History
The following factors increase the likelihood that a patient will have tuberculosis (TB):
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HIV infection
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History of a positive purified protein derivative (PPD) test result
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History of prior TB treatment
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TB exposure
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Travel to or emigration from an area where TB is endemic
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Homelessness, shelter-dwelling, incarceration
Classic clinical features associated with active pulmonary TB are as follows:
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Cough
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Weight loss/anorexia
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Fever
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Night sweats
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Hemoptysis
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Chest pain
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Fatigue
Chest pain in patients with TB can also result from tuberculous acute pericarditis. Pericardial TB can lead to cardiac tamponade or constriction.
Elderly individuals with TB may not display typical signs and symptoms of TB infection, because they may not mount a good immune response. Active TB infection in this age group may manifest as nonresolving pneumonitis.
Signs and symptoms of extrapulmonary TB may be nonspecific. They can include leukocytosis, anemia, and hyponatremia due to the release of ADH (antidiuretic hormone)-like hormone from affected lung tissue.
Tuberculous meningitis
Patients with tuberculous meningitis may present with a headache that has been either intermittent or persistent for 2-3 weeks. Subtle mental status changes may progress to coma over a period of days to weeks. Fever may be low grade or absent.
Skeletal TB
The most common site of skeletal TB involvement is the spine (Pott disease); symptoms include back pain or stiffness. Lower-extremity paralysis occurs in up to half of patients with undiagnosed Pott disease.
Tuberculous arthritis usually involves only 1 joint. Although any joint may be involved, the hips and knees are affected most commonly, followed by the ankle, elbow, wrist, and shoulder. Pain may precede radiographic changes by weeks to months.
Genitourinary TB
Symptoms of genitourinary TB may include flank pain, dysuria, and frequent urination. In men, genital TB may manifest as a painful scrotal mass, prostatitis, orchitis, or epididymitis. In women, genital TB may mimic pelvic inflammatory disease. TB is the cause of approximately 10% of sterility cases in women worldwide and of approximately 1% in industrialized countries.
Go to Tuberculosis of the Genitourinary System and Imaging of Genitourinary Tuberculosis for complete information on these topics.
Gastrointestinal TB
Any site along the gastrointestinal tract may become infected. Symptoms of gastrointestinal TB are referable to the infected site and include the following:
Nonhealing ulcers of the mouth or anus
Difficulty swallowing - With esophageal disease
Abdominal pain mimicking peptic ulcer disease - With stomach or duodenal infection
Malabsorption - With infection of the small intestine
Pain, diarrhea, or hematochezia - With infection of the colon
Physical Examination
Physical examination findings associated with TB depend on the organs involved. Patients with pulmonary TB have abnormal breath sounds, especially over the upper lobes or involved areas. Rales or bronchial breath signs may be noted, indicating lung consolidation.
Signs of extrapulmonary TB differ according to the tissues involved. They may include the following:
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Confusion
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Coma
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Neurologic defici
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Lymphadenopathy
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Cutaneous lesions
Lymphadenopathy in TB occurs as painless swelling of 1 or more lymph nodes. Lymphadenopathy is usually bilateral and typically involves the anterior and posterior cervical chain or supraclavicular nodes.
The absence of any significant physical findings does not exclude active TB. Classic symptoms are often absent in high-risk patients, particularly those who are immunocompromised or elderly. Up to 20% of patients with active TB may deny symptoms. Therefore, sputum sampling is essential when chest radiographic findings are consistent with TB.
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Acid-fast bacillus smear showing characteristic cording in Mycobacterium tuberculosis.
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This radiograph shows a patient with typical radiographic findings of tuberculosis.
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This is a chest radiograph taken after therapy was administered to a patient with tuberculosis.
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Anteroposterior chest radiograph of a young patient who presented to the emergency department (ED) with cough and malaise. The radiograph shows a classic posterior segment right upper lobe density consistent with active tuberculosis. This woman was admitted to isolation and started empirically on a 4-drug regimen in the ED. Tuberculosis was confirmed on sputum testing. Image courtesy of Remote Medicine (remotemedicine.org).
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Lateral chest radiograph of a patient with posterior segment right upper lobe density consistent with active tuberculosis. Image courtesy of Remote Medicine (remotemedicine.org).
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Pulmonary tuberculosis with air-fluid level.
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Under a high magnification of 15549x, this scanning electron micrograph depicts some of the ultrastructural details seen in the cell wall configuration of a number of Gram-positive Mycobacterium tuberculosis bacteria. As an obligate aerobic organism, M. tuberculosis can only survive in an environment containing oxygen. This bacterium ranges in length between 2-4 microns, with a width between 0.2-0.5 microns. Image courtesy of the Centers for Disease Control and Prevention/Dr. Ray Butler.
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Numerous acid-fast bacilli (pink) from a bronchial wash are shown on a high-power oil immersion.
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Necrotizing granuloma due to tuberculosis shown on low-power hematoxylin and eosin stain. There is central caseous necrosis and a multinucleated giant cell in the central left. Mixed inflammation is seen in the background.
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This chest radiograph shows asymmetry in the first costochondral junctions of a 37-year-old man who presented with cough and fever. Further clarification with computed tomography is needed.
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Axial noncontrast enhanced computed tomography with pulmonary window shows a cavity with an irregular wall in the right apex of a 37-year-old man who presented with cough and fever (same patient as above).
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Coronal reconstructed computed tomography image shows the right apical cavity in a 37-year-old man who presented with cough and fever (same patient as above).
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This posteroanterior chest radiograph shows right upper lobe consolidation with minimal volume loss (elevated horizontal fissure) and a cavity in a 43-year-old man who presented with cough and fever.
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Axial chest computed tomography without intravenous contrast with pulmonary window setting shows a right apical thick-walled cavity and surrounding lung consolidation in a 43-year-old man who presented with cough and fever (same patient as above).
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Coronal reconstructed computed tomography image shows the consolidated, partially collapsed right upper lobe with a cavity that is directly connected to a bronchus in a 43-year-old man who presented with cough and fever (same patient as above).
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The posteroanterior chest radiograph shows a large cavity with surrounding consolidation in the lingular portion of the left upper lobe in a 43-year-old man who presented with cough and hemoptysis. There are also a few nodular opacities in the right mid-lung zone.
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Axial chest computed tomography without intravenous contrast with pulmonary window setting through the mid-chest shows a large, irregular-walled cavity with nodules and air-fluid level and two smaller cavities in a 43-year-old man who presented with cough and hemoptysis (same patient as above). Small, patchy peripheral opacities are also present in the left lower lobe. In the right mid-lung, nodular opacities are in a tree-in-bud distribution, suggestive of endobronchial spread.
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Coronal reconstructed computed tomography image shows the lingular cavity with irregular nodules and right mid-lung nodular opacities in a 43-year-old man who presented with cough and hemoptysis (same patient as above).
