EXTRAPULMONARY

TUBERCULOSIS
HamidReza Naderi MD
Department of Infectious Diseases
Mashhad University of Medical Sciences

Extrapulmonary TB, like

pulmonary TB, is the result of
infection with organisms of the
Mycobacterium tuberculosis
complex, which include M.
tuberculosis, Mycobacterium
bovis or Mycobacterium
africanum.
Extrapulmonary TB is defined as
disease involving structures
other than lung parenchyma and
is less common than pulmonary

Extrapulmonary tuberculous
disease occurs as result of
contiguous spread of tubercle
organisms to adjoining
structures, such as pleura or
pericardium, or by
lymphohaematogenous spread
during primary or chronic
infection.
According to the World Health
Organization (WHO) patients
who are sputum smear-positive

Extrapulmonary TB may occur in multiple

sites, with relative frequencies of 42%
for lymphatic, 18% for pleural, 12% for
bone or joint, 6% for genitourinary, 6%
for meningeal, 5% for peritoneal, and
11% for other sites.
The lymph nodes are the most common
site of extrapulmonary TB for both
otherwise normal and HIV-infected
patients.
Involvement of the meninges is more
common in young children than in other
age groups (present in approximately 4%
of children with TB), and the incidence of

 Lymphadenitis
Tuberculous lymphadenitis (scrofula) is
the most common form of
extrapulmonary TB.
The diagnosis of scrofula usually is
made by fine needle aspiration of an
affected lymph node. Although AFB
smears are positive in only
approximately 20% of cases,
granulomatous inflammation may be
obvious.
Overall, fine needle aspiration has a
sensitivity of 77% and specificity of

 Pleural Effusion
Pleural extrapulmonary TB may
occur early after primary infection
with MTB and manifest as pleurisy
with effusion, or more rarely, it
may occur late in postprimary
cavitary disease and arise as an
empyema.
Tuberculous pleural involvement
often causes no symptoms and
resolves spontaneously; however,
in untreated patients, a 65%
relapse rate has been reported,

The diagnosis usually is confirmed

by microscopic and chemical
examination of pleural fluid or
. pleural biopsy
White blood cell counts usually
range from 500 to 2500 cells/mL.
The fluid is an exudate with
protein usually exceeding 50% of
the serum protein, and the
glucose may be normal to low.
Because there are few bacilli, AFB
smears rarely are positive, and
cultures grow MTB for only 25 to

Bone and joint TB remains a disease

of older children and young adults in
developing countries.
Skeletal TB presumably develops from
reactivation of dormant tubercles
originally seeded during stage 2 of the
primary infection or, in the case of
spinal TB, from contiguous spread
from paravertebral lymph nodes to the
vertebrae.
Generally, spinal TB (Pott's disease)
accounts for 50 to 70% of the reported
cases; the hip or knee is involved in 15
to 20% of cases, and the ankle, elbow,
wrists, shoulders, and other bones
and joints account for 15 to 20% of

 Paraspinal cold abscesses develop

in 50% or more of cases, with
occasional formation of sinus tracts.
The so-called skip lesions can easily
be missed in imaging the spine for
Pott's disease.
The main complication of Pott's
disease is spinal cord compression.
Medical management includes
chemotherapy, modified bedrest, and
early ambulation and results in
improvement in approximately 90% of
patients without neurologic
involvement.

 Central Nervous System Disease

Approximately 6% of all cases of
extrapulmonary TB involve the
central nervous system (CNS).
The peak incidence of CNS TB is
in newborn to 4-year-old
children.
Tuberculous meningitis usually
results from the rupture of a
subependymal tubercle into the
subarachnoid space, rather than
from direct hematogenous

 Gastrointestinal Disease
Gastrointestinal TB infection usually
is secondary to hematogenous or
lymphatic spread but also may result
from swallowed bronchial secretions
or direct spread from local sites, such
as lymph nodes or fallopian tubes.
TB may occur in any gastrointestinal
location from the mouth to the anus,
but lesions proximal to the terminal
ileum are rare.
The ileocecal area is the most
common site of involvement,
producing signs and symptoms of

 The most common clinical

manifestations of gastrointestinal TB
are abdominal pain, fever, weight
loss, anorexia, nausea, vomiting, and
diarrhea.
Approximately 12 to 16% of cases
present as an acute abdomen.
The signs and symptoms can be so
similar to those of other diseases that
the diagnosis often is made at
surgery.
The clinical manifestations of anal TB
include fissures, fistulas, and
perirectal abscesses.

 Peritonitis
Tuberculous peritonitis may develop
from local spread of MTB infection
from a tuberculous lymph node,
intestinal focus, or infected fallopian
tube.
In addition, peritonitis can develop
from seeding of the peritoneum in
miliary TB or from the reactivation of
a latent focus.
The patient commonly has pain and
abdominal swelling associated with
fever, anorexia, and weight loss.

Paracentesis is essential for

diagnosis.
The peritoneal fluid is exudative,
with a cell count of 500 to 2000
cells per mL. Lymphocytes
usually predominate, with rare
exceptions early in the process,
when polymorphonuclear
leukocytes may predominate.
AFB smears of the fluid have a
low diagnostic yield, with a
reported sensitivity of no more
than 7%, and the culture result

GENERAL COMMENTS ON TREATMENT

OF EXTRAPULMONARY TUBERCULOSIS

 Extrapulmonary foci usually respond

to treatment more rapidly than does
cavitary pulmonary tuberculosis due
to the lower burden of organisms in
the former.
Therapy with four-drug regimens
(INH, RMP, PZA, and EMB) for 2
months, followed by INH and RMP for
4 months, is advised in most cases
caused by drug-sensitive organisms.
The exceptions include bone and joint
disease (6 to 9 months), and
tuberculous meningitis (9 to 12
months though optimal duration
unknown).

In lymph node TB, the most common

form of extrapulmonary TB, the
affected nodes may enlarge while
patients are receiving appropriate
therapy and even after completion of
therapy without evidence of
.bacteriological relapse
For large lymph nodes that are
fluctuant and appear to be about to
drain spontaneously, aspiration
(traverse through normal skin) or
incision and drainage appears to be
.beneficial