FACULTY OF MEDICINE

UNSWAGATI
Introduction
• Two types of clinical manifestation of
tuberculosis are pulmonary TB (PTB) and
extrapulmonary TB (EPTB) 1

• EPTB refers to TB involving organs other than

lung (e.g., pleura, lymph nodes, adomen,
genitourniary tract, skin, join , bones or
meninges) 1
Epidemiology
• The most common anatomic sites affected by
extrapulmonary TB are lymph nodes, pleura,
bone and joints, urogenital tract, and
meninges. 2

• Of the 6.3 million new TB cases recognized by

WHO in 2017, 16% were extrapulmonary TB
cases 2
Categories for Classsifying TB cases. 3
• 1.Anatomical site of TB disease
• 2.Bacteriologic result (including drug
resistance)
• 3.History of previous TB treatment
• 4.HIV status of patient
 Anatomical Site Of Disease
• Pulmonary Tuberculosis (PTB) refers to
disease involving the lung parenchyma.

• excluding the pleura and hilum gland 3

• Extrapulmonary-Tuberculosis (EPTB) : refers
to TB disease of organs other than lung.
• eg pleura, lining of the brain, pericardium,
bones, joints, skin, intestines, kidneys,
urethra, genitals and others
• Classify as PTB if both pulmonary and
extrapulmonary sites involved 3
Extrapulonary Tuberculosis
• Inorder of frequency the extrapulmonary sites
most commonly involved in tuberculosis are
the lymph nodes, pleura,genitourinary tract,
bones, and joints, meninges, peritoneum, and
pericardium. 4
LYMPH-NODE TUBERCULOSIS
(TUBERCULOSIS LYMPHADENITIS) (1)
• The most frequent presentation of EPTB

• Lymph node disease is particularly frequent

among HIV-infected patients

• Lymph node tuberculosis presents as painles

swelling of the lymph nodes, most commonly
at posterior cervical and supraclavicular sites 4
LYMPH-NODE TUBERCULOSIS
(TUBERCULOSIS LYMPHADENITIS) (2)
• The diagnosis is established only bu fine-
needle aspiration or surgical biopsy
• AFB (Acid Fast Bacillus) ase seen in up to 50%
of cases, culturs are positive in 70-80% , and
histology examination shos granlomatous
lession. 4
LYMPH-NODE TUBERCULOSIS
(TUBERCULOSIS LYMPHADENITIS) (3)
• Different diagnosis includes a variety of
infectious conditions, neoplastic diseases such
as lymphomas or metastatic carcinomas, and
rare disoders like Kikuchi disease (necrotizing
histiocytic lymphadenitis) 4
PLEURAL TUBERCULOSIS (1)
• Involvement of the pleura, which accounts for
20% EPTB in US
• result from either contiguous spread of
parenchymal inflammation or, as in many
cases of pleurisy accompanying postprimary
disease, actual penetration by tubercle bacilli
into the pleural space. 4
 PLEURAL TUBERCULOSIS (2)
• symptoms such as fever, pleuritic chest pain, and
dyspnea.
• Physical findings are those of pleural effusion:
dullness to percussion and absence of breath
sounds.
• A chest radiograph reveals the effusion and, in up
to one-third of cases, also shows a parenchymal
lesion.
• Thoracentesis is required to ascertain the nature
of the effusion and to differentiate it from
manifestations of other etiologies. 4
 PLEURAL TUBERCULOSIS (2)
• Neutrophils may predominate in the early
stage, while mononuclear cells are the typical
finding later. Mesothelial cells are generally
rare or absent.

• AFB are seen on direct smear in only 10–25%

of cases, but cultures may be positive for M.
tuberculosis in 25–75% of cases. 4
GENITOURINARY TUBERCULOSIS (1)
• 15% of all extrapulmonary cases in the United
States, may involve any portion of the
genitourinary tract
• Urinary frequency, dysuria, nocturia, hematuria,
and flank or abdominal pain are common
presentations
• However, patients may be asymptomatic and the
disease discovered only after severe destructive
lesions of the kidneys have developed. 4
 GENITOURINARY TUBERCULOSIS (2)
• Genital tuberculosis is diagnosed more
commonly in female than in male patients
• female patients, it affects the fallopian tubes
and the endometrium and may cause
infertility, pelvic pain, and menstrual
abnormalities
• Diagnosis requires biopsy or culture of
specimens obtained by dilatation and
curettage. 4
 GENITOURINARY TUBERCULOSIS (3)
• In male patients, tuberculosis preferentially
affects the epididymis, producing a slightly
tender mass that may drain externally through
a fistulous tract; orchitis and prostatitis may
also develop. 4
 GENITOURINARY TUBERCULOSIS (4)
• Intravenous pyelography, abdominal CT, or
MRI may show deformities and obstructions,
and calcifications and ureteral strictures are
suggestive findings
• Culture of three morning urine specimens
yields a definitive diagnosis in nearly 90% of
cases. 4
GENITOURINARY TUBERCULOSIS (5)

MRI of culture-confirmed renal

tuberculosis. T2-weighted
coronary plane: coronal sections
showing several renal lesions in
both the cortical and the
medullary tissues of the right
kidney. (Courtesy of Dr. Alberto
Matteelli, Department of
Infectious Diseases, University of
Brescia, Italy; with permission.) 4
SKELETAL TUBERCULOSIS (1)
• In the United States, tuberculosis of the bones
and joints is responsible for ~10% of
extrapulmonary cases

• In bone and joint disease, pathogenesis is

related to reactivation of hematogenous foci
or to spread from adjacent paravertebral
lymph nodes. 4
SKELETAL TUBERCULOSIS (2)
• Weight-bearing joints (the spine in 40% of
cases, the hips in 13%, and the knees in 10%)
are most commonly affected. 4
SKELETAL TUBERCULOSIS (3)
• Spinal tuberculosis (Pott's disease or tuberculous
spondylitis) often involves two or more adjacent
vertebral bodies.

• While the upper thoracic spine is the most

common site of spinal tuberculosis in children,
the lower thoracic and upper lumbar vertebrae
are usually affected in adults.

• With advanced disease, collapse of vertebral

bodies results in kyphosis (gibbus). 4
SKELETAL TUBERCULOSIS (4)
• CT or MRI reveals the characteristic lesion and
suggests its etiology.
• Aspiration of the abscess or bone biopsy
confirms the tuberculous etiology, as cultures
are usually positive and histologic findings
highly typical. 4
SKELETAL TUBERCULOSIS (5)
CT scan demonstrating
destruction of the right
pedicle of T10 due to Pott's
disease. The patient, a 70-
year-old Asian woman,
presented with back pain and
weight loss and had biopsy-
proven tuberculosis. (Courtesy
of Charles L. Daley, M.D.,
University of California, San
Francisco; with permission.) 4
TUBERCULOUS MENINGITIS (1)
• Tuberculosis of the central nervous system
(CNS) accounts for 5% of EPTB cases in the US
• seen most often in young children but also
develops in adults, especially those infected
with HIV. 4
TUBERCULOUS MENINGITIS (2)
• Tuberculous meningitis results from the
hematogenous spread of primary or
postprimary pulmonary disease or from the
rupture of a subependymal tubercle into the
subarachnoid space. 4
TUBERCULOUS MENINGITIS (3)
• The disease often presents subtly as headache
and slight mental changes after a prodrome of
weeks of low-grade fever, malaise, anorexia,
and irritability.

• If not recognized, tuberculous meningitis may

evolve acutely with severe headache,
confusion, lethargy, altered sensorium, and
neck rigidity. 4
TUBERCULOUS MENINGITIS (4)
• If not recognized, tuberculous meningitis may
evolve acutely with severe headache, confusion,
lethargy, altered sensorium, and neck rigidity

• Paresis of cranial nerves (ocular nerves in

particular) is a frequent finding

• and the involvement of cerebral arteries may

produce focal ischemia. 4
TUBERCULOUS MENINGITIS (5)
• Lumbar puncture is the cornerstone of
diagnosis
• Culture of CSF is diagnostic in up to 80% of
cases and remains the gold

• Polymerase chain reaction (PCR) has a

sensitivity of up to 80%, but rates of false-
positivity reach 10%. 4
TUBERCULOMA
• Tuberculoma, an uncommon manifestation of
CNS tuberculosis
• presents as one or more space-occupying
lesions and usually causes seizures and focal
signs.
• CT or MRI reveals contrast-enhanced ring
lesions, but biopsy is necessary to establish
the diagnosis. 4
GASTROINTESTINAL TUBERCULOSIS(1)
• Gastrointestinal tuberculosis is uncommon,
making up 3.5% of extrapulmonary cases in
the United States

• Various pathogenetic mechanisms are

involved: swallowing of sputum with direct
seeding, hematogenous spread, or (largely in
developing areas) ingestion of milk from cows
affected by bovine tuberculosis. 4
GASTROINTESTINAL TUBERCULOSIS(2)
• terminal ileum and the cecum are the sites most
commonly involved.

• Abdominal pain (at times similar to that

associated with appendicitis) and swelling,
obstruction, hematochezia, and a palpable mass
in the abdomen are common findings at
presentation

• Fever, weight loss, anorexia, and night sweats are

also common. 4
GASTROINTESTINAL TUBERCULOSIS(3)
• Tuberculous peritonitis follows either the
direct spread of tubercle bacilli from ruptured
lymph nodes and intraabdominal organs

• abdominal pain, fever, and ascites should raise

the suspicion of tuberculous peritonitis. 4
HIV-Associated Tuberculosis
• Extrapulmonary tuberculosis is common among HIV-
infected patients.

• In various series, extrapulmonary tuberculosis, Alone

or in association with pulmonary disease has been
documented in 40–60% of all cases in HIV–co-infected
individuals.

• The most common forms are lymphatic, disseminated,

pleural, and pericardial. Mycobacteremia and
meningitis are also frequent, particularly in advanced
HIV disease. 4
DIAGNOSIS OF EPTB (1)
• symptoms and complaints depend on the
affected organs, such as neck stiffness in TB
meningitis, chest pain in pleural tuberculosis,
and spinal deformity in TB spondylitis and
others. 3
DIAGNOSIS OF EPTB (2)
• For all patients suspected of having
extrapulmonary TB, appropriate speciments
from the suspected sites of involvement
should be obtained for microscopy, culture
and histopathological examination 3
TREATMENT EPTB (1)
• TB treatment aims to cure patients, prevent
death, prevent recurrence, break the chain of
transmission and prevent bacterial resistance
to anti-tuberculosis drugs. 3
TREATMENT EPTB (2)
• TB treatment is given in 2 stages :
intensive and advance stages.

A combination of drugs used by the National

Program for Tuberculosis Control in Indonesia : 3
-Category 1 : 2(HRZE)/4(HR)3
-Category 2 :2(HRZE)S/(HRZE)/5(HR)3E3
TREATMENT EPTB (3)
• Category 1 : 2(HRZE)/4(HR)3
- New patients with smear positive pulmonary
TB
- Pulmonary TB patients with negative smear
positive chest X-ray
- Patients with extra pulmonary TB 3
TREATMENT EPTB (4)

The dose for fixed dose combination anti-tuberculosis drugs

for Category 1. 3

WEIGHT Intensive phase every day Advanced stage 3 times a

for 56 days week for 16 weeks
RHZE (150/75/400/275) RH (150/150)
30 – 37 kg 2 tablets 4 fFDC 2 tablets 2 FDC
38 – 54 kg 3 tablet 4 FDC 3 tablets 2 FDC
55 – 70 kg 4 tablets 4 FDC 4 tablets 2FDC
≥ 71 kg 5 tablets 4 FDC 5 tablet 2 FDC
TREATMENT EPTB (5)

The dose for kombipak anti-tuberculosis drugs for Category

1. 3

Treatment Duration Daily dose / time Amount

Phase of Tablet Caplet Tablet Tablet of day /
treatment Isoniasid Rifampisin Pirazinami Etambutol time to
@ 300 @ 450 mg d @ 500 @ 250 swallow
mgr mgr mgr medicine

Intensif 2 months 1 1 3 3 56
Advanced 4 months 2 1 - - 48
 TB patients who need to get
additional corticosteroids (1)
• Corticosteroids are only used in special
circumstances that endanger the patient's
soul such as:
-TB meningitis
-Miliary TB with or without meningitis
-TB with exudativa pleuritis
-TB with constrictive pericarditis
 TB patients who need to get
additional corticosteroids (2)
• the acute phase of prednisone is given at a
dose of 30-40 mg per day, then gradually
reduced.
 Indications of surgery

• Extra pulmonary TB patients with

complications, for example bone TB patients
accompanied by neurological abnormalities.
 BIBLIOGRAPHY

• 1.Ji Yeon Lee MD. Diagnosis and Treatment of

Extrapulmonary TB.NCBI.2 Apr 2015
• 2. World Health Organization. Global tuberculosis
report 2018. WHO/CDS/TB/2018.20. Geneva: The
Organization; 2018
3. national guidelines for tuberculosis control.
Ministry of Health of the Republic of Indonesia.
2011
4.Harrison’s Principle of Internal Medicine. 17th
Edition