Tuberculosis

The answer first

Tuberculosis is three clinical problems wearing one name, and almost every exam question and every hard ward decision is really asking which of the three you are dealing with ^[3]:

1. Infection or disease? A person with immune sensitisation to M. tuberculosis — a positive IGRA or tuberculin skin test — who has no symptoms, no radiological activity and no detectable organisms is latently infected: well, non-infectious, and a candidate for preventive therapy. The same person with a chronic cough, apical infiltrates and bacilli in sputum has active disease: infectious, notifiable, and needing four drugs. No blood test can tell these two states apart — only clinical assessment plus microbiology can ^{[3] [19]}.
2. Drug-susceptible or resistant? Every confirmed case starts with a molecular test that simultaneously detects M. tuberculosis and rifampicin resistance, because the regimen chosen on day one determines whether you cure the patient or amplify resistance ^{[6] [1]}.
3. Individual patient or public-health event? Active pulmonary TB obliges you to notify, isolate while infectious, and trace contacts. The consultation is not finished when the prescription is written ^[1].

---

References22ShowHide

1. [1]Nahid P, Dorman SE, Alipanah N, et al. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis Clin Infect Dis, 2016.PMID 27516382
2. [2]Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children Clin Infect Dis, 2017.PMID 28052967
3. [3]Getahun H, Matteelli A, Chaisson RE, Raviglione M. Latent Mycobacterium tuberculosis infection N Engl J Med, 2015.PMID 26017823
4. [4]Menzies D, Adjobimey M, Ruslami R, et al. Four Months of Rifampin or Nine Months of Isoniazid for Latent Tuberculosis in Adults N Engl J Med, 2018.PMID 30067931
5. [5]Sterling TR, Villarino ME, Borisov AS, et al. Three months of rifapentine and isoniazid for latent tuberculosis infection N Engl J Med, 2011.PMID 22150035
6. [6]Boehme CC, Nabeta P, Hillemann D, et al. Rapid molecular detection of tuberculosis and rifampin resistance N Engl J Med, 2010.PMID 20825313
7. [7]Dorman SE, Schumacher SG, Alland D, et al. Xpert MTB/RIF Ultra for detection of Mycobacterium tuberculosis and rifampicin resistance: a prospective multicentre diagnostic accuracy study Lancet Infect Dis, 2018.PMID 29198911
8. [8]Peter JG, Zijenah LS, Chanda D, et al. Effect on mortality of point-of-care, urine-based lipoarabinomannan testing to guide tuberculosis treatment initiation in HIV-positive hospital inpatients: a pragmatic, parallel-group, multicountry, open-label, randomised controlled trial Lancet, 2016.PMID 26970721
9. [9]Thwaites GE, Nguyen DB, Nguyen HD, et al. Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults N Engl J Med, 2004.PMID 15496623
10. [10]Mayosi BM, Ntsekhe M, Bosch J, et al. Prednisolone and Mycobacterium indicus pranii in tuberculous pericarditis N Engl J Med, 2014.PMID 25178809
11. [11]Abdool Karim SS, Naidoo K, Grobler A, et al. Timing of initiation of antiretroviral drugs during tuberculosis therapy N Engl J Med, 2010.PMID 20181971
12. [12]Blanc FX, Sok T, Laureillard D, et al. Earlier versus later start of antiretroviral therapy in HIV-infected adults with tuberculosis N Engl J Med, 2011.PMID 22010913
13. [13]Meintjes G, Wilkinson RJ, Morroni C, et al. Randomized placebo-controlled trial of prednisone for paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome AIDS, 2010.PMID 20808204
14. [14]Conradie F, Diacon AH, Ngubane N, et al. Treatment of Highly Drug-Resistant Pulmonary Tuberculosis N Engl J Med, 2020.PMID 32130813
15. [15]Conradie F, Bagdasaryan TR, Borisov S, et al. Bedaquiline-Pretomanid-Linezolid Regimens for Drug-Resistant Tuberculosis N Engl J Med, 2022.PMID 36053506
16. [16]Nyang'wa BT, Berry C, Kazounis E, et al. A 24-Week, All-Oral Regimen for Rifampin-Resistant Tuberculosis N Engl J Med, 2022.PMID 36546625
17. [17]Nunn AJ, Phillips PPJ, Meredith SK, et al. A Trial of a Shorter Regimen for Rifampin-Resistant Tuberculosis N Engl J Med, 2019.PMID 30865791
18. [18]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
19. [19]Abubakar I, Drobniewski F, Southern J, et al. Prognostic value of interferon-γ release assays and tuberculin skin test in predicting the development of active tuberculosis (UK PREDICT TB): a prospective cohort study Lancet Infect Dis, 2018.PMID 30174209
20. [20]Keane J, Gershon S, Wise RP, et al. Tuberculosis associated with infliximab, a tumor necrosis factor alpha-neutralizing agent N Engl J Med, 2001.PMID 11596589
21. [21]Mangtani P, Abubakar I, Ariti C, et al. Protection by BCG vaccine against tuberculosis: a systematic review of randomized controlled trials Clin Infect Dis, 2014.PMID 24336911
22. [22]Török ME, Yen NT, Chau TT, et al. Timing of initiation of antiretroviral therapy in human immunodeficiency virus (HIV)--associated tuberculous meningitis Clin Infect Dis, 2011.PMID 21596680