Tuberculosis in Clinical Practice

"This book is targeted at ensuring frontline clinical staff including seniors, trainees and specialist nurses can easily reference the optimum investigation and management of potential TB cases. This will mirror the annual London Advanced TB course which aims to equip all of the team delivering care to have a working knowledge of the entire spectrum of the real life aspects of TB management ranging from investigation of active TB to latent screening in pre biologic therapy. It includes an update of MDR TB management and also the approaches needed to ensure the entire medico-social spectrum of TB care is addressed." --back cover Contents The Natural History of TB and Latent Infection The Natural History of M.tuberculosis Infection The Pathogen The Mtb Infection Cycle Transmission Primary Mtb Infection and Primary TB Latent Infection and Post-primary TB The Epidemiological Cycle of TB Early Diagnosis of Infectious TB and Outcomes of Active Case Finding LTBI Screening and TB Prevention Summary References Bacillus Calmette–Guérin (BCG) Vaccine History of BCG Vaccine Efficacy of the BCG Vaccine Policy and Delivery of BCG Immunisation in the UK Immunology of BCG BCG Protection Beyond TB Adverse Events due to BCG BCG Vaccine: Revaccination Strategies References Pulmonary, Pleural and Mediastinal TB: Clinical Aspects and Diagnosis Pulmonary Tuberculosis Clinical Presentation of Pulmonary TB Diagnostic Approach Imaging: Chest Radiographs and CT Scans Sputum Induced Sputum Bronchoscopy and Bronchoalveolar Lavage (BAL) Paediatric Specimens Other Diagnostic Techniques and Biomarkers for Pulmonary TB Pleural TB Clinical Presentation of Pleural TB Diagnostic Approach Imaging Sputum in Pleural TB Pleural Fluid Pleural Tissue Closed Pleural Biopsies Thoracoscopy Intrathoracic Mediastinal TB Clinical Presentation of Mediastinal TB Diagnostic Approach Imaging Endobronchial Ultrasound Guided Transbronchial Needle Aspiration (EBUS-TBNA) References Extra Pulmonary Lymph Node, Abdominal and Pericardial Tuberculosis Extra Pulmonary Lymph Node Tuberculosis Epidemiology Clinical Features Diagnosis Treatment Abdominal Tuberculosis Introduction Clinical Features Peritoneal Tuberculosis Intestinal Tuberculosis Diagnosis Differentiating Intestinal Tuberculosis from Crohn’s Disease Hepatobiliary Tuberculosis Pancreatic Tuberculosis Treatment Pericardial Tuberculosis Introduction Clinical Manifestations and Presentation Diagnosis Treatment References Spinal and Bone Tuberculosis Introduction Incidence Aetiology Spinal Tuberculosis Presentation of Spinal TB Investigation of Spinal TB Differential Diagnosis Presentation of Bone and Joint TB Investigation of Bone and Joint TB Differential Diagnosis Isolation Precautions Non-tuberculous Mycobacterium (NTM) and Multi Drug Resistant TB (MDR TB) Poncet’s Disease Treatment of TB Osteomyelitis Non-pharmacological Treatment Surgical Intervention Outcomes and Long-Term Morbidity References Tuberculosis of the Central Nervous System Epidemiology Pathogenesis Clinical Features Prognosis Diagnosis CSF Examination Diagnostic Imaging Differential Diagnosis Drugs for Treatment of CNS Tuberculosis First Line TB Drugs in the Treatment of TB Meningitis Duration of Treatment for TB Meningitis Adjunctive Therapy for CNS Tuberculosis Additional Supportive Measures Management of Cerebral Tuberculomas HIV Treatment in the Setting of TBM and Tuberculomas Case Vignette Images References Tuberculosis in Renal Disease Introduction What Do We Mean by CKD? Incidence & Prevalence of LTBI & active TB in CKD Reasons for Susceptibility to Infection and Disease Screening Tuberculin Skin Test (TST) Interferon Gamma Release Assays (IGRA) When and How to Screen? Presentation of Active TB Diagnosis of Active TB Management of LTBI Chemoprophylaxis Management of Active TB Special Considerations when Treating TB in CKD Patients Haemodialysis Peritoneal Dialysis Post-Transplant Summary References Tuberculosis in Children and Adolescents Introduction Diagnosis Household Contacts Children Presenting with Symptoms or Abnormal Investigations Radiology Chest Radiology Computed Tomography (CT) Other Radiology Microbiology Specimen Collection Laboratory Tests Histology Immunological Tests Clinical Diagnosis Novel Tests Treatment Treatment Regimens Adverse Effects and Monitoring Drug Interactions Follow up Adherence Future of Treatment Central Nervous System Disease HIV Co-infection Decision-Making around Tuberculosis Infection Treatment Immune-Based Tests Management of TB Infection Other Issues Infection Control Impact on School and Education Child Protection Conclusions References HIV and TB Introduction Epidemiology Risk Factors for Tuberculosis in HIV Infection Clinical Features and Diagnosis of TB in HIV Co-infection Diagnosis of Pulmonary TB in HIV Molecular Testing in Pulmonary TB Diagnosis of Extrapulmonary TB in HIV Pleural TB Central Nervous System TB Disseminated TB Treatment of active TB/HIV Co-infection Timing of ART Initiation Choice of ART Initiation in HIV/TB Co-infection Types of ART Drug-Drug Interactions in HIV/TB Co-infection Choice of ART Regimen in HIV/TB Co-infection Patients on Established ART Choice of TB Treatment in HIV/TB Co-infection TB IRIS Clinical Features and Diagnosis of TB IRIS Outcomes and Treatment of TB IRIS Diagnosis and Treatment of Latent TB Infection in HIV Drug Resistant TB in HIV References Radiology of Tuberculosis Introduction Imaging Tuberculosis: The Modalities Imaging Considerations in Pulmonary and Abdominal Tuberculosis Radiology of Pulmonary Parenchymal, Pleural and Nodal Tuberculosis (See Tables 1, 2, and 3) Intra-thoracic Lymph Nodal Tuberculosis (ITLNTB) Parenchymal TB Pleural TB Miliary TB Non-tuberculous Mycobacteria TB in the Immunocompromised Host & TB-IRIS Latent TB and Radiological Markers of Disease Activity (Table 2) Cardiac TB Role of Interventional Radiology in Management of TB Abdominal and Pelvic TB Peritoneal TB Gastrointestinal Tract TB Hepatic and Splenic TB Adrenal TB Genitourinary TB Bone and Joint TB Extra-spinal Bone and Joint TB Imaging of Intracranial Tuberculosis Infection (See Tables 4 and 5) General Imaging Considerations Intracranial Pathology Meningeal Disease Parenchymal Disease Complications Spinal Tuberculosis General Imaging Considerations Spinal Pathology Head & Neck Tuberculosis Infection CNS Tuberculosis in Immunodeficiency Role of F18 -fluorodeoxyglucose (F18-FDG) PET-CT in Tuberculosis (Table 6) References Laboratory Diagnostic Techniques Introduction Specimen Collection Microscopy Culture and Susceptibility Methods Molecular Diagnostics and Whole Genome Sequencing References Whole Genome Sequencing: Applications and Cluster Investigations Introduction Identification of TB Strains and Predicting Drug Susceptibility Background The Advancement with WGS Identifying Genetically Similar Isolates Background Typing Before WGS Patient Benefits from WGS Relatedness Public Health Benefits from WGS Relatedness New Clusters/Incidents Established Clusters/Outbreaks Transmission and Evolution of TB Laboratory Errors Conclusion References The Tuberculin Skin Test and the IFN-γ Release Assays Introduction LTBI Definition and Diagnosis TST New Version of TST IGRA QuantiFERON Test: Interpretation of the QFT Values Within the Uncertainty Zone (IFN-γ Values: 0.2–0.7 IU/ml) Accuracy Indeterminate or Borderline Results in IGRAs Interpretation of Serial QFT Results Serial IFN-γ Assays New Experimental Tests LTBI: Who Does Need to Be Screened? Recent contacts Children Migrants HIV-Infected Individuals Subjects Exposed to Biological Therapy Chronic Kidney Disease, Organ Transplantation, Stem Cell Transplant, Diabetes Health Care Workers References TB Treatment and Complications Introduction Drug Regimens: Active Disease Standard Treatment Regimen Duration of Continuation Phase Modification of Drug Regimens, According to Drug Sensitivity Adjunctive Treatments Drug Regimens: Latent TB Infection (LTBI) Drug Doses and Routes Practical Considerations Drug Interactions Monitoring During Treatment Baseline Assessment Ongoing Monitoring Management of Complications GI Symptoms (Nausea, Vomiting, Poor Appetite, Abdominal Pain) Rashes Arthralgias Peripheral Neuropathy Neurotoxicity Drug Induced Liver Injury (DILI) Special Groups on First Line Regimen Pregnancy Renal Failure Liver Disease Elderly Alternative Drug Regimens Management of Treatment Interruptions Monitoring of Treatment Response Further Reading Multi-drug Resistant Tuberculosis Management Introduction, Background and Epidemiology Diagnosing a Case of Drug Resistant Tuberculosis Management of DR-TB Conclusion References Therapeutic Drug Monitoring in Tuberculosis Introduction When Should TDM Be Performed? Interpretation of TDM Data The Role of TDM on TB Treatment Alternative Drug Monitoring Methods Specific Drug Information Isoniazid Rifampicin Rifabutin Pyrazinamide Ethambutol Fluoroquinolones Bedaquiline Linezolid Clofazimine Cycloserine/Terizidone Delamanid Aminoglycosides Ethionamide/Prothionamide p-Aminosalicylic Acid Conclusion/Summary References Anti-tumour Necrosis Alpha Factor Treatment, Immunosuppression and Chemotherapy Prophylaxis Introduction Individuals at Increased Risk of Tuberculosis Reactivation Contacts of Patients with Active Tuberculosis New Entrant Screening Patients Receiving Biologic Drug Treatment Including Anti-TNFα Agents Other Medical Conditions that Increase TB Reactivation Risk Risk Assessment for Latent Tuberculosis Immunological Testing; Interferon Gamma Release Assays and Tuberculin Skin Tests Clinical Risk Assessment for Tuberculosis Exposure Treatment of Latent Tuberculosis Adverse Reactions to LTBI Treatment and Hepatotoxicity Timing of Starting Immunosuppression and Biologics Treatment Biologic Treatment with Active TB Disease Adherence and Treatment Support for Patients Taking Latent TB Treatment Further Reading Contact Investigation Introduction Decision to Initiate Contact Investigation Assessing the Index Case Estimate the Degree of Infectivity Infectious Period Proximity Susceptibility of Contacts Source Case Investigation Challenges Undertaking a Contact Investigation Interview Compile Information Schedule a Contact Investigation Focused Meeting Establishing a Rapport Framework for Identifying Contacts Prioritising Contacts Recommendations and Arrangements to Test Contacts Analyse Attendance and Results Consider Whether to Expand Special Circumstances Multidrug Resistant-TB (MDR-TB) and Extensive Drug Resistant-TB (XDR-TB) Air Travel Contact Investigation Following Contact with Bovine TB and Animals/Pets Infected with TB Congregate Settings Homelessness Social Network Analysis and Whole Genome Sequencing Conclusion References Approaches to New Entrant Screening and Occupational Health Screening Background Latent TB Screening What Is LTBI? Choice of the LTBI Test Choice of LTBI Management Choice of Eligible Population Programmatic Issues and Pathway Support Screening for Active TB Population Screened Setting Screening Test Occupational Health References Incident Management and Mass Contact Screening Introduction Risk Assessment for Contact Investigation Clinical Features of the Index Case Susceptibility of Contacts Duration and Proximity of Contact Environmental Factors Duration on Infectiousness Categorising Contacts Timing of Contact Tracing Assessment of Contacts Screening Tests Children Under 5 Years Pregnancy Chest X-ray Contact Investigation of MDR TB Cases Contacts Who Decline Investigations or Treatment Contact Investigations in Special Settings Educational Settings Prisons and Detention Centres Exposure on an Aircraft TB Clusters and Outbreaks Practical Aspects of Contact Investigation References