EM · Tuberculosis
Tuberculosis (ED)
The tuberculosis from the Mycobacterium tuberculosis through the primary and the reactivation (the secondary), the risk factors (the HIV, the immunosuppression, the malnutrition, the diabetes, the migrant, the alcohol, the smoking), the presentation (the chronic cough, the haemoptysis, the night sweats, the weight loss, the fever; the extrapulmonary — the cervical lymphadenitis, the meningitis, the miliary, the spinal Pott), the ED role (the suspect, the isolate, the airborne precautions, the sputum, the public health notification), the quadruple RIPE therapy and its toxicity, and the MDR-TB.
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Target exams
Red flags
- The TB is suspected in the chronic cough, the haemoptysis, the night sweats, the weight loss, and the upper-lobe cavity on the chest radiograph, with the risk factor
- The respiratory ISOLATION and the AIRBORNE precautions (the negative-pressure room, the N95 mask) are applied at the suspicion, before the confirmation
- The three sputum samples for the AFB smear and the culture and the NAAT (the GeneXpert) — the morning, the spot
- The quadruple RIPE therapy — the rifampicin, the isoniazid, the pyrazinamide, the ethambutol — for the 2 months, then the rifampicin and the isoniazid for the 4 months
- The drug toxicity — the rifampicin the LFT and the orange urine; the isoniazid the hepatitis and the peripheral neuropathy (the pyridoxine); the ethambutol the optic neuritis
Meet the patient
A 34-year-old man who arrived from a high-burden country eight months ago sits in your resuscitation bay with six weeks of productive cough, three days of streaky haemoptysis, night sweats that soak the sheets, and a six-kilogram weight loss. The chest radiograph shows a right upper-lobe cavity with surrounding infiltrate.[1]
The single question that decides the safety of your department is not is it TB? — it almost certainly is — but did you isolate him before the smear came back? The smear takes a day, the culture takes weeks, and the droplet nuclei he generates with every cough hang in the air for hours and sail straight through a surgical mask. Hold that question and the entire ED pathway falls into place.[1]
References8ShowHide
- [1]Furin J, Cox H, Pai M. Tuberculosis Lancet, 2019.PMID 30904262
- [2]Lange C, Dheda K, Chesov D, Mandalakas AM, Udwadia Z. Management of drug-resistant tuberculosis Lancet, 2019.PMID 31526739
- [3]Menon LJB, Feliciano CS, de Campos MR, Bollela VR. Decision making to discharge patients from airborne infection isolation rooms: The role of a single GeneXpert MTB/RIF strategy in Brazil Infect Control Hosp Epidemiol, 2020.PMID 32299529
- [4]Boehme CC, Nabeta P, Hillemann D, et al. Rapid molecular detection of tuberculosis and rifampin resistance N Engl J Med, 2010.PMID 20825313
- [5]Dorman SE, Nahid P, Kurbatova EV, et al. Four-Month Rifapentine Regimens with or without Moxifloxacin for Tuberculosis N Engl J Med, 2021.PMID 33951360
- [6]Diacon AH, Pym A, Grobusch M, et al. The diarylquinoline TMC207 for multidrug-resistant tuberculosis N Engl J Med, 2009.PMID 19494215
- [7]Tagmouti S, Slater M, Benedetti A, et al. Reproducibility of interferon gamma (IFN-γ) release Assays. A systematic review Ann Am Thorac Soc, 2014.PMID 25188809
- [8]Colditz GA, Berkey CS, Mosteller F, et al. The efficacy of bacillus Calmette-Guérin vaccination of newborns and infants in the prevention of tuberculosis: meta-analyses of the published literature Pediatrics, 1995.PMID 7596718