eMedicine Specialties > Infectious Diseases > Mycobacterial Infections

Tuberculosis: Follow-up

Author: Thomas Herchline, MD, Professor of Medicine, Wright State University Boonshoft School of Medicine; Medical Director, Public Health, Dayton and Montgomery County, Ohio
Coauthor(s): Judith K Amorosa, MD, FACR, Clinical Professor and Program Director, Department of Radiology, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School; Consulting Staff, Department of Radiology, Robert Wood Johnson University Hospital
Contributor Information and Disclosures

Updated: Nov 11, 2009

Follow-up

Further Inpatient Care

• Hospitalized patients with suspected or documented tuberculosis (TB) must be placed in appropriate isolation. This includes a private room with negative pressure and adequate air exchanges. Persons entering the room must wear masks or respirators capable of filtering droplet nuclei.
• Worldwide, TB rates are consistently higher among health care workers than in the general population; infection-control measures yield a significant impact in high-income countries but less impact in low- and middle-income countries.¹⁷
• Patients with TB should remain in isolation until sputum becomes smear-negative; however, patients should not ordinarily be kept in the hospital for the sole purpose of providing isolation. Special arrangements are necessary for patients with TB who live with children, individuals infected with HIV, or patients returning to a closed-group setting (eg, nursing home, correctional facilities, residential facility, homeless shelter).

Further Outpatient Care

• Patients diagnosed with active TB should undergo sputum analysis for M tuberculosis weekly until sputum conversion is documented. Monitoring for toxicity includes baseline and periodic liver enzymes, CBC count, and serum creatinine.
• In addition, patients with TB who are receiving pyrazinamide should undergo baseline or periodic serum uric acid assessments, and patients with TB who are receiving long-term ethambutol therapy should undergo baseline or periodic visual acuity and red-green color perception testing. The latter can be performed with a standard test such as the Ishihara test for color blindness.

Deterrence/Prevention

• Patients with a clinically significant result on tuberculin skin testing or positive IGRA result (see Other Tests) should receive a course of therapy once active infection and disease is ruled out. Guidelines published by the CDC in 2000 now refer to this as treatment of latent TB. The recommended regimens are listed below:
  • Isoniazid daily for 9 months
  • Isoniazid twice weekly for 9 months (administered as DOT)
  • Isoniazid daily for 6 months (should not be used in patients with fibrotic lesions on chest radiography, patients with HIV, or children)
  • Isoniazid twice weekly for 6 months (administered as DOT; should not be used in patients with fibrotic lesions on chest radiography, patients with HIV, or children)
  • Rifampin daily for 4 months
  • Rifampin plus pyrazinamide daily for 2 months (This regimen is no longer recommended because of an increased risk for liver toxicity.)
• Children should receive isoniazid for 9 months. In addition, children younger than 5 years who have close contact with a person who has active TB should be started on isoniazid, even if results on skin testing are negative; preventive therapy can be stopped if results on repeat skin testing are negative 2-3 months after last contact with a culture-positive source case.
• Patients exposed to MDR-TB may be administered ethambutol plus pyrazinamide for 6-12 months or pyrazinamide plus levofloxacin for 6-12 months; the index isolate should be susceptible to all drugs used.
• Recommended regimens in patients with HIV infection include rifampin alone daily for 4 months or isoniazid, daily or twice weekly, for 9 months. Patients on antiretroviral therapy may need rifabutin instead of rifampin because of potential drug interactions. The 2-month combination of pyrazinamide plus rifampin is no longer recommended.
• The BCG vaccine continues to be used throughout much of the world and provides protection mostly until early childhood. Immunity begins to wane as early as 3 months after administration.¹⁸

Complications

• Late complications of pulmonary TB include relapse, aspergilloma, bronchiectasis, broncholithiasis, fibrothorax, and possibly carcinoma. A copy of the chest radiograph at the time of completion of therapy should be provided to the patient to facilitate the diagnosis of late complications.
  • The relapse rate following appropriate completed therapy is only 0-4% and occurs within the first 2 years after completion. Therefore, re-treatment is usually unnecessary, especially after DOT.
  • Aspergilloma is a fungus ball that develops in a residual lung abnormality (eg, pneumatocele, bulla, bleb, cyst). It may appear as a crescent sign on chest radiographs. Other superinfections may manifest with an air-fluid level and often contain mixed bacteria, including anaerobes.
  • Hemoptysis is the most common late complication. Broncholithiasis is the result of spontaneous lymph node migration into the bronchial tree and may be associated with postobstructive pneumonia or esophageal perforation. Bronchiectasis may progress to chronic bronchitis; bleeding from submucosal bronchial veins is usually self-limited.
  • Fibrothorax is the development of trapped lung due to pleural fibrosis and scarring.
  • The risk of carcinoma is controversial but should be considered with newly developing clubbing.

Prognosis

Among published studies involving DOTS treatment, the rate of recurrence ranges from 0-14%.¹⁹ In countries with low TB rates, recurrences usually occur within 12 months of treatment completion and are due to relapse.²⁰ In countries with higher TB rates, most recurrences after appropriate treatment are probably due to reinfection rather than relapse.²¹

Patient Education

For excellent patient education resources, visit eMedicine's Bacterial and Viral Infections Center. Also, see eMedicine's patient education article Tuberculosis.

Miscellaneous

Medicolegal Pitfalls

• Laws vary from state to state, but communicable-disease laws typically empower public health officials to investigate suspected cases of tuberculosis (TB), including potential contacts. In addition, patients may be incarcerated for noncompliance with therapy. For example, in the Denver Metro Tuberculosis Clinic from 1984-1994, 5% of patients were incarcerated for noncompliance and an additional 5% who were lost to follow-up before completing therapy would have been candidates for incarceration.

Special Concerns

• Pregnancy
• Pregnancy provides an opportunity to screen for TB; all pregnant women can undergo tuberculin skin testing. If skin-testing results are positive, chest radiography can be performed with lead shielding (the amount of radiation exposure of a single chest radiograph has been compared to that incurred on a regular flight from New York to Los Angeles). Chest radiography should not be delayed during the first 3 months of pregnancy in patients with suggestive symptoms.
• Active TB should be treated, even in women in the first stage of pregnancy. Isoniazid, rifampin, and ethambutol may be used. In the United States, pyrazinamide is reserved for women with suspected MDR-TB. Elsewhere in the world, pyrazinamide is commonly used in pregnant women with TB.
• Preventive treatment is recommended during pregnancy, especially in the following situations:
• Pregnant women with a positive tuberculin skin test result who are HIV seropositive or who have behavioral risk factors for HIV infection but decline HIV testing
• Pregnant women with a positive tuberculin skin test result who have been in close contact with a patient who is smear-positive for pulmonary TB
• Pregnant women who have had a documented tuberculin skin test conversion in the past 2 years
• Pregnant women are at an increased risk for isoniazid-induced hepatotoxicity and should undergo monthly ALT monitoring while on treatment. This risk continues 2-3 months into the postpartum period. Pyridoxine should also be administered to pregnant women receiving isoniazid. Breastfeeding can be continued during preventive therapy. Many experts recommend supplemental pyridoxine to the breastfed infant.
• Tuberculosis in children
• TB in a child is a sentinel event indicating recent transmission, and contacts should be evaluated to find the source case as soon as possible. Children do not commonly infect other children because they rarely develop cough and sputum production is scant. However, cases of child-child and child-adult TB transmission are well-documented.
• Chest radiographs in children with TB may show only hilar lymphadenopathy or a patchy infiltrate. Most children with TB can be treated with isoniazid and rifampin for 6 months, along with pyrazinamide for the first 2 months if the culture from the source case is fully susceptible. Gastric aspirates or biopsies are not necessary if positive cultures have been obtained from the source case.
• In children younger than 5 years, the potential for development of fatal miliary TB or meningeal TB is a significant concern. TB disease is uncommon in children aged 5-15 years (the golden age of childhood).
• Isoniazid tablets may be crushed and added to food. Isoniazid liquid without sorbitol should be used to avoid osmotic diarrhea, causing decreased absorption. Rifampin capsules may be opened and the powder added to food. If rifampin is not tolerated, it may be taken in divided doses 20 minutes after light meals.
• Ethambutol is often avoided in young children because of difficulties monitoring visual acuity and color perception. However, studies show that ethambutol (15 mg/kg) is well tolerated and can prevent further resistance if the child is infected with a resistant strain.
• Human immunodeficiency virus
• Individuals infected with HIV are at an increased risk for TB, beginning within the first year of HIV infection.²² Based on historical data, the initiation of antiretroviral therapy decreases the risk of developing TB in these patients.²³
• Patients with TB must be tested for HIV, and patients with HIV need periodic evaluation for TB with tuberculin skin testing and/or chest radiography. Patients with HIV and a positive tuberculin skin test result develop active TB at a rate of 3-16% per year.
• Patients with TB and HIV are more likely to have disseminated disease and less likely to have upper-lobe infiltrates or classic cavitary pulmonary disease. Patients with a CD4 count of less than 200/μL may have mediastinal adenopathy with infiltrates.
• Treatment regimens for active or latent TB in patients with HIV infection are similar to the treatment of individuals who are HIV negative, but dose adjustments may be necessary.²⁴ The most significant differences involve the avoidance of rifampin in patients who are on protease inhibitors. Rifabutin may be used in place of rifampin in such patients.
• Patients with HIV and TB may develop a paradoxical response when starting antiretroviral therapy. This response has been attributed to a stronger immune response to M tuberculosis. Clinical findings include fever, worsening pulmonary infiltrates, and lymphadenopathy.
• Tumor necrosis factor-alpha (TNF-a) antagonists have been associated with a significantly increased risk for TB.²⁵ Reports have included atypical presentations, extrapulmonary and disseminated disease, and deaths. Patients scheduled to begin therapy with a TNF-α antagonist should be screened for latent TB and counseled regarding the risk of TB.

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