Tuberculosis (patient information)

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Tuberculosis

Overview

What are the symptoms?

What are the causes?

Who is at highest risk?

When to seek urgent medical care?

Diagnosis

Treatment options

Where to find medical care for Tuberculosis?

What to expect (Outlook/Prognosis)?

Possible complications

Prevention

Tuberculosis On the Web

Ongoing Trials at Clinical Trials.gov

Images of Tuberculosis

Videos on Tuberculosis

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Directions to Hospitals Treating Tuberculosis

Risk calculators and risk factors for Tuberculosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Mashal Awais, M.D.[2]; Ethan Leeman; João André Alves Silva, M.D. [3]

## Overview

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Tuberculosis (TB) is a bacterial infection that resulted 1.8 million deaths worldwide. About 10.4 million individuals in the world are infected with TB. If Ieft untreated, active tuberculosis kills 60% of patients; however, with treatment, 90% of patients get cured. In 2015, the total number of reported TB cases in the USA was about 9,421. Most individuals who get infected with TB have latent TB. This means that the bacteria is controlled by the immune system. Additionally, most of these TB cases are men; however, the impact of the disease is more severe on women and the mortality is more in womenEmpty citation (help). Individuals who develop latent TB do not have symptoms and do not transmit TB to other people.

## What are the Symptoms of Tuberculosis?

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Latent TB is dormant in the alveoli of the lungs. As active TB develops, the bacteria spread out from the alveoli to the lungs and then to other organ systems. Consequently, depending on which organ system is affected, the symptoms may be variable. The primary stage of TB often doesn't cause symptoms. If symptoms of pulmonary TB occur, they include:[1]

* Cough
* Night sweats
* Coughing up blood
* Excessive sweating, particularly at night
* Fatigue
* Fever
* Unintentional weight loss
* Shortness of breath
* Chest pain
* Wheezing

Symptoms of TB disease in other parts of the body will vary according to the affected area.

## What Causes Tuberculosis?

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Pulmonary tuberculosis (TB) is caused by the bacterium Mycobacterium tuberculosis. The bacteria often affect the lungs but TB bacteria can damage any part of the body such as the kidney, brain, and spine. If not well-managed, TB disease can be fatal.[1]

### Multidrug-Resistant Tuberculosis

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Multi-drug-resistant tuberculosis is due to the bacterium Mycobacterium tuberculosis resistant to anti-TB drugs. This resistance can occur due to misuse or mismanagement of the drugs:[1]

* Patients do not complete their full regimen of treatment
* Health-care providers prescribe the wrong treatment, the wrong dose, or duration for taking the drugs
* drugs are not always available
* drugs are of poor quality

## Who is at Highest Risk?

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Tuberculosis is transmitted from person to person through the air (cough, sneeze, or speaking) and physical contact.

The following individuals are at higher risk for developing active TB:

* Elderly
* Infants
* Patients with weakened immune systems (AIDS, chemotherapy, diabetes, or certain medications)

Your risk of getting TB increases if you:

* Have prolonged frequent contact with TB patients
* Have poor nutrition
* Live in a crowded place or with poor hygiene

The following factors may increase the risk of TB infection in a population:

* Increase in rate of HIV infections
* Increase in number of homeless people
* The appearance of drug-resistant strains of TB

### Multidrug-Resistant Tuberculosis

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Drug resistance is more common in people who:[2]

* Do not take their TB medicine regularly and are non-compliant.
* Do not take all of their TB medication as prescribed by their doctors or nurses.
* Develop TB disease again, after having taken TB medication previously.
* Immigrate from regions of the world where drug-resistant TB is prevalent.
* Have been in frequent contact with someone who has drug-resistant TB disease

## When to Seek Urgent Medical Care?

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Call your health care provider if:

* You have been exposed to TB or traveled to areas with endemic TB disease
* You develop signs and symptoms of TB
* Your symptoms continue in spite of treatment
* New symptoms develop

## Diagnosis

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The diagnosis of active TB is based on with a combination of symptoms, patient history (any known exposure to TB), TB tests, and x-rays.

Latent tuberculosis can be identified approximately 6-8 weeks after exposure. There are two tests that are used to detect TB infection:[1]

* TB skin test

* The skin test is more commonly used
* A small needle is used to put some testing material, called tuberculin, under the skin
* In 2-3 days, the patient must return to the health care provider to check if there is a reaction to the test

* TB blood test

* In some cases, a TB blood test is used to detect TB infection
* This blood test measures how an individual’s immune system reacts to the organisms that cause TB

The drug resistance will be revealed by a drug susceptibility test. To inform if someone has TB disease, other tests may be required:[1]

* Chest x-ray \- X-ray of the lungs may show cavities or lesions that are typical of TB
* sputum sample (the phlegm that is coughed up from deep inside the lungs)

It is essential to inform your health care provider if you have ever had a “positive” reaction to a TB skin test or TB blood test, or if you have previous treatment with anti-TB drugs in the past.

## Treatment Options

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The typical TB treatment includes one or a few antibiotics for months. Following two weeks of treatment, patients are typically no longer contagious. Some of the drugs given for TB have some bad side effects, particularly if combined with other drugs. Therefore, it is challenging for some patients to take their medication for the optimal duration. However, this makes the bacteria resistant to antibiotics and makes treatment even more difficult in the future. Treatment for multi-drug-resistant tuberculosis includes different treatment options with a far worse prognosis.

### Multidrug-Resistant Tuberculosis

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* TB is a treatable and curable disease. Treatment for multidrug-resistant tuberculosis should be confirmed by drug-susceptibility testing. However, as this testing takes weeks, treatment should be initiated with an empirical treatment regimen according to expert advice once drug-resistant TB disease is suspected. [1][2]

* When the drug-susceptibility testing results are available, the treatment regimen should be adjusted based on the results, to avoid suboptimal treatment. Patients should have close monitoring throughout treatment. [1]

* A common treatment regimen is at least 5 drugs, to which the bacteria was reported to be susceptible.[3]

* Treatment regimens are usually divided into 2 phases: the initial phase and the continuation phase.

* A fluoroquinolone is indicated for the treatment of patients with MDR-TB.

* Directly observed therapy (DOT) must be used for the treatment of drug-resistant TB to ensure adherence.[1]

#### Special Considerations

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##### HIV-Infected Persons

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* Treatment of drug-resistant TB in persons with HIV infection is the same as for patients without HIV.
* Management of HIV-related TB requires expertise in the management of both HIV and TB.
* Providers must monitor the interactions among many of the antiretroviral drugs.
* Rifampin should not be used with most antiretroviral drugs. Rifabutin, which has fewer problematic drug interactions, may be used in place of Rifampin.
* These recommendations are likely to be modified, as new antiretroviral agents and pharmacokinetic data become available.

##### Children

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* Treatment of children with TB disease after exposure to a drug-resistant patient must be guided by the source-case susceptibility results.
* If the source is unknown and circumstances are suggestive of a high risk of drug resistance, children must be treated with a standard four-drug initial-phase regimen until their susceptibility pattern is known.
* Ethambutol can be used safely (15-20 mg/kg per day), in case of the probability of Isoniazide resistance.
* Streptomycin, kanamycin, or amikacin can be selected as the fourth drug.
* Long-term use of fluoroquinolones in children has not been approved. However, most experts agree that fluoroquinolones should be considered for children with MDR-TB.
* Consultation with a specialist in pediatric TB treatment is recommended.

##### Pregnant Women

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* Case management for pregnant women who have drug-resistant TB requires consultation with an expert because most second-line drugs can have harmful effects on the fetus.
* Pyrazinamide should not be used as part of the treatment regimen for pregnant women.
* Counseling concerning risks to the fetus should be provided.

##### Close Contacts of Drug-Resistant TB Patients

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* Contacts of isoniazid-resistant TB.
* Persons who have been exposed to Isoniazid-resistant, Rifampin-susceptible TB and are known or suspected to have latent TB infection, a 4-month regimen of daily Rifampin is recommended.
* When Rifampin cannot be used, rifabutin is an alternative.

##### Contacts of MDR-TB

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* For individuals with known or suspected latent tuberculosis infection resistant to both Isoniazid and Rifampin, alternative regimens should be considered.
* Alternative regimens should include two drugs to which the TB strain is susceptible.
* A potential regimen should include a daily fluoroquinolone.
* Contacts who are not immunosuppressed may be treated for 6 months or observed without treatment.
* All individuals with suspected MDR latent TB should be monitored for 2 years regardless of the treatment regimen.

## Where to Find Medical Care for Tuberculosis?

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Directions to Hospitals Treating Tuberculosis

## What to Expect (Outlook/Prognosis)?

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Symptoms often improve in 2 - 3 weeks. A chest x-ray will not show this improvement until later. The outlook is excellent if pulmonary TB is diagnosed early and treatment is begun quickly.

### Multidrug-Resistant Tuberculosis

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The prognosis of multidrug-resistant TB is worse than that of tuberculosis susceptible to the regular common treatment. So it is necessary to do a drug susceptibility test and to monitor adherence to the treatment regimen to avoid new drug resistances and ensure a better prognosis.

## Possible Complications

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Pulmonary TB can lead to permanent damage of the lung if not diagnosed and treated early. Medication used to treat TB may be associated with side effects, such as liver problems. Other side effects include:

* Problems with vision
* Orange- or brown-colored tears and urine
* Skin rash

A vision test may be performed before treatment so your doctor can monitor any changes in your eyes' health over time.

## Prevention

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On an individual basis, covering sneezes and coughs can reduce the transmission of TB. On a wider scale, adequate ventilation and limiting the crowded areas can also reduce its transmission. As with all infectious diseases, early detection of the disease is essential to prevent its spreading. Isoniazid is a prophylactic antibiotic that can cure latent TB before it progresses to active TB and should be given to individuals who:

* Have latent TB
* Are close contact with known infected TB patients
* Live in countries where TB is endemic.
* Are at risk of TB infection

A vaccine called BCG can prevent the spread of TB to other parts of the body but not the infection. It is recommended just for infants in countries known to have high prevalence of TB. BCG can interfere with TB skin tests, giving false positives, and other tests are required to test for TB in these cases. It is not recommended for general use in the US because it has limited efficacy for preventing TB.[1]TB does not spread by: [4]

* Shaking someone’s hand
* Sharing food or drink
* Touching bed linens or toilet seats
* Sharing toothbrushes
* Kissing

### Travel warning and guidelines

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Travelers who expect possible prolonged exposure to patients with TB (for example, those who anticipate being in contact routinely with clinic, hospital, prison, or homeless shelter populations) must have a tuberculin skin test (TST) or TB blood test before leaving the United States. If the reaction to the TST or TB blood test is negative, the test should be repeated 8 to 10 weeks after returning to the United States.

Moreover, annual testing is recommended for those who expect repeated or prolonged exposure or an prolonged stay over a period of years. Because individuals with HIV infection are more likely to have an impaired response to both the TST and TB blood test, travelers who are HIV positive should inform their physicians of their HIV infection status. According to WHO, the list of countries having a high prevalence of TB is:

* India
* Pakistan
* Bangladesh
* South Africa
* China
* Congo
* Columbia
* Cambodia
* Indonesia
* Korea
* Brazil
* Ethiopia
* Myanmar
* Mozambique
* Thailand
* Angola
* Vietnam
* Kenya
* Central Africa
* Russia
* Liberia
* Zimbabwe
* Namibia
* Philippine
* Nigeria
* Tanzania
* Sierra leone Zambia
* Papua New Guinea
* Lesotho

### Multidrug-Resistant Tuberculosis

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To prevent multi-drug-resistant tuberculosis, the following recommendations should be followed:[1]

* Take all medications exactly as prescribed by the physician
* The doses should not be missed and treatment should not be stopped early or without returning to the physician
* Patients should inform their health care provider if they are having problems understanding or taking the medications
* In case of planning to travel, they should talk to their physicians and make sure they have sufficient medication to last while away
* Avoid exposure to patients with known MDR-TB and who are in crowded or closed places such as hospitals, prisons, or homeless shelters:

* If health care workers are more likely to have contact with TB patients, infection control or occupational health experts must be consulted
* Administrative and environmental procedures for preventing exposure to TB should be implemented. Once that is implemented, other measures may include using personal respiratory protective devices

Health care providers can help prevent MDR-TB by:[1]

* Quickly diagnosing cases
* Following recommended treatment guidelines
* Monitoring patients’ response to treatment
* Making sure therapy is completed

## Sources

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* NLM

Center for Disease Control or Prevention
World Health Organization

## References

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1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 "Tuberculosis Fact Sheet".
2. ↑ 2.0 2.1 "Multidrug-resistant tuberculosis".
3. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
4. ↑ http://www.cdc.gov/tb/publications/factsheets/general/tbtravelinfo.htm Accessed on October 14, 2016

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