0521779407-20 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:22
Tuberculosis 1461differential diagnosis
■Pulmonary disease must be differentiated from other bacterial and
fungal causes of pneumonia as well as neoplastic and non-infectious
causes of pulmonary infiltrates
■Extra-pulmonary disease usually insidious and must be distin-
guished from neoplasm and fungal infection
management
■Consider diagnosis in any high risk person with pulmonary infil-
trates, especially in presence of hilar or paratracheal adenopathy
■Hospitalization required if patient unreliable or too ill for self-care;
respiratory isolation in negative pressure private room until active
disease excluded by 3 negative AFB smears of sputum
■All documented or highly probable cases should be reported to pub-
lic health authorities
specific therapy
■Therapy based on sensitivities of organism, but results take weeks
■Because of increasing resistance, empirical therapy includes four
drugs: isoniazid (INH), rifampin (RIF), ethambutol (ETH), and pyraz-
inamide (PZA) 25 mg/kg daily; PZA discontinued after 8 weeks; ETH
discontinued if organism sensitive to INH and RIF; total duration
at least 6 months, or 3 months after cultures negative; fixed combi-
nations of INH and RIF (Rifamate) and INH, RIF and PZA (Rifater)
available to simplify regimen
■If drugs other than INH, RIF and PZA used because of adverse drug
reactions or resistance, longer courses of therapy (9–24 months)
required
■Directly observed therapy highly recommended to improve com-
pliance and decrease development of drug resistance; employs less
frequent administration of drugs (2 or 3 times weekly) at higher doses
■Duration of therapy for extra-pulmonary tuberculosis (especially
osteomyelitis and meningitis) 9–12 months
■Adjunctive corticosteroids used in tuberculous meningitis and peri-
carditis
■Baseline liver function tests obtained before starting INH, RIF or PZA;
visual acuity and test for red-green color discrimination before start-
ing ETH; monitoring of adverse reactions can be done by monthly
symptom checks
follow-up
■Clinical improvement seen within weeks