Old Tuberculosis 2018-01-30T16:38:20+08:00

Relevant physical signs

  • Thoracoplasty (surgical procedure designed to collapse a tuberculous cavity)
    • Deviation of the trachea towards the affected side
    • Flattening of the chest wall on the affected side
    • Posterior thoracotomy scar
    • Absent ribs (usually 3rd – 8th)
    • Dull percussion note over affected area
    • Reduced breath sounds over the affected area (but preserved at bases)
    • Reduced vocal resonance over the affected area
  • Phrenic nerve crush (causes ipsilateral diaphragmatic paralysis and basal lobe collapse)
    • Trachea usually central as it affects the bases
    • Scar over ipsilateral supraclavicular region
    • Reduced chest expansion over ipsilateral base
    • Dull percussion note
    • Reduced air entry and vocal resonance
  • No other physical findings on examination

Differential diagnosis

  • Thoracoplasty
    • Lobectomy
    • Pneumonectomy
    • Fibrothorax
    • Collapse of a lung lobe
  • Phrenic nerve crush
    • Phrenic nerve palsy
    • Hepatomegaly / splenomegaly
    • Hiatus hernia
    • Lower lobe collapse
    • Lower lobectomy
    • Pleural effusion

Investigations of pulmonary tuberculosis

  • Full blood count, renal function, liver function, baseline Ishihara chart (prior to starting anti-tuberculous Rx)
  • Chest radiograph to assess extent of disease
  • Sputum for acid fast bacilli smear and culture, molecular detection of MTB
  • Bronchoscopy and bronchoalveolar lavage if index of suspicion is high and sputum samples are negative
  • Diagnosis of latent TB (for patients at risk of TB re-activation and those in contact with active TB)
    • Tuberculin skin test
    • Interferon-gamma release assays (QuantiFERON-TB and TB-SPOT)

Management

  • Acute
    • Oxygen supplementation, intubation and mechanical ventilation if necessary
    • Bronchial artery embolisation / bronchoscopy / surgical resection for haemoptysis
  • Antibiotic therapy
    • Rifampicin (6 months) – orange discolouration of saliva, urine, hepatotoxicity, rash
    • Isoniazid + pyridoxine (6 months) – hepatotoxicity, neurotoxicity
    • Ethambutol (2 months) – ocular toxicity, hepatotoxicity, rash, eosinophilia
    • Pyrazinamide (2 months) – hepatotoxicity, arthralgia, interstitial nephritis
    • Stop if transaminitis is > 3x the upper limit of normal with symptoms, or 5x without symptoms

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