TuberculosisMANAGEMENT

INFECTIOUS DISEASE PRESENTATIONS · 12 SECTIONS

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597 items

☷ Legend

01Approach to the Critical Patient/attcp55

Immediate stabilization and infection control

›Initial priorities

›Airborne isolation

›N95 or higher for staff

›Patient surgical mask during transport

›Negative pressure room when available

›Resuscitation triggers

›Severe respiratory distress

›Escalate to resuscitation bay

›High flow oxygen or noninvasive ventilation if appropriate

›Hemodynamic instability

›IV access x2

›Crystalloid bolus for shock physiology

›Altered mental status

›If concern for TB meningitis, immediate empiric therapy pathway

›Massive hemoptysis pathway

›If hemoptysis threatening airway or ventilation, activate airway team

›If ongoing significant bleeding, interventional radiology for bronchial artery embolization

›If suspected focal source, consider lung isolation strategies with anesthesia support

›Immediate consultations

›Infectious diseases

›High suspicion for active TB

›Immunocompromised host

›Infection prevention and control

›Airborne isolation logistics

›Public health

›Suspected or confirmed active TB reporting

›Time critical high risk syndromes

›TB meningitis

›If suspected, do not delay treatment for imaging or LP when unstable

›Pericardial tamponade from TB pericarditis

›If shock with effusion, bedside ultrasound and urgent drainage pathway

›Disseminated or miliary TB with sepsis

›Broad sepsis evaluation and early antimicrobials including TB regimen when indicated

Key concepts

›High level framework

›Pulmonary TB contagiousness

›Highest risk with cavitary disease and cough

›Lower risk with isolated extrapulmonary TB without airway involvement

›Diagnostic confirmation principles

›NAAT supports rapid detection

›Culture required for full drug susceptibility testing

›Treatment principles

›Multidrug therapy required to prevent resistance

›Directly observed therapy recommended for many patients

Pitfalls

›Common misses

›Normal chest radiograph does not exclude TB

›Early disease

›HIV and other immunosuppression

›Negative smear does not exclude contagious TB

›Paucibacillary disease

›Sampling error

›Steroids without TB coverage can worsen unrecognized TB

›Risk highest in TB meningitis and pericarditis without regimen

›Fluoroquinolone monotherapy can partially treat TB and delay diagnosis

›Masked symptoms

›Resistance selection

02History/hx62

Presentation patterns and transmission risk

›Symptom profile

›Constitutional symptoms

›Fever

›Night sweats

›Weight loss

›Fatigue

›Respiratory symptoms

›Cough duration 2 weeks or longer

›Productive cough

›Hemoptysis

›Dyspnea

›Pleuritic chest pain

›Extrapulmonary symptoms

›Headache and confusion

›Concern for TB meningitis

›Back pain

›Concern for vertebral osteomyelitis

›Lymph node swelling

›Cervical lymphadenitis

›Abdominal pain or ascites

›Peritoneal TB

›Timeline

›Subacute or chronic course

›Recent symptom acceleration

›Exposure and epidemiology

›Close contact with known TB

›Household contact

›Congregate settings

›Birth or residence in high incidence region

›Recent immigration or travel

›Homelessness or shelter exposure

›Incarceration exposure

›Healthcare or laboratory exposure

›Host risk factors

›HIV risk or known HIV

›Low CD4 risk for disseminated TB

›Immunosuppression

›TNF inhibitor therapy

›Solid organ transplant

›Chronic corticosteroids

›Diabetes mellitus

›Chronic kidney disease or dialysis

›Silicosis

›Malnutrition

›Substance use disorder

›Prior TB and treatment history

›Previous active TB treatment

›Completion status

›Drug intolerance

›Documented resistance

›Prior latent TB therapy

›Regimen and adherence

›Previous abnormal TB testing

›TST or IGRA results

›Medication interactions and contraindications

›Antiretroviral therapy regimen

›Rifamycin interaction risk

›Anticoagulation

›Warfarin interaction risk with rifampin

›Pregnancy or breastfeeding

›Baseline liver disease

›Baseline neuropathy risk

03Physical Exam/exam36

Targeted exam and contagiousness clues

›General and vitals

›Fever pattern

›Persistent low grade fever

›High fever with sepsis physiology

›Respiratory rate and work of breathing

›Oxygen saturation

›Weight and cachexia

›Pulmonary

›Crackles

›Apical predominance

›Bronchial breath sounds

›Signs of pleural effusion

›Decreased breath sounds

›Dullness to percussion

›Lymphatic and skin

›Cervical or supraclavicular lymphadenopathy

›Fluctuance suggesting scrofula

›Cutaneous lesions

›Consider disseminated TB in immunocompromised

›Neurologic

›Meningismus

›Focal neurologic deficits

›Altered mental status

›Cardiovascular

›Pericardial rub

›Tamponade signs

›Hypotension

›JVP elevation

›Muffled heart sounds

›Musculoskeletal

›Spine tenderness

›Concern for Pott disease

›Pitfalls on exam

›Normal lung exam does not exclude TB

›Early disease

›HIV related atypical patterns

04Differential Diagnosis/ddx39

Pulmonary and systemic mimics

›Life threatening

›Bacterial pneumonia (ICD-10 J18.9)

›Acute onset

›Lobar consolidation

›Pulmonary embolism (ICD-10 I26.99)

›Pleuritic pain

›Sudden dyspnea

›Lung cancer with hemoptysis (ICD-10 C34.90)

›Weight loss

›Persistent cough

›Massive hemoptysis from bronchiectasis (ICD-10 J47.9)

›Chronic sputum

›Recurrent infections

›Infectious mimics

›Nontuberculous mycobacteria pulmonary disease (SNOMED CT 233604007)

›Structural lung disease risk

›Fungal pneumonia

›Histoplasmosis (ICD-10 B39.9)

›Coccidioidomycosis (ICD-10 B38.9)

›Pneumocystis pneumonia (ICD-10 B59)

›HIV with low CD4

›Marked hypoxia

›Viral respiratory infection (ICD-10 J06.9)

›Shorter course

›Extrapulmonary differentials

›Bacterial meningitis (ICD-10 G00.9)

›Acute severe presentation

›Cryptococcal meningitis (ICD-10 B45.1)

›HIV risk

›Vertebral osteomyelitis non TB (ICD-10 M46.20)

›Bacteremia risk

›Malignancy related lymphadenopathy (ICD-10 C77.9)

›Firm nodes

›TB spectrum codes

›Respiratory tuberculosis (ICD-10 A15.9)

›Miliary tuberculosis (ICD-10 A19.9)

›Tuberculous meningitis (ICD-10 A17.0)

›Tuberculous pleurisy (ICD-10 A15.6)

›Latent tuberculosis infection (ICD-10 Z22.7)

05Laboratory Tests/lt52

Microbiology and baseline safety labs

›Microbiologic confirmation

›Sputum AFB smear

›3 specimens recommended

›Early morning specimens improve yield

›Smear positive suggests infectiousness

›Sputum mycobacterial culture

›Gold standard confirmation

›Drug susceptibility testing basis

›Sputum NAAT for Mycobacterium tuberculosis complex

›Rapid detection

›Rifampin resistance detection if assay includes

›Induced sputum if unable to expectorate

›Airborne precautions during induction

›Bronchoscopy sampling when needed

›BAL for AFB smear and culture

›Post procedure airborne precautions continuation

›Baseline labs for treatment safety

›AST ALT alkaline phosphatase bilirubin

›Baseline hepatotoxicity risk assessment

›Complete blood count

›Baseline anemia or leukopenia

›Creatinine and electrolytes

›Drug dosing adjustment planning

›Pregnancy test when applicable

›Regimen selection

›HIV antigen antibody test

›High co infection prevalence in many settings

›Hepatitis B and C serology when risk present

›Hepatotoxicity risk

›Extrapulmonary fluid and tissue tests

›Pleural fluid studies

›Cell count differential

›Protein and LDH for exudate criteria

›AFB smear and culture

›Adenosine deaminase when available

›CSF studies for meningitis concern

›Cell count differential

›Protein

›Glucose with paired serum glucose

›AFB smear and culture

›NAAT when available

›Lymph node aspirate or biopsy

›AFB smear and culture

›Histopathology granulomas

›Pitfalls and limitations

›IGRA and TST do not distinguish latent from active TB

›Supportive only in active workup

›AFB smear can be negative in active TB

›Paucibacillary disease

›HIV and extrapulmonary disease

›Culture turnaround delay

›Treatment decisions often based on probability

06Diagnostic Tests/dt87

Scoring Systems

›Risk and screening tools

›Symptom based pulmonary TB screen

›Cough 2 weeks or longer

›Fever

›Night sweats

›Weight loss

›HIV associated TB symptom screen

›Current cough

›Fever

›Night sweats

›Weight loss

›Pediatric TB risk assessment

›Close contact with infectious TB

›Failure to thrive or weight loss

›Persistent cough

›Persistent fever

›Pretest probability integration

›High risk exposure plus compatible imaging

›Immunosuppression plus atypical imaging patterns

›Interpretation cautions

›Screening tools support triage

›Not confirmatory

›Require microbiology and imaging correlation

MRI

›MRI indications

›TB meningitis and intracranial tuberculoma

›Higher sensitivity than CT for meningeal enhancement

›Brainstem and posterior fossa assessment

›Spinal TB

›Epidural abscess assessment

›Cord compression evaluation

›Musculoskeletal TB

›Osteomyelitis and septic arthritis characterization

›MRI protocols and pearls

›Brain with contrast

›Basilar meningeal enhancement pattern

›Hydrocephalus assessment

›Spine with contrast

›Vertebral body destruction

›Paraspinal collections

›Contraindications and limitations

›MRI incompatible implants

›Hemodynamic instability limiting transport

›Delay should not defer empiric therapy in high suspicion meningitis

›CT chest

›Indications

›CXR equivocal with high clinical suspicion

›Assessment for cavitation and endobronchial spread

›Typical findings

›Upper lobe cavitary lesions

›Tree in bud nodularity

›Necrotic lymph nodes

›Special patterns

›Miliary nodules in disseminated TB

›Lower lobe involvement in older adults and immunocompromised

›CT brain

›Indications

›Focal deficits

›Concern for mass lesion before lumbar puncture

›Findings

›Hydrocephalus

›Tuberculomas

›CT abdomen pelvis

›Indications

›Suspected peritoneal TB

›Lymphadenopathy evaluation

›Findings

›Ascites

›Peritoneal thickening

›Necrotic lymph nodes

›Guideline style evidence notes

›Airborne isolation for suspected infectious pulmonary TB

›Expert consensus equivalent to Class I recommendation in hospital infection control policies

›NAAT use for rapid diagnosis support

›Equivalent to Class I recommendation in many national guidelines for suspected pulmonary TB

Ultrasound (or US)

›Point of care applications

›Pleural effusion evaluation

›Septations suggesting complicated effusion

›Guidance for thoracentesis

›Pericardial effusion evaluation

›Tamponade physiology support

›Abdominal free fluid and ascites

›Peritoneal TB support when combined with clinical context

›Lymph node assessment

›Necrotic appearing nodes support TB lymphadenitis differential

›Limitations

›Cannot confirm TB etiology

›Requires fluid or tissue microbiology

07Disposition/dispo42

Level of care and public health coordination

›Admit criteria

›Respiratory compromise

›Hypoxia requiring oxygen

›Rapidly progressive disease

›Massive or recurrent hemoptysis

›Airway risk

›Hemodynamic compromise

›Suspected TB meningitis

›Need for IV therapy and monitoring

›Disseminated or miliary TB with systemic illness

›Sepsis physiology

›Significant comorbidity

›HIV with advanced immunosuppression

›End stage kidney disease

›Inability to safely isolate at home

›Congregate living

›Unhoused

›ICU criteria

›Impending or actual respiratory failure

›Shock

›Severe CNS involvement

›Declining mental status

›Seizures

›Discharge with close follow up criteria

›Clinically stable

›No hypoxia

›No hemodynamic instability

›Able to maintain airborne precautions at home

›Separate room

›Mask use when around others

›Reliable follow up arranged

›TB clinic or infectious diseases

›Public health contact tracing initiation

›Transfer criteria

›Need for negative pressure isolation unavailable

›Need for specialty services

›Neurosurgery for hydrocephalus

›Interventional radiology for embolization

›Reporting and coordination

›Suspected or confirmed active TB notification per jurisdiction

›Public health case management

›Contact investigation

08Treatment/t101

Empiric therapy and definitive regimens

›Immediate ED and inpatient actions

›Airborne isolation continuation

›Maintain until noninfectious criteria met per local policy

›Supportive care

›Oxygen to target saturation

›Antipyretics

›Nutrition support planning

›Specialist driven initiation

›Infectious diseases involvement before regimen changes when feasible

›Drug susceptible active TB regimen

›Standard initial phase

›Isoniazid daily

›Adult dose 5 mg/kg

›Maximum 300 mg daily

›Pyridoxine supplementation

›25 to 50 mg daily

›Rifampin daily

›Adult dose 10 mg/kg

›Maximum 600 mg daily

›Pyrazinamide daily

›Adult dose 20 to 25 mg/kg

›Maximum 2000 mg daily

›Ethambutol daily

›Adult dose 15 to 20 mg/kg

›Maximum 1600 mg daily

›Continuation phase

›Isoniazid daily

›Typical duration 4 months

›Rifampin daily

›Typical duration 4 months

›Duration modifiers

›Cavitation on initial imaging plus culture positive at 2 months

›Extend total duration to 9 months in many guideline pathways

›Extrapulmonary TB

›Site specific durations

›Tuberculous meningitis regimen and adjuncts

›Antituberculous therapy

›Isoniazid daily

›Good CSF penetration

›Rifampin daily

›Drug interaction review with ART

›Pyrazinamide daily

›CSF penetration

›Ethambutol daily or substitute per specialist

›Consider high dose rifampin strategies per specialist protocols

›Corticosteroids

›Dexamethasone adjunct

›Typical initial dosing 0.3 to 0.4 mg/kg/day IV with taper per protocol

›Recommendation level

›Class I recommendation in multiple guideline frameworks for TB meningitis adjunct steroids

›Tuberculous pericarditis adjuncts

›Antituberculous therapy standard regimen

›RIPE based regimen

›Corticosteroids selected cases

›Consider when constriction risk high and specialist agrees

›Latent TB infection regimens

›Preferred shorter regimens when feasible

›Isoniazid plus rifapentine weekly

›Typical duration 12 doses

›Directly observed therapy or supported self administration per program

›Rifampin daily

›Typical duration 4 months

›Isoniazid daily

›Typical duration 6 to 9 months

›Baseline evaluation before LTBI therapy

›Exclude active TB symptoms and imaging concern

›LFT assessment in higher risk patients

›Multidrug resistant TB initial considerations

›High suspicion triggers

›Prior TB treatment failure

›Known exposure to MDR TB

›Rifampin resistance on rapid assay

›Actions

›Immediate infectious diseases consultation

›Avoid empiric regimen changes without susceptibility guidance

›Monitoring and adverse effects

›Hepatotoxicity monitoring

›Symptoms of hepatitis

›Nausea

›Abdominal pain

›Dark urine

›Jaundice

›If significant transaminitis with symptoms, stop hepatotoxic drugs and consult

›Ethambutol optic toxicity

›Baseline visual acuity and color vision when possible

›Vision change triggers urgent drug hold and consult

›Isoniazid neuropathy

›Pyridoxine supplementation

›Higher risk in pregnancy, diabetes, alcohol use, malnutrition, HIV

›Rifampin interactions

›Reduced efficacy of many medications

›Oral contraceptives

›Warfarin

›Many antiretrovirals

›Evidence and guideline framing

›Multidrug therapy for active TB

›Class I recommendation in major society guidelines

›Culture and susceptibility testing

›Class I recommendation to guide therapy and detect resistance

›Airborne infection isolation for suspected pulmonary TB

›Expert consensus aligned with Class I infection control standard

09Special Populations/sp42

Pregnancy

›Pregnancy considerations

›Maternal and fetal risk balance

›Untreated active TB higher risk than most first line drugs

›Increased risk of adverse pregnancy outcomes with active TB

›Drug safety

›Isoniazid use acceptable

›Pyridoxine supplementation essential

›Rifampin use acceptable

›Hemorrhage risk consideration and vitamin K planning per obstetrics

›Ethambutol use acceptable

›Pyrazinamide use

›Often used globally

›Local guideline variation

›Avoided drugs

›Streptomycin and other aminoglycosides

›Fetal ototoxicity risk

›Breastfeeding

›First line drugs generally compatible

›Infant monitoring per program

Geriatric

›Older adult considerations

›Atypical presentation

›Less fever

›Less hemoptysis

›Lower lobe disease more common

›Comorbidity and toxicity risk

›Higher hepatotoxicity risk

›Polypharmacy interactions with rifampin

›Renal adjustment considerations

›Ethambutol dosing interval adjustment in renal impairment

›Pyrazinamide dosing interval adjustment in renal impairment

Pediatrics

›Pediatric considerations

›Higher risk of rapid progression after infection

›Infants and young children highest risk

›Diagnostic challenges

›Paucibacillary disease with smear negative common

›Gastric aspirate or induced sputum yield considerations

›Weight based dosing programs

›Use local pediatric TB dosing tables

›Monitor growth and dosing updates

›Severe forms

›TB meningitis risk

›Miliary TB risk

10Background/b38

Epidemiology

›Core epidemiology

›Global burden concentrated in specific regions

›Higher incidence in many low and middle income countries

›High risk populations in higher income settings

›Recent immigrants from high incidence regions

›People experiencing homelessness

›Incarcerated individuals

›Immunocompromised individuals

›Transmission

›Airborne droplet nuclei

›Prolonged indoor exposure increases risk

Pathophysiology

›Disease mechanisms

›Primary infection and immune containment

›Granuloma formation

›Latent infection state possible

›Reactivation disease

›Immunosuppression lowers containment

›Typical apical predilection from higher oxygen tension

›Extrapulmonary dissemination

›Hematogenous spread

›Miliary pattern from widespread seeding

›Cavitation

›Higher organism burden

›Higher contagiousness

Therapeutic Considerations

›Antimicrobial principles

›Resistance prevention

›Multiple active drugs simultaneously

›Adherence support and directly observed therapy

›Drug penetration and site considerations

›CNS disease requires agents with CSF penetration

›Treatment phases

›Intensive phase reduces bacterial burden rapidly

›Continuation phase sterilizes persistent organisms

›Adjunct corticosteroids rationale

›Reduction of inflammatory complications in meningitis and some pericarditis

›Public health rationale

›Treatment reduces transmission risk

›Contact tracing interrupts spread

11Patient Discharge Instructions/pdi29

copy discharge instructions

›Discharge instructions for suspected or confirmed TB

›Infection control at home

›Mask when around others until cleared by TB program

›Stay in a separate room when possible

›Improve ventilation by opening windows when safe

›Avoid visitors and crowded indoor places

›Medication adherence

›Do not miss doses

›Do not stop meds without TB clinician direction

›Take pyridoxine if prescribed with isoniazid

›Expected side effects requiring urgent contact

›Yellow skin or eyes

›Dark urine

›Severe abdominal pain

›Persistent vomiting

›New severe rash

›Vision changes

›Severe weakness or numbness

›Emergency return now

›Trouble breathing

›Chest pain

›Fainting

›Coughing up large amounts of blood

›Severe headache or confusion

›New seizures

›Follow up plan

›TB clinic or infectious diseases appointment date and location

›Public health contact expected for questions and contact tracing

›Avoid work or school until cleared by TB program

12References/r14

Clinical guidelines and key sources

›Guideline sources

›World Health Organization consolidated guidelines on tuberculosis

›Active TB treatment recommendations

›LTBI treatment recommendations

›CDC tuberculosis clinical guidance

›Diagnostic testing and NAAT use

›LTBI regimens

›ATS IDSA CDC clinical practice guidelines for drug susceptible TB

›Standard RIPE regimen and duration

›National and provincial public health TB standards

›Reporting requirements

›Isolation discontinuation criteria

›Pediatric TB guidance

›Weight based dosing and severe TB forms

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.