TUBERCULOSIS

1. What are the clinical manifestations of pulmonary tuberculosis?

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They can be almost anything or nothing (it has been stated that if you know tuberculosis, you know all of medicine), but the most common symptoms and signs are chronic fever; weight loss; night sweats; and cough, sometimes with hemoptysis. Chest radiograph typically shows upper lobe infiltrates, with or without cavitation, and can be misdiagnosed as a neoplastic process. HIV-positive or immunocompromised patients usually have mediastinal adenopathy, pleural effusions, and a miliary pattern.

2. How is the diagnosis of pulmonary tuberculosis made?

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Positive acid-fast bacilli (AFB; “red snappers”) smear in sputum sample; sensitivity improves with bronchoalveolar lavage (BAL) specimens. Culture growth will identify specific organism (i.e., atypicals) as well as drug sensitivity (watch out for multidrug resistance [MDR]).

3. What is the current medical treatment for active tuberculosis?

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Initial therapy consists of a 6-month regimen with isoniazid, rifampin, and pyrazinamide for the first 2 months, and then isoniazid and rifampin for another 4 months. With this schedule, 95% of patients have tuberculosis-negative sputum at the end of therapy. Partial responders should receive therapy for longer than 6 months, and those with MDR-TB may receive ethambutol or streptomycin.

4. What are the indications for surgery in patients with tuberculosis?

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Surgery is indicated for complications of the disease. The most common surgical indication in the United States is MDR-TB with destroyed lung and persistent cavitary disease. This lung tissue is resistant to drug penetration and can also “spill” organsims into healthy lung tissue. Other indications include hemoptysis, exclusion of lung cancer, bronchial stenosis, bronchopleural fistula, middle lobe syndrome, or mycobacterium other than tubercle bacilli (MOTT).

5. What is MOTT, and what is the role of surgery with this disease?

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Atypical mycobacterial infections, nontuberculosis mycobacterial infections, and infection with mycobacteria other than tuberculosis are synonyms. The most common of these organisms is the Mycobacterium avium complex (MAC). Others include M. chelonae and abscesses, M. kansaii, M. fortuitum, and M. xenopi. MAC typically produces fibrocavitary disease of the upper lobes or the middle lobe or lingula of thin, white women. Surgery is indicated for localized disease, and in combination with drug therapy, it results in sputum conversion in ≥ 95% of patients with relapse rates of < 5%. Other indications for surgery are the same as for regular tuberculosis.