosis
TB laboratory equipment services and maintenance
Develop TB Lab manuals and guidelines
Primary link with NTP
Supervision of intermediate QA of culture and
microscopy
Operational and applied research
Provide EQA and monitor peripheral labs
Slide 6-33
Diagnosing Smear-Negative PTB

Some seriously ill patients may have sputum
AFB smear results and may die of TB if
untreated
High index of suspicion if there are:
Miliary changes on chest x-ray (CXR)
Compatible CXR and no response to Rx for bacterial
infection
Pleural effusion
Inthrathoracic adenopathy
Pericardial effusion
Source: Lockman S et al., 2003.

Slide 6-34
Algorithms for Diagnosis of PTB

Algorithm for diagnosis of PTB in ambulatory
patients
Algorithm for diagnosis of PTB in seriously ill
patients
Slide 6-35
Mycobacterial Culture (1)

Gold Standard of TB diagnosis
More expensive and more time
consuming than microscopy
Requires specialised training and
media to perform
Not recommended for routine
case detection in Botswana
Courtesy of: Kubica G, 2007.
Slide 6-36
Mycobacterial Culture (2)

Reasons to request mycobacterial culture:
Patient previously on anti-TB treatment
Still smear-positive after intensive phase of treatment
or after finishing treatment
Symptomatic and at high-risk of MDR-TB
To test fluids potentially infected with M. tuberculosis
Investigation of patients who develop active PTB
during or after IPT
TB in health workers
Slide 6-37
TB Drug Susceptibility Testing (DST)

DST performed on all cultures
Tests for isoniazid, rifampicin, ethambutol, and
streptomycin
If found to be multi-drug resistant, then send

for additional testing for susceptibility to
second-line medicines
Slide 6-38
Role of Radiography
Chest X-Ray (CXR) can support a diagnosis
of PTB
Not used routinely for follow-up
PTB can exist with normal CXR
Must be interpreted with other information
History and exam
Sputum smear results
Also useful in diagnosing other types of TB,

especially in bones, joints, and spine
Slide 6-39
Courtesy of: San Francisco City and County

Dept. of Public Health, TB Division
Slide 6-40
Pulmonary TB Diagnosis
Are there any special challenges in

diagnosing pulmonary TB among
persons with HIV?
Slide 6-41
Sputum Smear and HIV Status

HIV positive patients with pulmonary TB often
have negative sputum smears
Important to recognise the clinical and chest
radiographic characteristics of HIV-TB, so
patients who are smear-negative can be
recognised and treated appropriately
Slide 6-42
Effect of HIV Stage on

Manifestations of TB
Early HIV disease
Cavity or upper lobe pulmonary disease
Positive sputum smear microscopy
Pleural disease
Advanced HIV disease

Sputum smear negative pulmonary disease
Disseminated TB
Pleural or pericardial effusion with or without intrathoracic
adenopathy
Lower and middle lobe infiltrates
Slide 6-43
Effect of Immunosuppression
on CXR in HIV-Related TB
Severe immunodeficiency can have a dramatic
effect on the CXR manifestations of TB
Not classic TB picture on CXR
Reticulonodular infiltrates (disseminated TB)
seen, but often without the classic miliary pattern
Intrathoracic adenopathy (mediastinal or hilar
adenopathy) relatively common among patients
with advanced HIV-TB
It is critical to understand this relationship so that

patients with HIV-TB will be recognized and
treated
Source: Post FA et al. Tuber Lung Dis. 1995.
Slide 6-44
Chest X-Ray
Patterns and CD4 Counts
Radiographic features associated with the
degree of HIV-related immunosuppression
in patients with HIV-related pulmonary TB:
Intrathoracic adenopathy associated with low
CD4 count
Cavitation and infiltrates more common in
patients with CD4 > 200 and those with lessadvanced HIV
Source: Perlman DC, et al. Clin Infect Dis, 1997.

Slide 6-45
Example of
Immunosuppressed TB Suspect
23 year old male, HIV infected, recent CD4
count was 35
He has cough, loss of appetite and weight
loss for 3 weeks
His sputum smear for AFB was negative,
therefore a CXR was done
Slide 6-46
What Do You See? (1)
I-TECH, 2003
Slide 6-47
Courtesy of: Huang L, HIV InSite Knowledge Base, 1998.
Slide 6-48
Courtesy of: Gooze L,et al., HIV InSite Knowledge Base, 2003.
Slide 6-49
Courtesy of: Gooze L,et al. HIV InSite Knowledge Base, 2003.
Slide 6-50
Differential Diagnoses
for TB Suspects (1)
Bacterial pneumonia
Lung abscess or bronchiectasis
Asthma or chronic obstructive airways disease
Occupational lung disease, i.e., silicosis
Lung cancer other than Kaposis Sarcoma
Congestive cardiac failure
Slide 6-51
Differential Diagnoses for

TB Suspects (2)
Empyema
Pneumocystis carinii (Jirovecii) pneumonia
Chronic fungal pneumonia
CMV pneumonia
Kaposis Sarcoma
Lymphoma
Mycobacteria Other Than Tuberculosis (MOTT)
Lymphocytic interstitial pneumonitis (LIP) in children
Slide 6-52
Classic Sites of
Extrapulmonary TB
Pleura
Lymph nodes
Disseminated or miliary
Meninges
Pericardium
Abdominal (peritoneal)
Intestinal
Spine
Other bones
Liver
Kidney
Adrenal glands
Genitourinary tract
Upper airway
Skin
Source: Caminero Luna JA, 2003.
Slide 6-53
EPTB as % of All Cases

Botswana 2005
Source: BNTP, 2005.

Slide 6-54
Common Forms of EPTB

Among HIV-Infected Persons
Nodal
Peripheral nodes - cervical > axillary > inguinal
Central nodes - mediastinal > hilar, intra-abdominal
Disseminated disease
Serosal - pleural, pericardial > ascites
Central nervous system - meningitis, tuberculoma
Soft tissue abscesses
Slide 6-55
Source: Elliott AM et al., J Trop Med Hygiene, 1993.

Slide 6-56
Tuberculosis in
HIV-Positive Persons (1)
Persons with clinically significant
immunosuppression from HIV can have
Primary progressive pulmonary and
extrapulmonary TB
Reactivation pulmonary and extrapulmonary TB
A high risk of disseminated (miliary) and
meningeal TB like young (immunologically
immature) children
Slide 6-57
Tuberculosis in
HIV-Positive Persons (2)
HIV-positive persons have higher rates of
extrapulmonary tuberculosis than HIV-negative
persons
The lower the CD4 count, the more likely an HIVpositive person is to develop extrapulmonary TB
TB becomes a systemic multi-organ disease, rather
than primarily a pulmonary disease, with progressive
immunodeficiency
Slide 6-58
% Extra-Pulmonary TB
EPTB and Severity of

Immunosuppression
CD4 cell count

Source: Jones BE et al., Am J Respir Crit Care Med. 1993.

Slide 6-59
What Do You See?
Slice of Life and Suzanne S. Stensaas
I-TECH, 2003
AFB demonstrated in the pus

Slide 6-60
Diagnosing TB Lymphadenitis
Needle aspiration is a good test for TB adenitis
in HIV-infected persons
Can be done the same day in the health
facility
Has a low rate of adverse effects
Has a high yield for diagnosing TB
Slide 6-61
What Do You See?
I-TECH, 2003
Slide 6-62
Diagnosing Pleural TB
97-99% of all pleural effusions in high HIV
prevalence areas caused by TB
A diagnostic pleural aspiration and CXR are
done to confirm pleural effusion
The pleural fluid is normally an exudate
Pleural biopsy, although invasive, also gives

high diagnostic yield
Slide 6-63
What Do You See?
I-TECH, 2003
Slide 6-64
Miliary TB: Disseminated TB
Pathology: scattered lung lesions like millet seeds

Slide 6-65
TB Meningitis (1)
Subacute or chronic
Headache, fever, neck stiffness, decreasing mental
status
Lumbar puncture essential for diagnosis
CSF usually shows raised white cell count
(predominantly lymphocytes) with elevated protein,
reduced glucose, and negative AFBs.
Most important differential diagnosis in Botswana is
cryptococcal meningitis
Slide 6-66
TB Meningitis (2)
University of Alabama at Birmingham, Dept. of Pathology

Slide 6-67
Spinal TB
Thoracic, lumbar, and sacral vertebrae are
primarily affected by TB infection
Most spinal TB occurs in the lower thoracic
and lumbar spine
Always request x-rays of thoracic and lumbar
spine when vertebral TB is suspected
Hip and knee are most common joints infected
by TB
Slide 6-68
What Do You See?
Slide 6-69
What Do You See?
Slide 6-70
Renal TB
Typically see dilated calyces
Urine smears can be falsely + due to
acid fast staining of environmental
bacteria
Diagnosis confirmed with mycobacterial
urine culture
Three early morning urine specimens
Slide 6-71
Case Definition
Standardised way to identify type of TB case
in both adults and children
Determined by:
Site of TB disease
Results of bacteriology tests (sputum smear)
History of previous TB treatment
Severity of TB disease
Slide 6-72
Activity 6.1: Matching (1)

Using Worksheet 6.1, match the terms at the
top of the page with the definitions below
Slide 6-73
Activity 6.1: Matching (2)

Now, apply one of the following determinants
to each term:
I.
Site of Disease
II. Results of Bacteriology Tests
III. History of Previous TB Treatment
IV. Severity of Previous TB Treatment
Slide 6-74
Determining the Case Definition

Bacteriology
History of TB
Site of Disease
Smear-negative
NO
Pulmonary
Smear-positive
TB CASES
Extra-pulmonary
Severity of Disease
New
Return after
default
YES
Relapse
Failure
Slide 6-75
Site of TB Disease
May be pulmonary (PTB), extrapulmonary
(EPTB) or both
Pulmonary: involving lung parenchyma
Extrapulmonary: involving any organ beside
the lung parenchyma
Patient with BOTH PTB and EPTB is
classified as having pulmonary TB
Slide 6-76
Results of Bacteriology Tests (1)

In PTBdetermine presence of acid-fast
bacilli (AFB) in sputum
Sputum smear is positive or negative dependent
on presence of AFB
Smear-positive: at least one smear with AFB
Smear-negative: any PTB case which does not
meet smear-positive criteria
Slide 6-77
Results of Bacteriology Tests (2)

EPTB cases include:
Patients with one positive culture or positive AFB
smear from extrapulmonary site
Patients with extrapulmonary histology, lab/clinical
evidence, and doctors decision to start TB
treatment
Slide 6-78
Categories of
TB Treatment History
New
Never had treatment for TB, or has taken antituberculosis drugs for less than one month
Retreatment Previously treated for TB and declared cured,

after Relapse or treatment completed, and is diagnosed with
bacteriologically positive (smear or culture) TB
Retreatment
after Failure
Is started on a re-treatment regimen after

having failed previous treatment
Retreatment
after Default
Returns to treatment, positive bacteriologically,

following interruption of treatment for two
months or more
Source: WHO, 2003.
Slide 6-79
Severity of TB Disease
Based on quantity of bacteria and disease site
More severe:
Meningeal, spinal, pericardial, pulmonary cavitary
and miliary
Less severe:
Lymph nodes, bones (except spine), and skin
Slide 6-80
Key Points (1)

Confirmed diagnosis of PTB depends on positive
sputum smears
Order culture only in specific circumstances
Smear negative PTB diagnosed on supportive

clinical and CXR evidence
Persons with low immunity likely to have atypical
PTB, primary progressive TB, and extrapulmonary
TB
Slide 6-81
Key Points (2)

Extrapulmonary TB usually diagnosed on
supportive clinical and X-ray evidence
Biopsy is helpful
Culture provides proof (but still will only be positive
in about 50% of EPTB cases overall)
Slide 6-82

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Unit 6: Diagnosing TB

Botswana National Tuberculosis Programme

Common Sites of TB Disease

Source: CDC, 2001.

The Effect of HIV Infection on

Case Finding (1)

Source: WHO, 2003

Case Finding (2)

Active Case Finding

Do a general physical examination with

Have you had close contact with someone with TB?

Source: Chiang C-V et al., 2007.

How do you currently diagnose

PTB types, BNTP 2005

Source: BNTP, 2005

Sputum Collection Techniques (1)

Sputum Collection Techniques (2)

Only sputum (2-5 ml) should be accepted as a good

Poor quality sputum

Source: CDC, 2007

Sputum Smear Examination

University of Alabama at Birmingham, Department of Pathology

Per 100 fields

Per 100 fields

Scanty, record exact figure

Per 100 fields

1+ (10-99 AFB per 100 fields)

2+ (1-10 AFB per field in 50

More than 10 AFB

3+ (>10 AFB per field in 20

Why the Emphasis

University of Alabama at Birmingham, Department of Pathology

Direct Microscopy is the most reliable and cost effective way to

What does a Positive

Sensitivity and specificity of a positive smear

NTRL Culture Performance:

Data for analysis granted by NTRL and BOTUSA

Botswana Laboratory Network:

Primary and District Lab

Receipt of specimens: from clinics

Nyangagbwe Referral lab (Level 2)

Role of NTRL in TB Control

Identify mycobacterium other than MTB

Diagnosing Smear-Negative PTB

Source: Lockman S et al., 2003.

Algorithms for Diagnosis of PTB

Mycobacterial Culture (1)

Mycobacterial Culture (2)

TB Drug Susceptibility Testing (DST)

If found to be multi-drug resistant, then send

Also useful in diagnosing other types of TB,

Courtesy of: San Francisco City and County

Are there any special challenges in

Sputum Smear and HIV Status

Effect of HIV Stage on

Advanced HIV disease

It is critical to understand this relationship so that

Source: Post FA et al. Tuber Lung Dis. 1995.

Source: Perlman DC, et al. Clin Infect Dis, 1997.

What Do You See? (1)

What Do You See? (2)

Courtesy of: Huang L, HIV InSite Knowledge Base, 1998.

What Do You See? (3)