MODULE 2: UNIT 2.

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CLINICAL DIAGNOSIS OF TB

1
 Unit objectives

At the end of this unit participants will be able to:

• Appreciate how to make a clinical diagnosis of TB and EPTB

• Manage clinically diagnosed TB and EPTB patients

2
 Brief Introduction
60%
56% 56%
• The WHO recommends 85% of notified 54% 55%
TB cases to be bacteriologically 50%
confirmed (BC) TB cases while 15%
40% 40% 40%
clinically diagnosed (CD). 40%
39%

30%
• Almost 45% of notified TB patients
nationally, are clinically diagnosed 20%

(PCD, EPTB and Pediatric TB).

10%
6% 6% 5% 4%
• There is low capacity among health 0%
Apr to Jun 2020 Jul to Sep 2020 Oct to Dec Jan to Mar
workers to make a clinical diagnosis of % New and relapse P-BC TB cases registered 2020 2021
% of P-CD TB cases registered

TB and this affects quality of TB % of new and relapse EP TB cases registered

diagnosis 3
 Clinically Diagnosed (CD) TB

• A CD case is one who does not fulfil the criteria for bacteriological
confirmation
• But has been diagnosed with active TB by a clinician or other medical
practitioner who has decided to give the patient a full course of TB
treatment.
• This definition includes cases diagnosed on the basis of X-ray
abnormalities or suggestive histology, TB LAM and EPTB cases without
laboratory confirmation.
• CD cases found to be bacteriologically positive before or during Rx
should be re-classified as BC (Bacteriologically confirmed)
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 Steps to carrying a clinical TB diagnosis

• Identify TB signs and symptoms

• Make a physical examination

• Investigate the patient

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Clinical features - Pulmonary TB Adult patient

• Slow onset and chronic course

• Chest symptoms
• Cough ≥ 2 weeks
• Blood stained sputum (sometimes)
• Chest pain
• Evening fevers
• Excessive night sweats
• Noticeable weight loss
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 Clinical features - Pulmonary TB pediatric patient

Depends on age and organ affected

In new born TB presents with following:
• History of maternal TB or HIV infection.
• History of un-resolving pneumonia or contact with an index TB case
• Non-specific symptoms that may include any of the following
• Poor feeding
• Lethargy
• Low birth weight
• Poor weight gain
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 In children aged less than 5 years, with Pulmonary TB

The commonly present with following symptoms

• Persistent Cough for ≥ 2 weeks
• Persistent Fever for ≥ 2 weeks
• Poor weight gain for ≥ 1 month
• Painless swellings in the neck, armpit, or groin (lymph nodes)
• History of a close contact with a PTB case.
• Reduced physical activity

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 In children aged less than 5 years, with Extra-
Pulmonary TB

Commonly present with following symptoms

• Cough of any duration if HIV infected
• Non painful swelling in the neck, armpit, or groin with or
without discharging sinus (TB adenitis)
• Irritability/abnormal behavior, lethargic/reduced level of
consciousness, convulsions, neck stiffness, bulging fontanelle,
Headache, vomiting (without diarrhea) (TB meningitis)
• Non-specific symptoms such as lethargy, fever, wasting (Miliary
TB)
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 Presentation of pulmonary TB in children aged ≥ 5 years

The clinical presentation in this age group is similar to that of adults;

• Persistent cough for ≥ 2 weeks or more
• Cough of any duration in HIV infected children
• Poor weight gain or Weight loss
• Excessive night sweats
• Coughing out blood
• Non painful swelling in the neck, armpit, or groin
• History of a close or household contact with an individual who has PTB.
• Chest pain
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 Presentation of extra-pulmonary TB in children aged ≥ 5 years

Present with any of above symptoms

• Abdominal swelling, abdominal masses (Abdominal TB)
• Deformity of the spine, lower limb weakness, paralysis,
inability to walk (B Spine)
• Painless swelling of end of long bones with difficulty in
movement (Bone and joint TB)
• Difficulty in breathing, easy fatigability, palpitations, chest pain
(Pericardial TB)

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 PCD - Clinically Diagnosed TB

• 10-20% of TB cases have no symptoms at the time of diagnosis

• 42% of TB patients are HIV positive
• History of contact with: a known TB case, patient with chronic
cough or patient who died of cough of unknown etiology
• Note: Use ICF guide to screen TB patients (Refer to Module 2,
unit 2.1 on TB screening)

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 TB screening and diagnosis
algorithm

• Step 1: Screen for TB at every visit: Screen for cough, haemoptysis,

weight loss, fever, night sweats or chest pain. Ask about HIV status.
Conduct health education on TB, TB/HIV co-infection and other co-
morbidities
• Step 2: Separate – Fast track, send for a detailed history, examine and
send to lab for X-pert or another available TB test. Urine LAM test for
all hospitalised HIV clients. In presumptive TB patients with signs of E-
PTB such as lymph nodes, meningitis, TB spine, refer to an experienced
clinician
• Step 3: Evaluate and decide to treat as TB or not
 PTP with a positive TB lab test – treat as bacteriologically confirmed TB
 Presumptive TB patients who have a negative TB test should be re-evaluated
in 2 weeks for TB. If still symptomatic repeat TB test. If negative refer for
CXR. If CXR is suggestive of TB, register as CD-TB and initiate TB treatment.
• Step 4: Prescribe the appropriate regimen and link to treatment unit
• Step 5: Recording and reporting – register, update records and report
appropriately
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 Clinical diagnosis of Tuberculosis in children

• Because children mainly have paucibacillary disease (few TB bacteria in

their sputum), majority will have negative laboratory tests for TB and
will therefore be diagnosed clinically.
• Furthermore, obtaining a sputum sample in children is challenging.
Therefore making a clinical diagnosis of TB in children and taking a
decision to initiate TB treatment involves putting together findings
obtained from history, examination, and investigations.
• The algorithm below provides guidance to health workers to confidently
diagnose TB in children with presumptive TB that have a negative
laboratory test for TB or those in whom a sample has not been
obtained.
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Note: Use ICF guide
to screen TB patients
(Refer to Module 2,
unit 2.2 on TB
screening)

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 How to make a clinical diagnosis of TB in children (children with a negative
laboratory result or children without a sputum sample)
• Does the HIV NEGATIVE CHILD HAVE 2 OR MORE of the following?
OR
• Does the HIV POSITIVE CHILD HAVE 1 OR MORE of the following
a) 2 or more symptoms suggestive of TB (Persistent cough for 2 weeks or more, Persistent fever for 2
weeks or more, Poor weight gain in the last one month or more )
b) Positive history of contact with a PTB case
c) Any physical signs suggestive of TB (Severe malnutrition, Enlarged lymph nodes around the neck or the
arm pit (TB adenitis), Acute pneumonia not responding to a complete course of appropriate broad
spectrum antibiotics, Recurrent pneumonias (defined as at-least 2 episodes of pneumonia in a year
with at-least 1 month of clinical recovery between episodes), Persistent wheeze not responding to
bronchodilators (usually asymmetrical),Presence of a swelling on the back (Gibbus),Signs of meningitis
in a child with symptoms suggestive of TB)
d) CXR suggestive of PTB (Miliary picture, Hilar adenopathy, Cavitation)

If Yes to the questions above, start TB treatment and If No, Give appropriate treatment according to IMCI
refer to consolidated ART guidelines for TB/HIV co- guidelines and re-assess after
infected children 1 – 2 weeks.
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 Extra-Pulmonary TB (EPTB) forms occur in any tissue of the body

• Skin and soft tissue • Intra abdominal structures

• Kidneys
• Lymph nodes • Peritoneum
• Bones and joints • Adrenal glands
• Lymph nodes
• Middle ear • Central nervous system
• Tuberculoma
• Skin
• Meningitis
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 Clinical features: EPTB in adults

Depends on site/organ affected

• Signs and symptoms are normal in mild–moderate disease
• Physical examination helps to identify extra pulmonary sites of
involvement.
• TB lymphadenitis: lymph node swelling, +/- matted, +/- sinuses.
• TB Arthritis: Joint swelling, +-effusion, pain, tenderness
• TB Spine: bone tenderness, Gibbus - acute angulation of spine with or
without neurological damage
• TB meningitis: Apathy, headache, altered levels of consciousness, stiff
neck, convulsions
• Abdominal TB: Abdominal pain/swellings 18
 EPTB in adults
• TB lymphadenitis: lymph
node swelling, +/- matted,
+/- sinuses.
• TB Skin : Chronic ulcers
• TB Otitis media
• present with chronic
suppurative otitis media
Lymphadenitis in the
left posterior
triangle of the neck.

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 Clinical features: on examination

• Pleural TB: Chest rales, rhonchi; absent breath sounds and

dullness to percussion if pleural fluid is present

• Miliary TB: Extensive TB dissemination

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 Meningitis – diagnosis usually made on clinical grounds

Clinical CSF
• Acute or sub-acute
• Cell count 50-500 (50%
• Apathy, head ache, altered levels lymphocytes)
of consciousness, stiff neck,
convulsions, positive kerning's sign • High protein ++
• Prognosis related to severity of • Low glucose
disease at onset of treatment
• Commonly delay between • PCR/culture often
presentation and diagnosis important
• Common in children
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TB Spine

Gibbus (acute angulation of spine

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 What samples? Depends on clinical scenario

• Chest
• Sputum – if productive
• Induced sputum
• Bronchoscopic alveolar lavage (BAL)
• Pleural biopsy
• Pleural fluid
• Other
• E.g. Lymph node, aspiration of abscess, mesenteric biopsy, stool, bone
marrow etc.

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 Diagnosis -Investigate ALL Presumptive PTB cases by:

• Sputum examination (ZN or FM) Or

• GeneXpert (depending on availability of

machine on site or not)

• Other tests: Culture and Drug

Susceptibility Testing

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 Diagnosis: Extra pulmonary TB

• Obtain sample from site (e.g. pleural

fluid, CSF, Lymph node aspirate)

• Submit for analysis

• (ZN, FM, Xpert, Culture)

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 Chest X-ray findings in active TB
• Consolidation:
• Result of replacement of air in the
alveoli by fluid (transudate, pus,
blood), cells or other substances.
• TB is one of the causes of
consolidation but bacterial
pneumonia is a more common
cause.
• The disease usually starts within
the alveoli and spreads.
Consolidation right lung
Thursday, July 11, 2024
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 Consolidation

Homogeneous opacity similar to lobar Extensive consolidation in the

pneumonia caused by bacteria left lung.

Thursday, July 11, 2024

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 Nodules

• Nodules: Small round

opacities of different sizes
(1mm - 30 mm).
• Mass: larger than 30 mm.
• May be single or multiple,
localized or widespread
• May have calcification
Thursday, July 11, 2024 Nodules 28
 Miliary TB
• Usually seen in infants, the
immunocompromised & the
elderly.
• Presence of 1-3 mm nodules,
both sharply and poorly defined,
diffusely spread in random
distribution in both lungs.

Thursday, July 11, 2024

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 Cavities
• Abnormal lung spaces with a
definable wall, filled with air or
fluid, or both.
• Caused by tissue necrosis
(inflammatory)
• May be single or multiple.

Thursday, July 11, 2024

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 Pleural effusion

• Seen as homogeneous
opacity (without air-
bronchogram) obscuring
costophrenic angle, and
with a meniscus along
the chest wall.

Thursday, July 11, 2024

Right pleural effusion
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 Lymph node enlargement/
lymphadenopathy

• More common in children

• Typically unilateral, involving
the hilum and paratracheal
region.
• Bilateral in some cases.
• Can be the sole radiographic
• Bilateral hilar lymph node enlargement
finding especially in children. • Right mediastinal enlargement

Thursday, July 11, 2024

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 X-raySetset
2
1

Normal x-ray TB AFB + Healed TB after treatment

AFB négative

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 X-ray set 2

Infiltrate, AFB +/- Cavities AFB + Milliary AFB -

© OFCP © OFCP

TB AFB+ + TB adénopathies HIV - AFB - Péricarditis TB AFB -

Pulmonary TB typically affects the upper zones of the lung 34
• M 42y old X-ray set 3
smoker Cases
• Blood in
sputum Set 1
• Opacity right
lung
• AFB negative
• “X-pert TB
Negative”
• Treated for TB
for 8 months
with no It is a bronchial cancer Normal x-ray
improvement
Consider bronchoscopy in case of heavy smoker with Smear/X-pert negative TB

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 Forms of EPTB commonly seen in HIV-associated
TB and their preferred diagnostic work up

Site Diagnostic approach

Lymph a. Lymph node aspirate- smear, X-pert & culture (depends on volume
node obtained)
b. Lymph node biopsy- histology (can be crushed for smear, culture and
Xpert)
Pleura a. CXR to confirm presence of effusion
b. Pleural fluid tap and analysis (TB is suggested if it is lymphocytic
exudative in patients less than 45 years)
c. Pleural biopsy histology (can be crushed for smear, culture and X-pert)
Abdomen a. Abdominal ultrasound scan- lymph nodes, nodules in spleen, ascites
b. Ascitic fluid tap and analysis (TB is suggested if it is lymphocytic
exudative)
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 Forms of EPTB commonly seen in HIV-associated
TB and their preferred diagnostic work up

Site Diagnostic approach

Pericardium a. ECG- widespread T-wave changes and low voltage QRS
complex if effusion is big
b. Echocardiography- confirm presence of pericardial fluid
c. Pericardial fluid tap and analysis (TB is suggested if it is
lymphocytic exudative)
Miliary TB a. CXR
b. TB blood culture
Meningitis a. Lumbar puncture and cerebral spiral fluid analysis (TB is
suggested if it is lymphocytic exudative)

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 Criteria for the diagnosis of Clinically Diagnosed TB

• At least a biological specimen negative by smear microscopy, culture or

WHO-approved rapid diagnostics (WRD) such as X-pert MTB/RIF)
• And Chest radiography findings consistent with TB and ‘classic’ clinical
findings
• With any one of the following:
• Positive LAM test in an HIV patient
• With a CD4 cell count ≤ 200 cells/ul
• Who is seriously ill regardless of CD4 count/unknown CD4 count
• Lack of response to a trial of broad-spectrum antibiotics
• Clinical decision has been made to treat as TB.
• EPTB case with no bacteriological confirmation
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 Conclusion

• PCD and EPTB are challenging forms to diagnose for the clinician

• Where necessary, there is need for microbiology before starting

treatment – more rapid lab tests –Xpert

• Need for multidisciplinary approach to diagnosis and management

and control

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 References

1. Manual of the National Tuberculosis and Leprosy program, Uganda.

2nd Edition 2010

2. WHO Guidelines for treatment of drug-susceptible tuberculosis and

patient care, 2017 UPDATE

3. Definitions and reporting framework for tuberculosis – 2013

revision (updated December 2014)

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