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  • • Gram-positive rods, often dormant but remain alive for the life of the host

    • Initial infection affects midzone of lungs, causing caseation in a few weeks

    • Regional hilar lymph nodes become enlarged; most cases arrest at this stage

    • If progresses, giant cells produce a typical tubercle

    • Latent disease occurs when dormant tubercles reactivate in elderly or immunocompromised patients

    • Apical segments of upper lobes most often affected in latent disease

    • Extrapulmonary disease may involve pericardium, bones, joints, urinary tract, meninges, lymph nodes, pleural space

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Epidemiology

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  • • Had markedly declined from 1953 until 1984 due to anti-TB drugs

    • Since 1984, has increased due to emergence of HIV

    • 25,000 new cases annually

    • < 20% of population in the United States is tuberculin-positive

    • 95% of cases are due to infection with Mycobacterium tuberculosis, Mycobacterium bovis, and Mycobacterium avium-intracellulare

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Symptoms and Signs

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  • • Minimal symptoms in many

    • Fever, cough

    • Anorexia, weight loss

    • Night sweats, excessive perspiration

    • Chest pain

    • Lethargy, fatigue

    • Dyspnea

    • Erythema nodosum seen in active disease

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Laboratory Findings

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  • • Purified protein derivative (PPD): False-negative due to improper testing, anergy

    • Anergy due to disseminated disease, sarcoidosis, lymphomas, immunosuppressive drugs (used in HIV, transplant patients)

    • Sputum culture for mycobacterium

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Imaging Findings

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  • Chest film

    • -Involvement of apical and posterior upper lobes (85%)

      -10% of cases affect superior lower lobes and seen most often in women, blacks and diabetics

      -Variations: Cavitation, acute TB pneumonia, miliary TB, bronchiectasis, tuberculoma

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Rule Out

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  • • Bronchogenic carcinoma

    • Fungal infections, such as histoplasmosis

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  • • PPD

    • Sputum culture

    • Gastric aspirate, tracheal washing culture

    • Pleural fluid culture; pleural and lung biopsies may be needed for diagnosis

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  • • Multidrug regimens including isoniazid, rifampin, pyrazinamide, and ethambutol

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Surgery

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  • • Role of surgery diminished dramatically by effective medications

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Indications

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  • • Failure of medical therapy

    • Performance of diagnostic procedures

    • Destroyed lung, cavitary lesions

    • Postoperative complications

    • Persistent bronchopleural fistula

    • Intractable hemorrhage

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Medications

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  • • Isoniazid

    • Streptomycin

    • Ethambutol

    • Rifampin

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Complications

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  • • TB empyema: Treated by pulmonary decortication, or drainage if associated with pyogenic infection or bronchopleural fistula

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Prognosis

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  • • Mortality 10% with medical treatment

    • Perioperative mortality: 1-10%

    • Relapse rate is 4%

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References

Horowitz MD et al: Late complications of plombage. Ann Thorac Surg 1992;53:803.  [PubMed: 1570974]
Langston HT: Thoracoplasty: the how and the why. Ann Thorac Surg 1991;52:1351.  [PubMed: 1755696]
Nolan CM: Failure of therapy for tuberculosis in human immunodeficiency virus infection. Am J Med Sci 1992;304:168.  [PubMed: 1476156]
Pomerantz M et al: ...

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