Extra-pulmonary TB (EPTB)

Clinical description

EPTB may affect any organ outside of the lungs. Commonly involved sites include the pleura, lymph nodes, meninges, bones, joints, spine, genitourinary tract, peritoneum and pericardium.

28 National Tuberculosis Control Programme Table 4.1-1: Clinical features of the most common EPTB presentations

• Commonly affects posterior cervical and supraclavicular

lymph nodes;

TB Lymphadenitis

• Usually painless enlarged lymph nodes early in course.
• Pleuritic chest pain and shortness of breath;

Pleural TB

• An effusion around the lungs.
• Tender swelling of the back, sometimes with weakness of the

legs due to compression of the spinal cord;

Spinal TB

• Most frequently affects the thoracic or lumbar portions of

the spine.

• Slow onset (> 4 weeks) with little or no pain;
• Usually hip, knee, elbows or wrists;

Osteoarticular

• Signs of joint destruction (clinical or radiological);
• Often associated with pulmonary TB.
• Presents subtly with headache and mental status changes

after 1-2 weeks of low-grade fever, loss of appetite and irritability;

TB Meningitis

• May progress acutely to severe headache, confusion/

coma and neck stiffness.

• May present suddenly with shortness of breath, fever,

Pericardial TB oedema and retrosternal chest pain.

• Abdominal pain, abdominal swelling (ascites), bowel

Gastrointestinal TB obstruction, fever, weight loss and bloody stools are (Peritoneal TB)

common.

National Tuberculosis Control Programme 29 Table 4.1-2: Type of TB by clinical features Type of TB Investigation, finding suggestive of TB Type of TB Investigation, finding suggestive of TB Pleural TB Recommended investigation Lymph Recommended Investigation node TB

• Rapid HIV test • Rapid HIV test
• Chest x-ray (CXR) • Sputum smear or Xpert MTB/

RIF

• Sputum smear or Xpert MTB/RIF
• Needle aspiration for AFB
• Aspiration and inspection of

pleural fluid • Lymph node excisional biopsy

• Differential white blood cell count

and protein determination (if Finding suggestive of TB possible) of aspirate

• Lymph nodes (LN) > 2 cm
• Painless swelling, asymmetrical/

Finding suggestive of TB localized

• One-sided effusion
• Posterior cervical
• Aspirated fluid is clear and straw- location

coloured

• Firm/fluctuant/
• Lymphocytes predominance in pleural presence of fistula

fluid

• Weight loss, night sweats, chest Non-suggestive of TB

pain, fever

• KS in skin or mouth
• Evidence of TB in another part of
• Symmetrical (concern for

the body lymphoma or HIV)

• Tender or red/inflamed

Non-suggestive of TB

• Bilateral pleural effusions
• Clinical evidence of Kaposi sarcoma

(KS) or other cancer

• Aspirated fluid contains pus

(empyema) or blood (usually cancer)

30 National Tuberculosis Control Programme Type of TB Investigation, finding suggestive of TB Type of TB Investigation, finding suggestive of TB TB Recommended investigation Disseminated Recommended investigation Pericarditis • Rapid HIV test TB • Rapid HIV test, CXR

• Sputum smear or Xpert MTB/ • Sputum smear or Xpert

RIF MTB/RIF

• CXR • Aspiration of ascetic fluid
• Ultrasound (US) examination

Finding suggestive of TB Finding suggestive of TB • Abnormal CXR including

• Fever, chest pain, night sweats “Miliary” pattern
• Evidence of TB in another part of • Fever, cough, night sweats,

the body weight loss

• Pericardial effusion or pericardial • Large spleen and/or liver

thickening on US Non-suggestive of TB Non-suggestive of TB • Rigors

• Streaky shadowing of lung • Severe diarrhoea or blood

fields on CXR in stool

• Murmur • Shock/sepsis (very low BP)
• High blood pressure (BP) • Pathogen from blood culture

Osteoarticular, Recommended investigation TB meningitis Recommended investigation including TB • Rapid HIV test • Rapid HIV test of the spine

• Appropriate x-rays • Lumbar puncture
• Fine needle aspirate (FNA) • Laboratory tests on

or biopsy for AFB cerebrospinal fluid (CSF)

including Gram stain, AFB, differential cell count, Finding suggestive of TB protein and glucose in CSF,

• Signs of spinal cord Cryptococci CSF antigen

compression (paraplegia, (CRAG) or India ink urinary and bowel incontinence)

Finding suggestive of TB

• Fever, night sweats, weight

loss • Fever, weight loss, night sweats

• CSF of 100-500 cells/

Non-suggestive of TB mm3 with lymphocyte

• Clinical evidence of cancer predominance
• Clinical evidence of rheumatologic • CSF with high protein and low

disease (e.g., rheumatoid arthritis) glucose

• India ink and/or

cryptococcal antigen negative

• Evidence of TB in another

part of the body Non-suggestive of TB

• Rapid onset
• Very high opening CSF

pressure (more likely cryptococcal)

• CSF cloudy or

with neutrophilic predominance (more likely bacterial)

• India ink or CRAG test

positive National Tuberculosis Control Programme 31