Summary
Definition
History and exam
Key diagnostic factors
- enlarged lymph node
- pleuritic chest pain
- skeletal pain
- urinary symptoms
- abdominal swelling
- abdominal pain
- headache
Other diagnostic factors
- cough
- altered mental status
- neurologic symptoms
- hepatomegaly
- abnormal chest examination
- fever
- weight loss of more than 10% body weight
- anorexia
- malaise
- night sweats
- dyspnea
- asymptomatic
- erythema nodosum and erythema induratum
Risk factors
- exposure to TB
- born in Asia, Latin America, or Africa
- HIV infection
- immunosuppressive medications
- hematologic or head/neck malignancy
- end stage renal disease
- apical fibrosis
- intravenous drug use
- female sex
- Asian, black, and Native American ethnicity
- malnutrition
- alcoholism
- diabetes
- cirrhosis
- high-risk congregate settings
- low socioeconomic status
- very young age
Diagnostic investigations
1st investigations to order
- chest x-ray
- sputum smear
- sputum culture
- CBC (complete blood count)
- lymph node fine-needle aspiration
- pleural fluid analysis
- ascitic fluid analysis
- bone films
- cerebrospinal fluid analysis
- urinalysis
- nucleic acid amplification test (NAAT)
Investigations to consider
- lymph node biopsy
- pleural biopsy
- synovial biopsy
- liver biopsy
- bone marrow biopsy
- blood culture
- peritoneal biopsy
- gastric aspirate
- bronchoscopy
- thoracoscopy
- drug susceptibility testing
- genotyping
- HIV test
- lateral flow urine lipoarabinomannan (LF-LAM) assay
- empiric treatment
- CT scan chest or abdomen
- abdominal ultrasound
- colonoscopy
- pericardial fluid analysis
- pericardial biopsy
- tuberculin skin testing
- interferon-gamma release assays
- TB antigen-based skin tests (TBST)
Treatment algorithm
latent TB infection: nonpregnant
latent TB infection: pregnant
active TB: nonpregnant, HIV-negative
active TB: nonpregnant, HIV-positive
active TB: pregnant
Contributors
Authors
David J. Horne, MD, MPH
Associate Professor
Division of Pulmonary, Critical Care, and Sleep Medicine
University of Washington
Seattle
WA
Disclosures
DJH declares that he has no competing interests.
Masahiro Narita, MD
Professor of Medicine
Division of Pulmonary, Critical Care, and Sleep Medicine
University of Washington
Co-Founder
Firland Northwest TB Center
Seattle
WA
Disclosures
MN declares that he has no competing interests.
Peer reviewers
Carlos Acuña-Villaorduña, MD
Infectious Diseases Physician
Boston University Medical Center
Boston
MA
Disclosures
CA-V declares that he has no competing interests.
James Shepherd, MD, PhD
Infectious Disease Consultant
Yale University School of Medicine
New Haven
CT
Disclosures
JS declares that he has no competing interests.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
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 Jan 15;64(2):e1-33.Full text Abstract
World Health Organization. WHO consolidated guidelines on tuberculosis: module 5: management of tuberculosis in children and adolescents. Sep 2022 [internet publication].Full text
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 Oct 1;63(7):e147-95.Full text Abstract
National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. Mycobacterium tuberculosis infection and disease. May 2024 [internet publication].Full text
Nahid P, Mase SR, Migliori GB, et al. Treatment of drug-resistant tuberculosis. An official ATS/CDC/ERS/IDSA clinical practice guideline. Am J Respir Crit Care Med. 2019 Nov 15;200(10):e93-142.Full text Abstract
World Health Organization. WHO consolidated guidelines on tuberculosis: tuberculosis preventive treatment. Module 1: prevention. 2020 [internet publication].Full text
World Health Organization. WHO consolidated guidelines on tuberculosis, module 4: treatment - drug-resistant tuberculosis treatment, 2022 update. Dec 2022 [internet publication]Full text Abstract
British HIV Association. BHIVA guidelines for the management of tuberculosis in adults living with HIV 2018 (2023 interim update). 2023 [internet publication].Full text
World Health Organization. WHO consolidated guidelines on tuberculosis: module 4: treatment: drug-susceptible tuberculosis treatment. May 2022 [internet publication].Full text
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Lymphoma
- Nontuberculous mycobacteria lymphadenitis
- Sarcoidosis
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