tuberculosis



Overview of tuberculosis

Mycobacterium tuberculosis is a chronic infectious disease that can invade many organs of the body, and the most common form of tuberculosis is pulmonary tuberculosis, which can have systemic symptoms such as prolonged low-grade fever, lethargy, night sweats, etc. Symptoms of tuberculosis in different organs are different, and are caused by the infection of Mycobacterium tuberculosis, which is mainly treated with anti-tuberculosis medication, and can be combined with surgical treatment if necessary.

Definition

Tuberculosis is a chronic granulomatous inflammatory disease caused by Mycobacterium tuberculosis and is infectious.

Typical lesions are tuberculous nodule formation with varying degrees of caseous necrosis.

Tuberculosis can occur in all parts of the body, with pulmonary tuberculosis being the most common, accounting for 80% to 90% of cases.

Classification

Tuberculosis is mainly categorized into pulmonary and extrapulmonary tuberculosis.

Pulmonary tuberculosis refers to tuberculosis lesions occurring in the lungs, trachea, bronchi and pleura. It includes primary tuberculosis, hematogenously disseminated tuberculosis, secondary tuberculosis, tracheal and bronchial tuberculosis, and tuberculous pleurisy.

Extrapulmonary tuberculosis refers to tuberculous lesions in organs other than the lungs, such as osteoarticular tuberculosis, tuberculosis of the digestive system, tuberculosis of the genitourinary system, tuberculous meningitis, and tuberculosis of the lymph nodes.

There is also a category of latent tuberculosis infection in which Mycobacterium tuberculosis is present in the body without evidence of clinically active tuberculosis and is not infectious.

Incidence

Global situation

The epidemiologic status of TB worldwide correlates with economic level, with 95% of TB diagnoses and TB-related deaths occurring in developing countries.

With the improvement of prevention, control and medical care, TB incidence and mortality rates are decreasing by about 2% to 3% per year.

HIV and TB co-infection and drug-resistant TB are currently the two major problems threatening global TB prevention and control.

Situation in China

According to the estimation of the World Health Organization, the number of annual incidence of tuberculosis patients in China is about 889,000, accounting for 9% of the global annual incidence of patient cases, second only to India, ranking second in the world.

The mortality rate of tuberculosis in China is 2.6/100,000, ranking 29th among 30 countries with a high burden of tuberculosis.

Multidrug-resistant tuberculosis is a growing problem. The number of new drug-resistant TB patients in China each year accounts for 1/5 of the total number of TB patients in the country, and the high rate of drug resistance is one of the reasons why TB is difficult to control in China.

Causes

Causes

Mycobacterium tuberculosis infection is the root cause of tuberculosis, which is transmitted through the following 3 basic conditions.

Source of infection

People who carry Mycobacterium tuberculosis, mainly patients with open excretory tuberculosis.

Route of transmission

The most common and important route of transmission is via respiratory droplet infection.

It can also be transmitted through the digestive tract (by ingesting bacteria-carrying food, such as bacteria-containing milk), and in a few cases through skin wounds.

Who is susceptible?

People are generally susceptible to TB, and those with the following risk factors are more likely to get TB.

People with diabetes, AIDS, cancer, and chronic wasting disease with weakened immunity.

Malnutrition due to poverty or other illnesses.

Low immunity due to the use of certain drugs, smoking, and heavy alcohol consumption.

Staying in crowded and poorly ventilated places such as crowded living, schools, hospitals, prisons, etc. for long periods of time.

Pathogenesis

Mycobacterium tuberculosis is an intracellular bacterium that does not produce endotoxin or exotoxin. The pathogenesis of tuberculosis is caused by Mycobacterium tuberculosis-induced cellular immunity and type-IV hypersensitivity (allergic reaction), which kills the bacterium and leads to tissue destruction at the same time.

When Mycobacterium tuberculosis multiplies intracellularly, it can cause local inflammation on the one hand, and systemic hematogenous dissemination on the other hand, which becomes the root cause of subsequent extrapulmonary tuberculosis.

It generally takes 30 to 50 days for the organism to develop specific cellular immunity to Mycobacterium tuberculosis, which manifests itself clinically as a positive skin tuberculin test.

The development and outcome of tuberculosis depends on the paradoxical relationship between the body’s resistance and the pathogenicity of Mycobacterium tuberculosis.

In the case of increased body resistance, Mycobacterium tuberculosis is inhibited and killed, and the lesion shifts to healing, and vice versa, to deterioration.

Symptoms

Tuberculosis

Tuberculosis is the main type of tuberculosis.

Systemic symptoms

Fever, mostly prolonged low-grade fever, starting in the late afternoon or evening and dropping to normal the next morning, may be accompanied by tiredness, fatigue, night sweats, or no obvious self-consciousness.

Some patients have unstable body temperature, which rises slightly after light labor and is still difficult to recover even after resting for more than half an hour.

In women, body temperature increases before menstruation and does not return to normal quickly after menstruation.

When the disease progresses rapidly, high fever occurs, and the body temperature reaches 39℃ or more, which is either episodic fever (24-hour fluctuation of temperature <1℃ for several weeks or days) or flaccid fever (24-hour fluctuation of temperature can be >2℃), and there can be chills (fear of cold), and chills seldom occur.

Respiratory symptoms

Cough, sputum

Infiltrative lesions have mild cough, dry cough or only a small amount of mucus sputum.

The amount of sputum increases when there is cavity formation, and the sputum is purulent if there is secondary infection.

In combination with bronchial tuberculosis, the cough worsens and irritating choking may occur, which may be accompanied by limited rales or wheezing.

Hemoptysis

Hemoptysis can occur in patients with tuberculosis at different stages of the disease.

Hemoptysis can also be caused indirectly by pulling of a few healing fibrotic and calcified lesions, resulting in secondary bronchiectasis.

Shortness of breath (tachypnea)

Severe sepsis and hyperthermia may cause shortness of breath.

Shortness of breath also occurs with extensive lung tissue destruction, pleural thickening, and emphysema, and can be complicated by pulmonary heart disease and cardiopulmonary insufficiency in severe cases.

Milquetoast tuberculosis may occasionally be complicated by acute respiratory distress syndrome, which is characterized by severe dyspnea and persistent hypoxemia.

Extrapulmonary tuberculosis

Clinical manifestations include persistent emaciation, night sweats, generalized weakness, anorexia, low-grade fever, etc. Symptoms of tuberculosis in different systems are different, as follows.

Bone and joint tuberculosis

Osteoarticular tuberculosis can occur at any age and is more prevalent in adolescents.

Caseous necrosis type

Apparent caseous necrosis and dead bone formation can be seen, and there may be cysts, sinus tracts and deformities.

The lesion often involves the surrounding soft tissues, causing caseous necrosis and tuberculous granulomatous tissue formation, and the necrotic material forms a tuberculous “abscess”, but there is no redness, swelling, or heat, which is known as a cold abscess (swelling).

The lesions may break through the skin and form long-lasting sinus tracts.

Hyperplasia

Comparatively rare.

There is no obvious caseous necrosis or dead bone formation.

Spinal tuberculosis

It is the most common form of bone tuberculosis, with spinal tuberculosis accounting for 50% of the incidence of bone tuberculosis.

It destroys the intervertebral discs and adjacent cones, causing posterior vertebral deformities, and can also form “cold abscesses” on either side of the spine.

Joint tuberculosis

Tuberculosis of the joints of the hip, knee, ankle and elbow is common.

Secondary to tuberculosis of the bone, it causes ankylosis of the joints and loss of motion.

Intestinal tuberculosis

Most common in adults, rare in children.

Ulcerative

Commonly, Mycobacterium tuberculosis invades the lymphatic tissues of the intestinal wall and forms tuberculous nodules, causing ulcers to form when they break down.

Hyperplasia

Less common, characterized by massive tuberculous granuloma formation and fibrous tissue proliferation in the intestinal wall.

Abdominal mass: common, mostly located in the right lower abdomen, characterized by toughness, greater fixity and pain on pressure.

Abdominal pain and paroxysmal colic may occur, mostly in the right lower abdomen and around the umbilicus, worsening after eating.

Tuberculosis of genitourinary system

Renal tuberculosis

Commonly found in men aged 20 to 40 years old, unilateral and frequent.

The earliest symptom is frequent urination, which is caused by irritation of the bladder by urine containing pus and Mycobacterium tuberculosis after the caseous lesion has penetrated into the renal pelvis.

When bladder lesions occur and tuberculous ulcers of the bladder appear, the frequency of urination is more serious, and symptoms such as urinary urgency and urinary pain may appear.

Hematuria is the first symptom in some patients.

Tuberculosis of the reproductive system

Men may have enlarged and hardened epididymis and testicles, leading to infertility.

Prostate and seminal vesicle tuberculosis has no conscious symptoms, and a few may have perineal discomfort, bloody semen, and painful ejaculation.

Tuberculosis of the female reproductive system may have unexplained menstrual abnormalities and infertility.

Tuberculous meningitis

It is common in adolescents.

Symptoms of central nervous system infection such as headache, projectile vomiting, and impaired consciousness may occur.

It may cause hydrocephalus, with headache and other signs of increased intracranial pressure.

Tuberculosis of lymph nodes

It is common in adolescents.

It is characterized by gradual enlargement of the lymph nodes, which may form large masses.

It may also penetrate the surrounding tissues (skin, trachea, intestines, etc.) to form a fistula.

Consultation

Department of Medicine

Infectious diseases

If you have close contact with a patient with tuberculosis and develop a low-grade fever, cough, sputum, blood in the sputum or hemoptysis, it is recommended that you consult a doctor promptly.

Respiratory Medicine

Low-grade fever, cough, sputum, blood in sputum or hemoptysis, etc., timely consultation is recommended.

Emergency Medicine

For hemoptysis and respiratory distress, it is recommended to go to the Emergency Department immediately.

Preparation

Consultation: registration, preparation of documents, common problems

Tips for seeking medical treatment

Wear a mask and avoid public transportation.

Avoid self-medication before going to the doctor, so as not to influence the doctor’s judgment of the condition. For patients with fever, physical cooling can be done first, such as applying cold compresses to the forehead and wiping hands, feet and armpits with warm water.

Chest X-ray or CT scan is often needed, so avoid wearing clothes made of metal, and inform your doctor if you are pregnant or planning to become pregnant.

Preparation Checklist

Symptom list

Pay particular attention to the time of onset of symptoms, special manifestations, etc.

Is there fever? What is the highest degree? Is there any pattern?

Is there a cough or sputum? Is there blood in the sputum?

Is there frequent sweating at night while sleeping?

Are there any breathing difficulties and chest pains?

Are there symptoms such as weight loss, fatigue, and lack of appetite?

When did these symptoms appear?

Medical History Checklist

Has there been any contact with a person with tuberculosis?

Are there any chronic medical conditions such as diabetes?

Has there been any BCG vaccination?

Checklist

Examination results in the last six months, which can be brought to the doctor’s appointment

Imaging tests: chest X-ray, chest CT scan

Medication List

Medication in the last 3 months, bring along the box or package if available

Anti-tuberculosis drugs: isoniazid, rifampicin, streptomycin, etc.

Glucocorticoids: prednisone, dexamethasone, etc.

Immunosuppressants: cyclophosphamide, methotrexate, etc.

Diagnosis

Diagnosis is based on

Medical history

Diabetes mellitus, immunocompromised disease, or glucocorticoid and immunosuppressant therapy.

Recurrent or prolonged episodes of cough and sputum, or respiratory infections that do not improve after 2 weeks of anti-infective treatment.

Close contact with patients with active tuberculosis.

Clinical manifestations

Symptoms

Blood in sputum or hemoptysis.

Prolonged low-grade fever.

There are allergic manifestations such as joint pain and skin nodular erythema.

There is exudative pleurisy, anal fistula, and prolonged lymph node enlargement.

Signs

Signs of tuberculosis depend on the nature, location, extent and degree of the lesion.

If the lesion is mainly exudative and extensive, or in case of caseous pneumonia, there is turbidity on percussion and bronchial breath sounds and fine wet rales on auscultation.

Secondary tuberculosis occurs in the apical posterior segment of the upper lobes, and the detection of fine moist rales in the interscapular region is more suggestive of the diagnostic value.

When the cavity lesion is superficial and the draining bronchus is patent, bronchial breath sounds or wet rales are heard.

In the presence of large cavities, metallic toned hollow urn sounds may be heard.

In patients with long-term, extensive chronic fibrocavitary tuberculosis, there may be collapse of the affected side of the thorax, displacement of the trachea and mediastinum, turbid percussion, decreased breath sounds, or audible wet rales.

In patients with bronchial tuberculosis, limited dry rales may be heard, which are more pronounced at the end of expiration or cough.

Laboratory tests

Mycobacterium tuberculosis sputum test

The most specific method of confirming the diagnosis of tuberculosis.

Sputum smear antacid staining: microscopic examination is fast and easy, non-tuberculous mycobacteria are a minority in China, antacid bacillus-positive (smear-positive) diagnosis of tuberculosis is basically established.

Bacterial culture: it is also a necessary examination, an important supplement to smear examination, and an important evidence for the diagnosis of active tuberculosis, but it takes a longer time.

The results of sputum smear and culture are indicated by smear (+), smear (-), pe (+), pe (-), or smear-positive, smear-negative, pe-positive, pe-negative.

Tuberculin test

The method promoted in China is the internationally accepted method of intradermal injection of pure protein derivatives of Mycobacterium tuberculosis mycobacterin. The significance of the test results is as follows.

A positive reaction indicates a high probability of tuberculosis infection.

A strong positive reaction indicates the possibility of active tuberculosis.

A negative reaction, especially if the test remains negative at higher concentrations, basically excludes tuberculosis.

False-positive or false-negative tuberculin tests occur in some special cases.

In people vaccinated with BCG, a positive skin test may occur even in the absence of tuberculosis infection and may be considered a false-positive reaction to a tuberculin test.

Because cellular immune responses to Mycobacterium tuberculosis are present in both latent TB infection and active TB, it is not currently possible to differentiate between active TB infection or latent TB infection by virtue of them.

In immunodeficient patients, especially in immunodeficient AIDS patients, there may be an increased false-negative rate due to impaired cellular immunity, with a negative Mycobacterium tuberculosis test despite definite TB infection.

At the same time, there are a few patients without evidence of immunodeficiency who have been shown to have active tuberculosis but have a negative tuberculin test, i.e., “non-reactive,” the mechanism of which is not yet fully understood.

Gamma-interferon release assays (IGRAs)

Determination of the number of cells releasing γ-interferon (IFN-γ) or the level of released γ-interferon in whole blood after stimulation with specific tuberculosis antigen peptides.

It is commonly measured by enzyme-linked immunospot (ELISPOT) technique in China, called T-cell test for tuberculosis infection (T-SPOT.TB).

This is a new generation of immunological diagnostic technique for detecting tuberculosis infection, which has higher sensitivity and specificity than tuberculin test, and is able to better differentiate between true tuberculosis infection and positive reaction caused by BCG vaccination induction.

It can reflect the presence of tuberculosis infection in the body, but cannot distinguish latent tuberculosis infection from active tuberculosis infection.

Molecular biology tests

Polymerase Chain Reaction (PCR)

Amplification of trace amounts of M. tuberculosis DNA in the specimen is possible with higher sensitivity.

False positives can occur due to technical reasons such as contamination of the DNA extraction process, so it cannot be used for evaluating the effectiveness of M. tuberculosis treatment, epidemiologic investigations, etc.

Genetic testing

Detection of TB drug resistance-related genes is performed using probe hybridization or Xpert MTB/RIF real-time PCR.

It can quickly determine whether there is rifampicin resistance or isoniazid resistance.

Imaging

X-ray

X-ray images are very helpful to assist in confirming the diagnosis of tuberculosis, and are also valuable in diagnosing intestinal tuberculosis, urinary system tuberculosis, reproductive system tuberculosis, and osteoarticular tuberculosis.

Primary TB typically presents as a dumbbell-shaped lesion consisting of an intrapulmonary primary, lymphangitis, and enlarged hilar or mediastinal lymph nodes.

Acute hematogenously disseminated TB appears on chest X-ray as scattered, relatively evenly distributed, corn-like shadows of similar density and size in both lung fields.

The X-ray presentation of secondary tuberculosis is complex and variable, or cloudy flocculent flaky, or speckled (flaky) nodular, caseous lesions with high and uneven density, often with translucent areas or cavity formation.

CT examination

CT of the chest is helpful in detecting occult area lesions as well as for the differential diagnosis of isolated nodules.

It is more sensitive than chest X-ray in showing mediastinal/ hilar lymph nodes, intrapulmonary cavities, calcifications, bronchial tuberculosis and bronchiectasis, and is an important reference for diagnostically difficult cases.

The upper, middle and lower lung fields are recorded on each side according to the extent of the lesion (by left and right).

Other imaging tests

Magnetic resonance imaging (MRI), ultrasound and other tests can also assist in the diagnosis.

Other examinations

Fiberoptic endoscopy

Fiberoptic endoscopy can be used to examine diseased organs such as laryngeal tuberculosis, endobronchial tuberculosis, bladder tuberculosis, etc. Pathologic specimens can be obtained to arrive at a definitive diagnosis.

Diagnostic anti-tuberculosis treatment

Diagnostic treatment can be tried for those who have not been diagnosed by existing methods and invasive tests and cannot be excluded from tuberculosis, and whose clinical condition is highly suggestive of active tuberculosis.

The effect of diagnostic anti-tuberculosis treatment can also be used as a basis for clinical diagnosis.

Differential diagnosis

Lung cancer

Similarities

Central lung cancer often has blood in sputum and mass-like shadow near the hilum.

Peripheral lung cancer may have lumpy, lobular or flaky shadows, which should be differentiated from tuberculosis balls.

Lung cancer and tuberculosis may co-exist.

Differences

Lung cancer is most common in men over 40 years of age and is characterized by irritating dry cough, chest pain and progressive wasting.

The combination of sputum tuberculosis, exfoliative cytology, and fiberscopy and biopsy can promptly differentiate it.

There may be satellite foci and calcification around the tuberculosis ball on chest radiographs, while the edge of lung cancer lesions often has cut marks and burrs.

Chest CT is helpful for differentiation.

Pneumonia

Similarities

Tuberculosis mainly presents as exudative lesions or caseous pneumonia, similar to bacterial pneumonia.

Differences

Bacterial pneumonia has a rapid onset, high fever, chills, and chest pain with shortness of breath.

The key is pathogenetic testing.

Radiographic lesions are often confined to one lobe or segment of the lung.

Total blood leukocytes and neutrophils are increased.

Antibiotic therapy is effective.

Lung abscess

Similarities

Chronic fibrotic empyema in combination with infection is easily confused with chronic lung abscess, which is sputum negative for tuberculosis bacilli.

Differences

Lung abscess cavities are more common in the lower lobes of the lungs, the inflammatory infiltrate around the abscess is more severe, and there is often a fluid plane in the cavity.

Tuberculosis cavity occurs in the upper lobe of the lung, the cavity wall is thinner, and there is seldom a liquid plane or only a shallow liquid level inside the cavity.

Lung abscess has a rapid onset, high fever, coughing up a large amount of pus sputum, no tuberculosis bacteria in the sputum, but there are a variety of other bacteria, the total number of blood leukocytes and neutrophils are increased, and antimicrobial therapy is effective.

Sputum bacteriologic tests may assist in the diagnosis.

Bronchiectasis

Similarities

History of chronic cough, coughing up purulent sputum and recurrent hemoptysis, similar to secondary tuberculosis.

Differences

Septic bronchiectasis can be complicated by tuberculosis infection and the possibility of tuberculosis infection should be considered during bacteriologic testing.

CT helps to confirm the diagnosis.

Non-tuberculous mycobacterial lung disease

Similarities

The clinical presentation of nontuberculous mycobacterial lung disease is similar to that of tuberculosis.

Differences

Non-tuberculous mycobacteria refer to all mycobacteria other than Mycobacterium tuberculosis and Mycobacterium leprae, which can cause lesions in various tissues and organs.

Differential diagnosis is based on strain identification and molecular biology.

Other diseases

Typhoid fever, lymphoma, mediastinal lymphoma, etc. have more similarities with tuberculosis, and a negative tuberculin test or gamma-interferon release test can assist in the differentiation.

Colon cancer, Crohn’s disease and other intestinal diseases have similar clinical manifestations to intestinal tuberculosis, and enteroscopy can help in differential diagnosis.

Treatment

Aims and principles of treatment

Depending on the site of infection, individual differences and the symptoms present, doctors will formulate individualized treatment plans.

Chemotherapy with anti-tuberculosis drugs is the main basic treatment for modern tuberculosis (both pulmonary and extra-pulmonary), referred to as chemotherapy.

Other treatments, such as symptomatic treatment and surgery, are adjunctive.

The purpose of chemotherapy is not only to kill bacteria and prevent the emergence of drug resistance, but also to ultimately sterilize the disease and prevent and eliminate recurrence.

Currently, the internationally recognized principles of chemotherapy are: early, combined, appropriate amount, regularity, and full course.

Early stage: early tuberculosis lesions are active lesions, Mycobacterium tuberculosis metabolism is vigorous, growth and reproduction is active, anti-tuberculosis drugs can play the biggest bactericidal effect, can make sputum bacteria quickly turn negative, make infectiousness reduce or disappear, and it is not easy to relapse after stopping drugs.

Combination of drugs: to bring into play the synergistic effect of drugs, enhance the therapeutic effect, delay and reduce the emergence of drug resistance.

Appropriate dosage: the dosage of anti-tuberculosis drugs can achieve bacteriostatic and bactericidal effects, maximize the therapeutic effect, be tolerated by patients, and not produce toxic side effects.

Regularity: This refers to the uninterrupted use of drugs according to the prescribed chemotherapy regimen and completion of the prescribed course of treatment. Regular dosing can reduce drug resistance, allergic reactions and recurrence, and improve efficacy.

Full course: adequate course of treatment is most closely related to the reduction of TB relapse rate, while regular chemotherapy also has an important relationship with relapse. The key to chemotherapy for tuberculosis is to adhere to regular treatment and complete the full course of treatment, otherwise it will increase the failure rate and relapse rate of chemotherapy.

Treatment method

Chemotherapy

Chemotherapy drugs

First-line (class) anti-tuberculosis drugs

Good therapeutic efficacy and low adverse effects.

Includes isoniazid (H), rifampicin (R), streptomycin (S), pyrazinamide (Z), ethambutol (E).

Second-line (class) anti-tuberculosis drugs

Not as effective or safe as first-line drugs and are chosen when first-line drugs are refractory or have intolerable adverse effects.

They include kanamycin (Km), amikacin (Amk), para-aminosalicylic acid (PAS), levofloxacin (Lvx), moxifloxacin (Mfx), etc.

New anti-tuberculosis drugs

Some newer drugs have been found to have anti-tuberculosis activity in clinical use, such as Bedaquiline (Bedaquiline) and Linezolid (Linezolid), which can be used in combination to treat drug-resistant tuberculosis.

Standardized anti-tuberculosis treatment

Primary treatment regimen

Primary treatment patients are defined as those who have not received prior antituberculosis treatment or who have received a course of antituberculosis treatment shorter than 1 month.

The standardized treatment regimen for first-treatment cases is divided into 2 phases, a 2-month intensive phase and a 4-month consolidation phase of treatment.

The standardized regimen is the 2HRZE/4HR (the “2” before the slash represents the 2-month intensive phase, and the “4” after the slash represents the 4-month consolidation phase, and so on) regimen with first-line antituberculosis drugs.

If a patient with new smear-positive TB is still sputum positive at the end of 2 months, the intensive phase should be extended by 1 month, and the chemotherapy regimen remains unchanged.

Retreatment regimen

The standard regimen for retreatment is 2HRZES/6HRE.

The following patients are eligible for the retreatment regimen.

Treatment of drug-resistant tuberculosis

Classification of drug-resistant TB

Mono-resistant: refers to tuberculosis patients infected with Mycobacterium tuberculosis that have been proven in vitro to be resistant to 1 anti-tuberculosis drug.

Multidrug-resistant: refers to patients with tuberculosis infected with Mycobacterium tuberculosis that have been confirmed in vitro to be resistant to more than 1 antituberculosis drug, but does not include cases that are resistant to isoniazid and rifampicin at the same time.

Multidrug-resistant tuberculosis (MDR-TB): tuberculosis that is resistant to both isoniazid and rifampicin.

Extensively drug-resistant tuberculosis (XDR-TB): multidrug-resistant tuberculosis with concomitant resistance to fluoroquinolones and resistance to one of the second-line injectable antituberculosis drugs (kanamycin, amikacin, colistin, and streptomycin).

Principles of chemotherapy regimen development

Anti-tuberculosis drugs are selected individually based on the results of drug sensitivity tests provided by laboratories or regional drug resistance monitoring data, and the patient’s response to and tolerance of previous drugs.

Drug selection and duration of chemotherapy regimen

Generally, the regimen is composed of 1 second-line injectable and 1 fluoroquinolone as the core, with 2 to 3 oral second-line drugs and sensitive first-line drugs, and the final regimen includes at least 4 effective drugs.

The regimen needs to include 1 sensitive injectable agent, and the injectable agent should be applied continuously for at least 3 months in drug-resistant TB, and for at least 6 and 12 months in multidrug-resistant TB and extensively drug-resistant TB, respectively.

The total duration of treatment for mono- and multidrug-resistant TB ranged from 9 to 18 months (3 months for injection and 6 to 15 months for continuation).

Multidrug-resistant TB and extensively drug-resistant TB require 24 months or more (injection period of 6 to 12 months and continuation period of 18 to 24 months).

Preventive treatment for latent TB infection

Preventive treatment is required for people with human immunodeficiency virus (HIV) infection and patients with latent TB who are intended to use biologics, among others, as recommended by their doctors.

Preventive treatment is usually chemotherapy, treatment with isoniazid alone, or treatment with isoniazid in combination with rifampicin or rifapentine.

Surgical treatment

Surgical treatment should be considered when lesions remain uncontrolled after TB chemotherapy.

Surgical treatment may be considered for unilateral tuberculosis, especially for limited lesions, such as injury to one side of the lung and the presence of uncontrollable hemoptysis, which should be selected according to the actual situation.

If the disease is serious, with repeated TB dissemination and extensive lesions, cardiopulmonary function and control of the disseminated foci should be taken into account, and the surgeon will weigh the effectiveness of the surgery, the degree of risk and recovery to make a reasonable choice.

Symptomatic treatment

High fever, toxic symptoms

When acute hematogenous TB and plasmacytoid TB are accompanied by severe symptoms of toxicity, such as high fever, anti-infective treatment with glucocorticoids can help improve the symptoms.

Glucocorticoids need to be applied only in the presence of sufficiently effective anti-tuberculosis medication to promote the absorption of exudate, reduce adhesions, and decrease the risk of long-term complications.

Treatment of hemoptysis

Hemoptysis in tuberculosis can lead to asphyxia, which is life-threatening, and signs of asphyxia should be detected as early as possible and treated promptly.

If the hemoptysis process is suddenly interrupted and there is shortness of breath, cyanosis, agitation and extreme mental stress, the airway should be cleared immediately and life support should be provided.

Pharmacologic therapy can be performed with posterior pituitary hormone.

If medication fails to control the hemoptysis, the doctor may consider fibrinoscopic intervention to stop the hemoptysis, bronchial artery embolization, or surgical resection.

Prognosis

Cure

Patients who are diagnosed early and receive regular anti-tuberculosis treatment are usually cured.

Drug-resistant TB and patients with immunocompromised diseases such as AIDS are more difficult to treat.

Hazards

Tuberculosis

Patients with active tuberculosis who have failed to receive multiple treatments have expanded lesions, and long-term disease activity can lead to damage to one or both lungs, and are susceptible to combining with other lung infections.

Pneumothorax, pyothorax, pulmonary aspergillosis, secondary bronchodilatation and chronic pulmonary heart disease may occur.

Uncontrolled hemoptysis is a common cause of death in patients with TB.

Extrapulmonary tuberculosis

Untreated renal TB can lead to kidney injury, tuberculous cystitis, etc.

Poorly controlled spinal TB may result in paraplegia.

Intestinal TB can cause intestinal obstruction.

Tuberculosis of the joints can cause joint deformities.

Tuberculosis of the reproductive system can easily cause infertility if not treated early and effectively.

Daily life

Daily life

Dietary management

It is advisable to eat high-quality protein foods: meat, eggs, poultry, aquatic products, dairy products, and soy products.

Intake of fresh vegetables, especially dark green leafy vegetables such as spinach and rape, yellow and red vegetables and fruits such as pumpkin, carrot, yellow peach, tomato, grapefruit and watermelon.

Psychological adjustment

Correctly recognizing tuberculosis as a treatable disease, maintaining a happy spirit, stable emotions and a relaxed mood is conducive to the recovery of the disease.

When the patient is depressed or socially isolated, family members can help the patient reduce psychological pressure by praising and encouraging him/her, and gradually help him/her build up confidence.

Daily life management

Pay attention to rest and combine work and rest.

Perform appropriate exercise to enhance immunity.

Patients with pulmonary tuberculosis should quit smoking and drink less alcohol, so as not to cause vasodilatation and aggravate cough and hemoptysis.

Follow-up and review

Take medication according to the doctor’s instruction, on time, according to the dosage, according to the course of treatment, and do not stop the medication on your own.

According to the doctor’s instructions, go to the designated TB hospital for regular checkups to monitor the response to drug treatment.

Prevention

Vaccination

There is no ideal vaccine for TB, and the vaccine now widely used is BCG.

BCG is not sufficient to prevent infection, but it can significantly reduce childhood morbidity and its severity, especially the incidence of severe tuberculosis such as tuberculous meningitis.

The World Health Organization has included BCG in the Expanded Programme on Childhood Immunization.

The rate of TB infection and morbidity is still high in China, and BCG vaccination of newborns at birth plays an important role in prevention and treatment.

Self-protection

Learn about tuberculosis, pay attention to protection in public places, wear masks and wash hands frequently when in contact with patients.

Balanced nutrition, moderate exercise to improve immunity and resistance.