Extrapulmonary tuberculosis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 5 Jun 2025

Last updated: 01 Nov 2024

Extrapulmonary tuberculosis (EPTB) is an infectious disease caused by Mycobacterium tuberculosis that occurs in organ systems other than the lungs.

Epidemiological risk factors include birth in high TB-prevalent countries, exposure at place of residence/work in an institutional setting, and homelessness.

Diagnosis may be delayed as a result of non-specific clinical manifestations that progress slowly and the low sensitivity of acid-fast bacilli (AFB) smear on extrapulmonary specimens.

Microbiological proof is the key to diagnosis and treatment, and tissue biopsy is frequently required. Other supportive findings are granulomas and positive AFB stain on pathology, and chest x-ray findings.

Initial therapy is a 4-drug regimen typically consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol; treatment lasts for at least 6 months.

Definition

Tuberculosis (TB) is caused by Mycobacterium tuberculosis. In many cases, M tuberculosis infection becomes latent before progression to active TB disease. Patients who are infected but who have no clinical, bacteriological, or radiographic evidence of active TB are said to have latent TB infection. When there is progression from latent infection to active disease, it most commonly involves the lungs and is communicable in this form, but it may affect almost any organ system, including the lymph nodes, central nervous system, bones/joints, genitourinary tract, abdomen (intra-abdominal organs, peritoneum), and pericardium. When TB occurs in organ systems other than the lungs, it is referred to as extrapulmonary TB (EPTB).

History and exam

Key diagnostic factors

presence of risk factors
enlarged lymph node
pleuritic chest pain
skeletal pain
urinary symptoms
abdominal swelling
abdominal pain
headache

Full details

Other diagnostic factors

cough
altered mental status
neurological symptoms
hepatomegaly
abnormal chest examination
fever
weight loss of more than 10% body weight
anorexia
malaise
night sweats
dyspnoea
asymptomatic
erythema nodosum and erythema induratum

Full details

Risk factors

exposure to TB
born in Asia, Latin America, or Africa
HIV infection
immunosuppressive medicines
haematological 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

Full details

Diagnostic investigations

1st investigations to order

chest x-ray
sputum smear
sputum culture
FBC (full blood count)
lymph node fine-needle aspiration
pleural fluid analysis
ascitic fluid analysis
bone films
cerebrospinal fluid analysis
urinalysis
nucleic acid amplification test (NAAT)

Full details

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)

Full details

Treatment algorithm

INITIAL

latent TB infection: non-pregnant

latent TB infection: pregnant

ACUTE

active TB: non-pregnant, HIV-negative

active TB: non-pregnant, 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

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

Disclosures

MN declares that he has no competing interests.

Peer reviewers

Carlos Acuña-Villaorduña, MD

Infectious Diseases Physician

Boston University Medical Center

Boston

Disclosures

CA-V declares that he has no competing interests.

James Shepherd, V

Infectious Disease Consultant

Yale University School of Medicine

New Haven

Disclosures

JS declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

World Health Organization. WHO consolidated guidelines on tuberculosis: module 5: management of tuberculosis in children and adolescents. Sep 2022 [internet publication].Full text

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

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

World Health Organization. WHO consolidated guidelines on tuberculosis: tuberculosis preventive treatment. Module 1: prevention. 2020 [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

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

World Health Organization. WHO consolidated guidelines on tuberculosis: module 4: treatment: drug-susceptible tuberculosis treatment. May 2022 [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. British HIV Association guidelines for the management of tuberculosis in adults living with HIV 2018 (2023 interim update). 2023 [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.

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Extrapulmonary tuberculosis

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

latent TB infection: non-pregnant

latent TB infection: pregnant

active TB: non-pregnant, HIV-negative

active TB: non-pregnant, HIV-positive

active TB: pregnant

Contributors

Authors

David J. Horne, MD, MPH

Disclosures

Masahiro Narita, MD

Disclosures

Peer reviewers

Carlos Acuña-Villaorduña, MD

Disclosures

James Shepherd, V

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Videos

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice