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• W2019550064 abstract "Tuberculosis (TB) poses a serious threat to public health throughout the world but disproportionately afflicts low-income nations. Persons in close contact with a patient with active pulmonary TB and those from endemic regions of the world are at highest risk of primary infection, whereas patients with compromised immune systems are at highest risk of reactivation of latent TB infection (LTBI). Tuberculosis can affect any organ system. Clinical manifestations vary accordingly but often include fever, night sweats, and weight loss. Positive results on either a tuberculin skin test or an interferon-γ release assay in the absence of active TB establish a diagnosis of LTBI. A combination of epidemiological, clinical, radiographic, microbiological, and histopathologic features is used to establish the diagnosis of active TB. Patients with suspected active pulmonary TB should submit 3 sputum specimens for acid-fast bacilli smears and culture, with nucleic acid amplification testing performed on at least 1 specimen. For patients with LTBI, treatment with isoniazid for 9 months is preferred. Patients with active TB should be treated with multiple agents to achieve bacterial clearance, to reduce the risk of transmission, and to prevent the emergence of drug resistance. Directly observed therapy is recommended for the treatment of active TB. Health care professionals should collaborate, when possible, with local and state public health departments to care for patients with TB. Patients with drug-resistant TB or coinfection with human immunodeficiency virus should be treated in collaboration with TB specialists. Public health measures to prevent the spread of TB include appropriate respiratory isolation of patients with active pulmonary TB, contact investigation, and reduction of the LTBI burden. Tuberculosis (TB) poses a serious threat to public health throughout the world but disproportionately afflicts low-income nations. Persons in close contact with a patient with active pulmonary TB and those from endemic regions of the world are at highest risk of primary infection, whereas patients with compromised immune systems are at highest risk of reactivation of latent TB infection (LTBI). Tuberculosis can affect any organ system. Clinical manifestations vary accordingly but often include fever, night sweats, and weight loss. Positive results on either a tuberculin skin test or an interferon-γ release assay in the absence of active TB establish a diagnosis of LTBI. A combination of epidemiological, clinical, radiographic, microbiological, and histopathologic features is used to establish the diagnosis of active TB. Patients with suspected active pulmonary TB should submit 3 sputum specimens for acid-fast bacilli smears and culture, with nucleic acid amplification testing performed on at least 1 specimen. For patients with LTBI, treatment with isoniazid for 9 months is preferred. Patients with active TB should be treated with multiple agents to achieve bacterial clearance, to reduce the risk of transmission, and to prevent the emergence of drug resistance. Directly observed therapy is recommended for the treatment of active TB. Health care professionals should collaborate, when possible, with local and state public health departments to care for patients with TB. Patients with drug-resistant TB or coinfection with human immunodeficiency virus should be treated in collaboration with TB specialists. Public health measures to prevent the spread of TB include appropriate respiratory isolation of patients with active pulmonary TB, contact investigation, and reduction of the LTBI burden. Effective medical therapy for tuberculosis (TB) has existed for more than half a century, yet TB remains among the most pressing public health issues of our day. Tuberculosis is, in part, a disease of poverty.1Spence DP Hotchkiss J Williams CS Davies PD Tuberculosis and poverty.BMJ. 1993; 307: 759-761Crossref Scopus (208) Google Scholar The fact that it remains the eighth leading cause of death in the world speaks to the challenges facing practitioners and public health officials as they try to control a disease that is so entwined in the cultural and economic fabric of society. Challenges to effective solutions include lack of access to diagnosis and treatment, the frequent coexistence of epidemics of TB and human immunodeficiency virus (HIV), and the increasing prevalence of multidrug-resistant TB (MDR-TB).2Lonnroth K Castro KG Chakaya JM et al.Tuberculosis control and elimination 2010-50: cure, care, and social development.Lancet. 2010; 375: 1814-1829Abstract Full Text Full Text PDF PubMed Scopus (596) Google Scholar Although a chasm in disease burden exists between resource-rich and poor regions, an increasingly mobile and connected global community has ensured that TB remains highly relevant to practitioners throughout the world. This review highlights key principles in the management of TB. For purposes of definition, TB infection (TBI) occurs when a susceptible person inhales droplets containing Mycobacterium tuberculosis nuclei that travel through the respiratory tract to the alveoli. In most patients, an immune response limits propagation of TBI, resulting in an asymptomatic, noninfectious, localized infection that may remain in the body for many years. These patients have positive immunologic test results for M tuberculosis and carry a diagnosis of latent TBI (LTBI). A constellation of clinical, radiographic, microbiological, and histopathologic hallmarks are used to diagnose active TB disease.3Jensen PA Lambert LA Iademarco MF Ridzon R Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005.MMWR Recomm Rep. 2005; 54: 1-141PubMed Google Scholar An estimated one-third of the world's population is infected with TB.4Lonnroth K Raviglione M Global epidemiology of tuberculosis: prospects for control.Semin Respir Crit Care Med. 2008; 29: 481-491Crossref PubMed Scopus (222) Google Scholar Tuberculosis accounted for 1.3 million deaths in 2007, and the prevalence of active disease is estimated at 13.7 million (206 per 100,000 persons).5World Health Organization Global Tuberculosis Control: Epidemiology, Strategy, Financing: WHO Report 2009. World Health Organization, Geneva, Switzerland2009Google Scholar Incident cases of active TB are highest (≥100 cases per 100,000 persons) in sub-Saharan Africa, India and Central Asia, parts of Eastern Europe, Southeast Asia, and Micronesia. Intermediate incidence rates (26-100 per 100,000 persons) are observed in Central and South America, China, and northern Africa. Low rates (<25 per 100,000 persons) occur in the United States, Canada, Australia, Western Europe, and Japan.5World Health Organization Global Tuberculosis Control: Epidemiology, Strategy, Financing: WHO Report 2009. World Health Organization, Geneva, Switzerland2009Google Scholar, 6World Health Organization Global Tuberculosis Control: A Short Update to the 2009 Report. World Health Organization, Geneva, Switzerland2009Google Scholar While absolute numbers have been on the rise, the prevalence of TB in relationship to population has trended downward during the past 15 years, and global public health efforts have averted an estimated 6 million deaths during this time.2Lonnroth K Castro KG Chakaya JM et al.Tuberculosis control and elimination 2010-50: cure, care, and social development.Lancet. 2010; 375: 1814-1829Abstract Full Text Full Text PDF PubMed Scopus (596) Google Scholar Nevertheless, the emergence of drug resistance coupled with the persistence of HIV and global poverty have thwarted a more substantive break in the TB epidemic. Indeed, 0.5 million cases of MDR-TB, in which the infecting organism is resistant to at least isoniazid (INH) and rifampin (RIF), were reported in 2007, and 55 countries reported at least 1 case of extensively drug-resistant TB (XDR-TB),5World Health Organization Global Tuberculosis Control: Epidemiology, Strategy, Financing: WHO Report 2009. World Health Organization, Geneva, Switzerland2009Google Scholar in which the organism is resistant to at least INH, RIF, fluoroquinolones, and either aminoglycosides or capreomycin, or both. The magnitude of the problem is particularly overwhelming in parts of the Russian Federation and Central Asia, where the proportion of MDR-TB among incident TB cases ranged from 12% to 28% between 1994 and 2009, compared with 0% to 3% in the United States.7World Health Organization Multidrug and Extensively Drug-Resistant TB (M/XDR-TB): 2010 Global Report on Surveillance and Response. World Health Organization, Geneva, Switzerland2010Google Scholar As in the rest of the world, the incidence of TBI in the United States has declined during the past decade, but this decline has been much less pronounced among foreign-born Americans. More than half of active TB cases in the United States currently occur in foreign-born individuals,5World Health Organization Global Tuberculosis Control: Epidemiology, Strategy, Financing: WHO Report 2009. World Health Organization, Geneva, Switzerland2009Google Scholar, 8Centers for Disease Control and Prevention (CDC) Reported Tuberculosis in the United States, 2009. US Department of Health and Human Services, CDC, Atlanta, GA2010http://www.cdc.gov/tb/statistics/reports/2009/pdf/report2009.pdfGoogle Scholar and most cases result from reactivation of LTBI.9Geng E Kreiswirth B Driver C et al.Changes in the transmission of tuberculosis in New York City from 1990 to 1999.N Engl J Med. 2002; 346: 1453-1458Crossref PubMed Scopus (211) Google Scholar, 10Cain KP Benoit SR Winston CA Mac Kenzie WR Tuberculosis among foreign-born persons in the United States.JAMA. 2008; 300: 405-412Crossref Scopus (186) Google Scholar The effect of global migration on TB has been seen throughout the developed world, most dramatically in London, where cases of active TB increased by 50% between 1999 and 2009, mostly among foreign-born individuals.11Zumla A The white plague returns to London–with a vengeance.Lancet. 2011; 377: 10-11Abstract Full Text Full Text PDF Scopus (30) Google Scholar Sociodemographic risk factors for TBI include recent residence in an endemic region of the world, low socioeconomic position, being a member of a racial or ethnic minority (in the United States), homelessness, residency or employment at high-risk facilities (eg, correctional facilities, homeless shelters, skilled nursing facilities), and employment as a health care worker caring for patients with TB. Tuberculosis is transmitted through droplet aerosolization by an individual with active pulmonary disease. The highest risk of transmission occurs among patients with cavitary or positive acid-fast bacilli (AFB) smears12Loudon RG Spohn SK Cough frequency and infectivity in patients with pulmonary tuberculosis.Am Rev Respir Dis. 1969; 99: 109-111Google Scholar; however, patients with negative smears but positive cultures may still transmit the disease.13Tostmann A Kik SV Kalisvaart NA et al.Tuberculosis transmission by patients with smear-negative pulmonary tuberculosis in a large cohort in the Netherlands.Clin Infect Dis. 2008; 47: 1135-1142Crossref PubMed Scopus (219) Google Scholar Host factors dramatically influence which of those exposed to TB are most likely to contract primary disease or progress to active disease. Those with greater susceptibility include persons with immune systems that have been compromised through either diseases, such as HIV infection and hematologic and reticuloendothelial malignancies, or through immunosuppressive medications, such as corticosteroids, tumor necrosis factor α inhibitors, calcineurin inhibitors, and cytotoxic chemotherapeutic agents. Furthermore, patients with chronic diseases, such as diabetes, chronic kidney disease, and silicosis, are at elevated risk. Finally, age younger than 4 years, long-term malnutrition, and substance abuse are independent risk factors for disease.3Jensen PA Lambert LA Iademarco MF Ridzon R Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005.MMWR Recomm Rep. 2005; 54: 1-141PubMed Google Scholar Primary Pulmonary TB. Symptoms occurring around the time of inoculation are referred to as primary pulmonary TB. Symptoms are generally mild and include low-grade fever.14Poulsen A Some clinical features of tuberculosis; 1: incubation period.Acta Tuberc Pneumol Scand. 1950; 24: 311-346Google Scholar, 15Poulsen A Some clinical features of tuberculosis [concl].Acta Tuberc Pneumol Scand. 1957; 33: 37-92Google Scholar Two-thirds of persons with primary pulmonary TB remain asymptomatic. Physical examination findings are generally unremarkable, and the most common radiographic finding is hilar adenopathy.16Krysl J Korzeniewska-Kosela M Muller NL FitzGerald JM Radiologic features of pulmonary tuberculosis: an assessment of 188 cases.Can Assoc Radiol J. 1994; 45: 101-107PubMed Google Scholar Less common radiographic findings include pulmonary infiltrates in the mid and lower lung field. Reactivation TB. Approximately 90% of TB cases among adults can be attributed to reactivation TB. Symptoms present insidiously, most commonly with fever, cough, weight loss, fatigue, and night sweats. Less common symptoms include chest pain, dyspnea, and hemoptysis. Physical examination findings are nonspecific and may include rales or signs of pleural effusion (eg, dullness to percussion). Chest radiography demonstrates infiltrates in the apical-posterior segment of the upper lobes, and up to 20% of these infiltrates are associated with cavities characterized by air-fluid levels. Although not specific for TB, apical computed tomographic findings may show a “tree in bud” morphology manifested by centrilobular lesions, nodules, and branching linear densities.17Lee KS Song KS Lim TH Kim PN Kim IY Lee BH Adult-onset pulmonary tuberculosis: findings on chest radiographs and CT scans.AJR Am J Roentgenol. 1993; 160: 753-758Crossref Scopus (104) Google Scholar, 18Im JG Itoh H Shim YS et al.Pulmonary tuberculosis: CT findings–early active disease and sequential change with antituberculous therapy.Radiology. 1993; 186: 653-660PubMed Google Scholar Among the roughly 15% of patients who present without upper lung field infiltrates, a variety of radiographic findings have been described, including lower lung infiltrates (especially superior segments), nodules, effusions, and hilar adenopathy. Finally, up to 5% of patients with active pulmonary disease may have normal findings on chest radiography.19Marciniuk DD McNab BD Martin WT Hoeppner VH Detection of pulmonary tuberculosis in patients with a normal chest radiograph.Chest. 1999; 115: 445-452Crossref Scopus (68) Google Scholar, 20Pepper T Joseph P Mwenya C et al.Normal chest radiography in pulmonary tuberculosis: implications for obtaining respiratory specimen cultures.Int J Tuberc Lung Dis. 2008; 12: 397-403Google Scholar This is particularly worth noting among patients coinfected with HIV, who are more likely to have atypical (eg, less predisposition for upper lobes) or normal findings on chest radiography.21Greenberg SD Frager D Suster B Walker S Stavropoulos C Roth-pearl A Active pulmonary tuberculosis in patients with AIDS: spectrum of radiographic findings (including a normal appearance).Radiology. 1994; 193: 115-119PubMed Google Scholar Endobronchial TB. Endobronchial TB develops as the direct extension of TB from a pulmonary parenchymal source or sputum inoculation into the bronchial tree.22Rikimaru T Endobronchial tuberculosis.Expert Rev Anti Infect Ther. 2004; 2: 245-251Crossref Scopus (32) Google Scholar Symptoms may include barking cough with sputum production, and examination may reveal rhonchi and wheezing23Lee JH Park SS Lee DH Shin DH Yang SC Yoo BM Endobronchial tuberculosis: clinical and bronchoscopic features in 121 cases.Chest. 1992; 102: 990-994Crossref PubMed Scopus (139) Google Scholar, 24Van den Brande PM Van de Mierop F Verbeken EK Demedts M Clinical spectrum of endobronchial tuberculosis in elderly patients.Arch Intern Med. 1990; 150: 2105-2108Crossref Google Scholar; the wheezing may lead to misdiagnosis of asthma.25Rikimaru T Kinosita M Yano H et al.Diagnostic features and therapeutic outcome of erosive and ulcerous endobronchial tuberculosis.Int J Tuberc Lung Dis. 1998; 2: 558-562Google Scholar Diagnosis and response to therapy may be assessed through bronchoscopy.26Chung HS Lee JH Bronchoscopic assessment of the evolution of endobronchial tuberculosis.Chest. 2000; 117: 385-392Crossref PubMed Scopus (160) Google Scholar Extrapulmonary TB accounts for roughly 15% of TB cases among immunocompetent hosts27Peto HM Pratt RH Harrington TA LoBue PA Armstrong LR Epidemiology of extrapulmonary tuberculosis in the United States, 1993-2006.Clin Infect Dis. 2009; 49: 1350-1357Crossref PubMed Scopus (479) Google Scholar and for 50% to70% of cases that occur in the context of coinfection with HIV.28Raviglione MC Narain JP Kochi A HIV-associated tuberculosis in developing countries: clinical features, diagnosis, and treatment.Bull World Health Organ. 1992; 70: 515-526Google Scholar, 29Haas DW Des Prez RM Tuberculosis and acquired immunodeficiency syndrome: a historical perspective on recent developments.Am J Med. 1994; 96: 439-450Abstract Full Text PDF PubMed Scopus (83) Google Scholar, 30Jones BE Young SM Antoniskis D Davidson PT Kramer F Barnes PF Relationship of the manifestations of tuberculosis to CD4 cell counts in patients with human immunodeficiency virus infection.Am Rev Respir Dis. 1993; 148: 1292-1297Crossref PubMed Scopus (491) Google Scholar In low-incidence countries, immigrants from endemic countries are much more likely to present with extrapulmonary TB.31te Beek LA van der Werf MJ Richter C Borgdorff MW Extrapulmonary tuberculosis by nationality, The Netherlands, 1993-2001.Emerg Infect Dis. 2006; 12: 1375-1382Crossref Scopus (88) Google Scholar, 32Kempainen R Nelson K Williams DN Hedemark L Mycobacterium tuberculosis disease in Somali immigrants in Minnesota.Chest. 2001; 119: 176-180Crossref Scopus (35) Google Scholar, 33Rieder HL Snider Jr, DE Cauthen GM Extrapulmonary tuberculosis in the United States.Am Rev Respir Dis. 1990; 141: 347-351Crossref PubMed Scopus (370) Google Scholar As a rule, TB can present in any organ system; therefore, vigilance and examination for extrapulmonary disease are important for all persons being evaluated for TBI. A summary of the most common presentations of extrapulmonary TB follows (see also Table 1).TABLE 1Diagnosis of Common Extrapulmonary TB ManifestationsSiteDiagnostic procedureTuberculous lymphadenitisExcisional biopsy with cultureCNS TB Characteristic CSF exam (see text for details)AFB smear and culture of CSFPolymerase chain reaction for TB of CSFPleural TBPleural biopsy with pathology and cultureTuberculous peritonitisLaparoscopic peritoneal biopsy with cultureTuberculous pericarditisPericardiocentesis with cultureSkeletal TBNeedle biopsy and cultureGenitourinary TB Biopsy and culture of massesCulture of urineMiliary (disseminated) TBCulture of involved sitesAFB = acid-fast bacilli; CNS = central nervous system; CSF = cerebrospinal fluid; TB = tuberculosis. Open table in a new tab AFB = acid-fast bacilli; CNS = central nervous system; CSF = cerebrospinal fluid; TB = tuberculosis. Tuberculous Lymphadenitis. Up to 40% of extrapulmonary TB cases are attributable to tuberculous lymphadenitis.27Peto HM Pratt RH Harrington TA LoBue PA Armstrong LR Epidemiology of extrapulmonary tuberculosis in the United States, 1993-2006.Clin Infect Dis. 2009; 49: 1350-1357Crossref PubMed Scopus (479) Google Scholar It presents most commonly in the cervical lymph nodes, followed by the mediastinal and axillary nodes.34Thompson MM Underwood MJ Sayers RD Dookeran KA Bell PR Peripheral tuberculous lymphadenopathy: a review of 67 cases.Br J Surg. 1992; 79: 763-764Crossref Scopus (61) Google Scholar, 35Geldmacher H Taube C Kroeger C Magnussen H Kirsten DK Assessment of lymph node tuberculosis in northern Germany: a clinical review.Chest. 2002; 121: 1177-1182Crossref Scopus (135) Google Scholar A typical presenting symptom is long-term, unilateral, nontender lymphadenopathy; systemic symptoms are often absent.36Dandapat MC Mishra BM Dash SP Kar PK Peripheral lymph node tuberculosis: a review of 80 cases.Br J Surg. 1990; 77: 911-912Crossref PubMed Scopus (203) Google Scholar On examination, the node is typically matted and adherent to surrounding structures.36Dandapat MC Mishra BM Dash SP Kar PK Peripheral lymph node tuberculosis: a review of 80 cases.Br J Surg. 1990; 77: 911-912Crossref PubMed Scopus (203) Google Scholar, 37Jones PG Campbell PE Tuberculous lymphadenitis in childhood: the significance of anonymous mycobacteria.Br J Surg. 1962; 50: 302-314Crossref Scopus (46) Google Scholar If tuberculous lymphadenitis is clinically suspected, fine-needle aspiration should be pursued, followed by lymph node biopsy if the aspiration is nondiagnostic.38Ellison E Lapuerta P Martin SE Fine needle aspiration diagnosis of mycobacterial lymphadenitis: Sensitivity and predictive value in the United States.Acta Cytol. 1999; 43: 153-157Crossref Scopus (59) Google Scholar, 39Lee KC Tami TA Lalwani AK Schecter G Contemporary management of cervical tuberculosis.Laryngoscope. 1992; 102: 60-64Crossref Scopus (69) Google Scholar Pleural TB. Accounting for roughly 4% of all TB cases, pleural TB is the second leading cause of extrapulmonary TB.40Baumann MH Nolan R Petrini M Lee YC Light RW Schneider E Pleural tuberculosis in the United States: incidence and drug resistance.Chest. 2007; 131: 1125-1132Crossref Scopus (112) Google Scholar In addition to constitutional symptoms, patients may present with nonproductive cough and pleuritic chest pain.41Berger HW Mejia E Tuberculous pleurisy.Chest. 1973; 63: 88-92Crossref PubMed Scopus (255) Google Scholar Chest radiography typically shows a unilateral effusion, and pleural fluid analysis shows lymphocyte-predominant exudative features with low glucose levels and low pH.42Valdes L Alvarez D San Jose E et al.Tuberculous pleurisy: a study of 254 patients.Arch Intern Med. 1998; 158: 2017-2021Crossref PubMed Scopus (349) Google Scholar Pleural fluid culture is positive in only roughly 30% of cases, whereas the combination of histology and culture from a closed pleural biopsy specimen yields a diagnosis in most cases.43Gopi A Madhavan SM Sharma SK Sahn SA Diagnosis and treatment of tuberculous pleural effusion in 2006.Chest. 2007; 131: 880-889Crossref Scopus (319) Google Scholar Central Nervous System TB. A devastating manifestation of the disease, central nervous system TB occurs in approximately 1% of all TB cases.44Phypers M Harris T Power C CNS tuberculosis: a longitudinal analysis of epidemiological and clinical features.Int J Tuberc Lung Dis. 2006; 10: 99-103Google Scholar Tuberculous meningitis is clinically heralded by a 2- to 3-week prodrome of malaise, headache, low-grade fever, and personality changes. This prodrome is followed first by a meningitic phase that mimics bacterial meningitis (fever, nuchal rigidity, altered mental status) and then by a paralytic phase characterized by rapid progression to stupor, coma, seizures, paralysis, and death.45Sutlas PN Unal A Forta H Senol S Kirbas D Tuberculous meningitis in adults: review of 61 cases.Infection. 2003; 31: 387-391Google Scholar, 46Kent SJ Crowe SM Yung A Lucas CR Mijch AM Tuberculous meningitis: a 30-year review.Clin Infect Dis. 1993; 17: 987-994Crossref PubMed Scopus (229) Google Scholar, 47Hinman AR Tuberculous meningitis at Cleveland Metropolitan General Hospital 1959 to 1963.Am Rev Respir Dis. 1967; 95: 670-673PubMed Google Scholar Diagnosis requires a high index of suspicion, and cerebrospinal fluid analysis demonstrates elevated protein levels (100-150 mg/dL; to convert to g/L, multiply by 10), low glucose levels (<45 mg/dL; to convert to mmol/L, multiply by 0.0555), mononuclear pleocytosis, and an elevated cell count (100-150 cells/μL). A less common manifestation of the disease is central nervous system tuberculoma, which is characterized by single or multiple conglomerate caseous foci within the brain that cause focal neurologic symptoms and signs of elevated intracranial pressure. Finally, spinal tuberculous arachnoiditis represents a focal inflammatory disease producing gradual encasement of the cord with associated neurologic deficits. Tuberculous Peritonitis. The most common manifestation of TB in the gastrointestinal tract is tuberculous peritonitis.48al Karawi MA Mohamed AE Yasawy MI et al.Protean manifestation of gastrointestinal tuberculosis: report on 130 patients.J Clin Gastroenterol. 1995; 20: 225-232Crossref Scopus (86) Google Scholar, 49Sheldon CD Probert CS Cock H et al.Incidence of abdominal tuberculosis in Bangladeshi migrants in east London.Tuber Lung Dis. 1993; 74: 12-15Abstract Full Text PDF Scopus (21) Google Scholar Cirrhosis and portal hypertension are associated with an increased proclivity for tuberculous peritonitis.50Aguado JM Pons F Casafont F San Miguel G Valle R Tuberculous peritonitis: a study comparing cirrhotic and noncirrhotic patients.J Clin Gastroenterol. 1990; 12: 550-554Crossref PubMed Scopus (73) Google Scholar, 51Shakil AO Korula J Kanel GC Murray NG Reynolds TB Diagnostic features of tuberculous peritonitis in the absence and presence of chronic liver disease: a case control study.Am J Med. 1996; 100: 179-185Abstract Full Text PDF Scopus (94) Google Scholar Patients present with insidious onset of ascites (73%), abdominal pain (65%), weight loss (61%), and low-grade fever (59%).52Sanai FM Bzeizi KI Systematic review: tuberculous peritonitis–presenting features, diagnostic strategies and treatment.Aliment Pharmacol Ther. 2005; 22: 685-700Crossref PubMed Scopus (283) Google Scholar Clinically, tuberculous peritonitis may be mistaken for ovarian carcinoma or peritoneal carcinomatosis.53Bilgin T Karabay A Dolar E Develioglu OH Peritoneal tuberculosis with pelvic abdominal mass, ascites and elevated CA 125 mimicking advanced ovarian carcinoma: a series of 10 cases.Int J Gynecol Cancer. 2001; 11: 290-294Crossref PubMed Scopus (105) Google Scholar, 54Rodriguez E Pombo F Peritoneal tuberculosis versus peritoneal carcinomatosis: distinction based on CT findings.J Comput Assist Tomogr. 1996; 20: 269-272Crossref PubMed Scopus (78) Google Scholar Unexplained lymphocytic ascites should prompt definitive diagnostic testing for peritoneal TB. Culture of tubercles obtained through peritoneal biopsy remains the criterion standard for diagnosis. Tuberculous Pericarditis. In the developing world, tuberculous pericarditis is likely the most common cause of pericardial effusion and constrictive pericarditis55Jain S Sharma N Varma S Rajwanshi A Verma JS Sharma BK Profile of cardiac tamponade in the medical emergency ward of a North Indian hospital.Can J Cardiol. 1999; 15: 671-675PubMed Google Scholar, 56Reuter H Burgess LJ Doubell AF Epidemiology of pericardial effusions at a large academic hospital in South Africa.Epidemiol Infect. 2005; 133: 393-399Crossref Scopus (106) Google Scholar; however, in high-income nations, it is rare.57Cameron J Oesterle SN Baldwin JC Hancock EW The etiologic spectrum of constrictive pericarditis.Am Heart J. 1987; 113: 354-360Abstract Full Text PDF PubMed Scopus (196) Google Scholar Patients can present with pericardial effusion, constrictive pericarditis, or a mixed effusive and constrictive condition.58Mayosi BM Wiysonge CS Ntsekhe M et al.Clinical characteristics and initial management of patients with tuberculous pericarditis in the HIV era: the Investigation of the Management of Pericarditis in Africa (IMPI Africa) registry.BMC Infect Dis. 2006; 6: 2Crossref Scopus (82) Google Scholar Symptoms are those of effusion or constriction from any cause (dyspnea, cough, orthopnea, edema) in the context of systemic symptoms (night sweats, low-grade fevers, weight loss).59Fowler NO Manitsas GT Infectious pericarditis.Prog Cardiovasc Dis. 1973; 16: 323-336Abstract Full Text PDF PubMed Scopus (74) Google Scholar Skeletal TB. Skeletal TB occurs in 1% to 5% of patients with TB60Mehta JB Dutt A Harvill L Mathews KM Epidemiology of extrapulmonary tuberculosis: a comparative analysis with pre-AIDS era.Chest. 1991; 99: 1134-1138Crossref PubMed Scopus (220) Google Scholar and presents most commonly in the thoracolumbar spine. Patients present with localized pain over the afflicted site; systemic symptoms are often absent.61Hodgson SP Ormerod LP Ten-year experience of bone and joint tuberculosis in Blackburn 1978-1987.J R Coll Surg Edinb. 1990; 35: 259-262Google Scholar Diagnosis is confirmed through culture of specimens obtained through needle aspiration or biopsy.62Mondal A Cytological diagnosis of vertebral tuberculosis with fine-needle aspiration biopsy.J Bone Joint Surg Am. 1994; 76: 181-184Google Scholar Miliary TB. The lymphatic and hematogenous spread of TB is referred to as miliary TB.63Sharma SK Mohan A Sharma A Mitra DK Miliary tuberculosis: new insights into an old disease.Lancet Infect Dis. 2005; 5: 415-430Abstract Full Text Full Text PDF PubMed Scopus (264) Google Scholar Patient presentation is variable, and systemic symptoms (fever, weight loss, night sweats) are common.64Kim JH Langston AA Gallis HA Miliary tuberculosis: epidemiology, clinical manifestations, diagnosis, and outcome.Rev Infect Dis. 1990; 12: 583-590Crossref PubMed Scopus (152) Google Scholar When miliary TB occurs in the context of primary infection, patients maypresent with septic shock and acute respiratory distress syndrome.65Ahuja SS Ahuja SK Phelps KR Thelmo W Hill AR Hemodynamic confirmation of septic shock in disseminated tuberculosis.Crit Care Me" @default.
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• W2019550064 title "Current Concepts in the Management of Tuberculosis" @default.
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