Emergency Medicine

156 Infectious Disease and Foreign Travel Emergencies

TUBERCULOSIS

2 Pulmonary tuberculosis has a significant risk of secondary transmission,

although the risk to staff and other patients in the ED is small.

3 Request an acid-fast stain for Mycobacteria in the following clinical settings,

even though their differential diagnosis is wide-ranging and includes malig-

nancy:

(i) Family history of tuberculosis.

(ii) Previous migration from overseas, particularly Africa, Asia and

southern Europe.

(iii) Fever and cough in a patient with HIV/AIDS, or risk behaviour.

(iv) Fever, productive cough and haemoptysis of unknown cause,

particularly if homeless or indigenous.

(v) Fever, chronic cough, weight loss and night sweats.

4 Perform a chest X-ray, although the appearances are not diagnostic.

(i) Radiographic presentations include apical shadowing, hilar

lymphadenopathy and apparent bronchial consolidation.

5 Send blood and sputum for microscopy with Ziehl–Neelsen staining, culture

and polymerase chain reaction (PCR) assay for M. tuberculosis.

(i) An acid-fast smear is rapid but less sensitive than culture,

although culture may take several weeks to produce a definitive

result.

(ii) A negative sputum smear does not rule out pulmonary

tuberculosis, and a positive smear does not confirm M.

tuberculosis, as atypical mycobacteria have the same appearance.

MANAGEMENT

1 Assess any patient with suspected pulmonary tuberculosis in a separate

room (isolat ion room), a nd not i n a st a nd a rd E D re su scit at ion or obser vat ion

cubicle.

2 Pulmonary tuberculosis is rarely severe enough to warrant commencing

immediate antimycobacterial therapy. Rather ensure that you:

(i) Send a series of sputum samples for microscopy and culture.

(ii) Liaise with the on-call infectious disease team or respiratory

medicine team to determine the best treatment course and area

for admission:

(a) standard short-course therapy consists of 2 months treatment

with isoniazid, rifampicin, pyrazinamide and ethambutol

followed by 4 months of isoniazid and rifampicin

(b) starting therapy in the ED is rarely ever indicated.

(iii) Contact the infection control service for a patient with suspected

pulmonary tuberculosis to determine an infection control risk

assessment and to initiate contact tracing.

3 Tuberculosis is a notifiable disease to the relevant public health authority.