Tuberculosis in the ED

Patient presents to Elmhurst ED with cough, hemoptysis, night sweats and fatigue – quick, what’s the first diagnosis that comes to mind?

This is the classic presentation for tuberculosis. But several times now I have been surprised by less typical symptoms of TB. So I thought it might be helpful to review how TB might present in the ED, especially since some estimates say that ⅓ of the world’s population is infected. And the populations at highest risk – residents from endemic regions (especially India, China, the Philippines, Pakistan, Nigeria, Bangladesh), unhoused persons, those in institutional living or employment (prisons, shelters, nursing homes, hospitals), the elderly or very young, and immunosuppressed – are people we see very often in our EDs.

TB is caused by the acid-fast bacillus Mycobacterium Tuberculosis and spreads via aerosolized respiratory secretions. It migrates into the lung alveoli, activating the host’s defense mechanisms. So its presentation often depends on the host’s immune system. 

Adapted from: Sharma SK, Mohan A, Sharma A, et al. Miliary tuberculosis: New insights into an old disease. Lancet Infect Dis 2005;5:415-430.

Let’s start from exposure. Out of those with primary infection, most patients’ immune systems can contain the organism in regional lymph nodes, leading to latent TB. Primary pulmonary TB is usually asymptomatic. Only 10% of patients with primary infection will present with pulmonary TB symptoms. In immunocompromised patients, these primary symptoms can be rapidly progressive.

Similarly, patients with latent TB who are at high risk may experience reactivation of previously contained focus.

Here’s a list on how TB might present:

Pulmonary – apical and posterior upper lobes, superior segment of lower lobeProductive cough, dyspnea, hemoptysis, pleuritic chest pain
Immunocompromised may have more atypical findings
LymphTends to be unilateral and non-tender
Can develop scrofula= enlarged cervical nodes that sometimes rupture and form fistulas
PleuralPleuritic chest pain, cough, and unilateral pleural effusion on CXR
CNS1: Indolent h/a, fever, AMS2: meningitic phase3: paralytic phase
PeritonealAscites, abd pain, weight loss, fever
AdrenalUsually bilateral, may present in shock
Consider steroids!
SkeletalMost commonly thoracolumbar spine, osteomyelitis (Pott’s)
Miliary (Disseminated)Wide hematogenous spread, often with multi-organ failure and shock

Next steps when you suspect TB:

  1. Isolate in negative pressure room
  2. Get CXR and quant-gold (culture is definite but won’t come back in ED)
  3. Report to public health services
  4. Consent for HIV co-testing
  5. Baseline labs for treatment: CBC (platelet), LFTs, serum urea, creatinine
  6. Don’t initiate treatment unless in consult with ID

Discharge instructions: home isolation procedures and follow up at appropriate clinic

Admit: uncertain dx, noncompliant, concert for multidrug resistant, or severe illness with respiratory compromise, shock, or multi-organ failure

June 2023