Tuberculosis natural history, complications and prognosis: Difference between revisions
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==Overview== | ==Overview== | ||
[[Tuberculosis]] [[complications]] are [[Lung|pulmonary]] and extra-pulmonary. Moreover, they include severe [[parenchymal]], [[vascular]], [[pleural]] and [[Thoracic cavity|chest wall]] complications. The pulmonary [[complications]] of [[tuberculosis]] include [[pneumonia]], [[pleural effusion]]s, [[bronchiectasis]], [[cavitations]], and [[lymphadenopathy]]. The [[hematogenous]] [[Metastasis|spread]] of infection resuts in [[miliary tuberculosis]]. Without effective medical [[therapy]], 1/3 of patients with active [[tuberculosis]] die within 1 year of [[diagnosis]], and more than 50% die during the first 5 years. However, ''M. [[tuberculosis]]'' [[Infection|infections]] carry a good [[prognosis]] if diagnosed early and treated effectively. | |||
==Natural History== | ==Natural History== | ||
Without | Without proper medical [[therapy]], 1/3 of patients with active [[tuberculosis]] die within 1 year of the diagnosis, and more than 50% during the first 5 years. The 5-year [[mortality rate]] in patients with a positive sputum smear test for ''[[M. tuberculosis]]'' is 65%. Patients who survive the 5 years have [[probability]] of 60% of spontaneous [[Remission (medicine)|remission]]. <ref name="Harrisons">{{cite book | last = Longo | first = Dan | title = Harrison's principles of internal medicine | publisher = McGraw-Hill | location = New York | year = 2012 | isbn = 007174889X }}</ref> | ||
===Primary Pulmonary Tuberculosis=== | ===Primary Pulmonary Tuberculosis=== | ||
Primary tuberculosis | Primary tuberculosis occurs soon after infection with ''[[M. tuberculosis]]'' and differs from clinical illness. In [[endemic]] areas, primary TB is usually observed at a young age. Primary TB may be completely [[asymptomatic]], or iinvolves mild [[symptoms]], such as [[fever]], [[cough]], and [[chest pain]], due to [[pleurisy]]. Some patients can have other symptoms, such as [[erythema nodosum]] in the lower limbs and [[phlyctenulosis]]. The initial lesion ([[Ghon focus]]) often resolves spontaneously, becoming a calcified nodule that may be identified on the [[chest X-Ray]]. [[Pleuritic chest pain]] usually occurs as a result of the [[pleural]] reaction to the underlying [[Ghon focus]].<ref name="Harrisons"></ref> | ||
The progression of primary TB is more rapidly in patients with impaired [[immune system|immunity]] and in children. Progression of primary [[tuberculosis]] results in the enlargement of the [[Ghon focus]]. The disease may have the following manifestations:<ref name="Harrisons"></ref> | |||
*[[Pleural effusion]] - results from invasion of the [[pleural space]] by ''[[M. tuberculosis]]''. | *[[Pleural effusion]] - results from invasion of the [[pleural space]] by ''[[M. tuberculosis]]''. Usually occurs with [[subpleural]] focus of infection. | ||
*[[Cavitation]] - | *[[Cavitation]] - results from progressive enlargement of the [[Ghon focus]] and [[necrosis]] of its center. | ||
*[[Lymphadenopathy]] - the | *[[Lymphadenopathy]] - the [[dissemination]] of ''[[M. tuberculosis]]'' from the [[lungs]] to [[lymph]] leads to the enlargement of [[lymph nodes]] particularly the [[Paratracheal lymph nodes|paratracheal]] and [[hilar|perihilar]] [[Lymph nodes|lymph node]]<nowiki/>s. | ||
*[[Airway obstruction]] - with | *[[Airway obstruction]] - presents with [[shortness of breath]] and [[wheezing]]. Usually occurs as a result of severe enlargement of the [[lymph nodes]], compressing the [[airways]] resulting in distal [[Collapse (medical)|collapse]], partial [[obstruction]], or [[hyperinflation]]. | ||
*[[Pneumonia]] - | *[[Pneumonia]] - results from rupture and leakage of [[lymph node]] content into the [[airways]]. | ||
*[[Bronchiectasis]] - progressive [[pneumonia]] | *[[Bronchiectasis]] - results from progressive [[pneumonia]] that damages a specific segment of the [[lung]], or an entire [[lung|lobe]], leading to [[bronchiectasis]]. | ||
Primary [[infection]] leads to dissemination of ''[[M. tuberculosis]]'' through the [[blood]]. | Primary [[infection]] leads to dissemination of ''[[M. tuberculosis]]'' through the [[blood]]. With impaired [[immune]] response, [[miliary tuberculosis]] may occur resulting in the formation of [[granulomatous]] lesions in several organs.<ref name="Harrisons"></ref> | ||
[[image:Miliary TB.jpg|600px|thumb|center|Chest X-Ray of patient with Miliary Tuberculosis<SMALL><SMALL>''[http://commons.wikimedia.org/wiki/Main_Page Image from Wikimedia Commons]''<ref name="Wikimedia Commons">{{Cite web | title = Wikimedia Commons | url = http://commons.wikimedia.org/wiki/Main_Page}}</ref></SMALL></SMALL>]] | [[image:Miliary TB.jpg|600px|thumb|center|Chest X-Ray of patient with Miliary Tuberculosis<SMALL><SMALL>''[http://commons.wikimedia.org/wiki/Main_Page Image from Wikimedia Commons]''<ref name="Wikimedia Commons">{{Cite web | title = Wikimedia Commons | url = http://commons.wikimedia.org/wiki/Main_Page}}</ref></SMALL></SMALL>]] | ||
===Secondary Pulmonary Tuberculosis=== | ===Secondary Pulmonary Tuberculosis=== | ||
Also known as "adult-type" or "post-primary tuberculosis". May result from recent [[infection]] with ''[[M. tuberculosis]]'', or from the reactivation of an [[endogenous]] focus containing the latent form of the infection. Without | Also known as "adult-type" or "post-primary tuberculosis". May result from recent [[infection]] with ''[[M. tuberculosis]]'', or from the reactivation of an [[endogenous]] focus containing the latent form of the infection. Without effective medical therapy, approximately 1/3 of patients die within months of disease onset. Of the remaining 2/3, some can develop spontaneous remission, while others experience a chronic infection with severe [[symptoms]]. The survivors may have fibrotic and calcified lesions, and cavitations in some areas of the [[lungs]], that can be detected later on a [[chest X-Ray]].<ref name="Harrisons"></ref> | ||
The onset of illness is insidious and nonspecific, and the [[symptoms]] include: | |||
*[[Fever]] | *[[Fever]] | ||
Line 39: | Line 39: | ||
*[[Hemoptysis]] (20-30% cases) may occur in the following cases: | *[[Hemoptysis]] (20-30% cases) may occur in the following cases: | ||
:*Rupture of a [[blood vessel]] on a cavity wall | :*Rupture of a [[blood vessel]] on a cavity wall leads to severe [[hemoptysis]] | ||
:*Rupture of a [[pulmonary artery]] [[aneurysm]] adjacent or within a tuberculous cavity ([[Rasmussen's aneurysm]]) | :*Rupture of a [[pulmonary artery]] [[aneurysm]] adjacent or within a tuberculous cavity ([[Rasmussen's aneurysm]]) | ||
:*Formation of an [[aspergilloma]] in a lung cavity | :*Formation of an [[aspergilloma]] in a lung cavity |
Revision as of 07:04, 23 March 2021
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mashal Awais, M.D.[2]; João André Alves Silva, M.D. [3]
Overview
Tuberculosis complications are pulmonary and extra-pulmonary. Moreover, they include severe parenchymal, vascular, pleural and chest wall complications. The pulmonary complications of tuberculosis include pneumonia, pleural effusions, bronchiectasis, cavitations, and lymphadenopathy. The hematogenous spread of infection resuts in miliary tuberculosis. Without effective medical therapy, 1/3 of patients with active tuberculosis die within 1 year of diagnosis, and more than 50% die during the first 5 years. However, M. tuberculosis infections carry a good prognosis if diagnosed early and treated effectively.
Natural History
Without proper medical therapy, 1/3 of patients with active tuberculosis die within 1 year of the diagnosis, and more than 50% during the first 5 years. The 5-year mortality rate in patients with a positive sputum smear test for M. tuberculosis is 65%. Patients who survive the 5 years have probability of 60% of spontaneous remission. [1]
Primary Pulmonary Tuberculosis
Primary tuberculosis occurs soon after infection with M. tuberculosis and differs from clinical illness. In endemic areas, primary TB is usually observed at a young age. Primary TB may be completely asymptomatic, or iinvolves mild symptoms, such as fever, cough, and chest pain, due to pleurisy. Some patients can have other symptoms, such as erythema nodosum in the lower limbs and phlyctenulosis. The initial lesion (Ghon focus) often resolves spontaneously, becoming a calcified nodule that may be identified on the chest X-Ray. Pleuritic chest pain usually occurs as a result of the pleural reaction to the underlying Ghon focus.[1]
The progression of primary TB is more rapidly in patients with impaired immunity and in children. Progression of primary tuberculosis results in the enlargement of the Ghon focus. The disease may have the following manifestations:[1]
- Pleural effusion - results from invasion of the pleural space by M. tuberculosis. Usually occurs with subpleural focus of infection.
- Cavitation - results from progressive enlargement of the Ghon focus and necrosis of its center.
- Lymphadenopathy - the dissemination of M. tuberculosis from the lungs to lymph leads to the enlargement of lymph nodes particularly the paratracheal and perihilar lymph nodes.
- Airway obstruction - presents with shortness of breath and wheezing. Usually occurs as a result of severe enlargement of the lymph nodes, compressing the airways resulting in distal collapse, partial obstruction, or hyperinflation.
- Pneumonia - results from rupture and leakage of lymph node content into the airways.
- Bronchiectasis - results from progressive pneumonia that damages a specific segment of the lung, or an entire lobe, leading to bronchiectasis.
Primary infection leads to dissemination of M. tuberculosis through the blood. With impaired immune response, miliary tuberculosis may occur resulting in the formation of granulomatous lesions in several organs.[1]
![](/images/4/45/Miliary_TB.jpg)
Secondary Pulmonary Tuberculosis
Also known as "adult-type" or "post-primary tuberculosis". May result from recent infection with M. tuberculosis, or from the reactivation of an endogenous focus containing the latent form of the infection. Without effective medical therapy, approximately 1/3 of patients die within months of disease onset. Of the remaining 2/3, some can develop spontaneous remission, while others experience a chronic infection with severe symptoms. The survivors may have fibrotic and calcified lesions, and cavitations in some areas of the lungs, that can be detected later on a chest X-Ray.[1]
The onset of illness is insidious and nonspecific, and the symptoms include:
- Fever
- Night sweats
- Weakness
- Malaise
- Anorexia
- Weight loss
- Cough (90% cases) - nonproductive at the outset, more frequent during the morning, that gradually progresses to productive cough, with purulent sputum, with occasional streaks of blood
- Hemoptysis (20-30% cases) may occur in the following cases:
- Rupture of a blood vessel on a cavity wall leads to severe hemoptysis
- Rupture of a pulmonary artery aneurysm adjacent or within a tuberculous cavity (Rasmussen's aneurysm)
- Formation of an aspergilloma in a lung cavity
- Pleuritic chest pain
- Dyspnea (in severe disease)
- ARDS
Complications
Tuberculosis may be localized to the lungs, or involve other organs of the body. Pulmonary TB may lead to permanent damage of the lungs and affected structures. Depending on the pulmonary, or extrapulmonary nature of the lesions, potential complications that may arise include:[3][4]
Parenchymal Lesions
Complication | Description |
---|---|
Tuberculoma |
|
Cicatrization |
|
Thin-walled cavity |
|
Aspergilloma |
|
Lung destruction[3] |
|
Bronchogenic carcinoma[3] |
Airway Lesions
Complication | Description |
---|---|
Bronchiectasis |
|
Tracheobronchial stenosis |
|
Broncholithiasis |
|
Vascular Lesions
Complication | Description |
---|---|
Pulmonary or bronchial arteritis and thrombosis |
|
Bronchial artery dilatation |
|
Rasmussen's aneurysm |
|
Mediastinal Lesions
Complication | Description |
---|---|
Esophagobronchial fistula |
|
Esophagomediastinal fistula |
|
Constrictive pericarditis |
|
Lymph node calcification |
|
Fibrosing mediastinitis |
|
Extranodal extension |
|
Pleural Lesions
Complication | Description |
---|---|
Bronchopleural fistula |
|
Fibrothorax and chronic empyema |
|
Pneumothorax |
|
Chest Wall Lesions
Complication | Description |
---|---|
Tuberculous spondylitis (Pott's disease) |
|
Rib tuberculosis |
|
Malignancy |
|
Prognosis
- If untreated, active TB is often fatal. According to studies performed in several countries, 1/3 of the untreated patients died within 1 year after the diagnosis, while > 50% died within the first 5 years. However, with early diagnosis and adequate treatment, these patients have a good prognosis.[1]
- Symptoms of uncomplicated TB usually improve after 2-3 weeks of treatment initiation.[4]
- Improvements in the chest X-ray require several weeks to months to be noted.[4]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Longo, Dan (2012). Harrison's principles of internal medicine. New York: McGraw-Hill. ISBN 007174889X.
- ↑ "Wikimedia Commons".
- ↑ 3.0 3.1 3.2 3.3 Kim HY, Song KS, Goo JM, Lee JS, Lee KS, Lim TH (2001). "Thoracic sequelae and complications of tuberculosis". Radiographics. 21 (4): 839–58, discussion 859-60. doi:10.1148/radiographics.21.4.g01jl06839. PMID 11452057.
- ↑ 4.0 4.1 4.2 "Prognosis of TB".
- ↑ 5.0 5.1 Woodring JH, Vandiviere HM, Fried AM, Dillon ML, Williams TD, Melvin IG (1986). "Update: the radiographic features of pulmonary tuberculosis". AJR Am J Roentgenol. 146 (3): 497–506. doi:10.2214/ajr.146.3.497. PMID 3484866.
- ↑ 6.0 6.1 6.2 6.3 Lee KS, Song KS, Lim TH, Kim PN, Kim IY, Lee BH (1993). "Adult-onset pulmonary tuberculosis: findings on chest radiographs and CT scans". AJR Am J Roentgenol. 160 (4): 753–8. doi:10.2214/ajr.160.4.8456658. PMID 8456658.
- ↑ Palmer PE (1979). "Pulmonary tuberculosis--usual and unusual radiographic presentations". Semin Roentgenol. 14 (3): 204–43. PMID 472765.
- ↑ Fraser, Richard (1994). Synopsis of diseases of the chest. Philadelphia: W.B. Saunders. ISBN 0721636691.
- ↑ Logan PM, Müller NL (1996). "CT manifestations of pulmonary aspergillosis". Crit Rev Diagn Imaging. 37 (1): 1–37. PMID 8744521.
- ↑ Miller WT (1996). "Aspergillosis: a disease with many faces". Semin Roentgenol. 31 (1): 52–66. PMID 8838945.
- ↑ Thompson BH, Stanford W, Galvin JR, Kurihara Y (1995). "Varied radiologic appearances of pulmonary aspergillosis". Radiographics. 15 (6): 1273–84. doi:10.1148/radiographics.15.6.8577955. PMID 8577955.
- ↑ Snider GL, Placik B (1969). "The relationship between pulmonary tuberculosis and bronchogenic carcinoma. A topographic study". Am Rev Respir Dis. 99 (2): 229–36. PMID 4975011.
- ↑ Ting YM, Church WR, Ravikrishnan KP (1976). "Lung carcinoma superimposed on pulmonary tuberculosis". Radiology. 119 (2): 307–12. doi:10.1148/119.2.307. PMID 1265261.
- ↑ Lee KS, Hwang JW, Chung MP, Kim H, Kwon OJ (1996). "Utility of CT in the evaluation of pulmonary tuberculosis in patients without AIDS". Chest. 110 (4): 977–84. PMID 8874255.
- ↑ Hatipoğlu ON, Osma E, Manisali M, Uçan ES, Balci P, Akkoçlu A; et al. (1996). "High resolution computed tomographic findings in pulmonary tuberculosis". Thorax. 51 (4): 397–402. PMC 1090675. PMID 8733492.
- ↑ 16.0 16.1 Galdermans D, Verhaert J, Van Meerbeeck J, de Backer W, Vermeire P (1990). "Broncholithiasis: present clinical spectrum". Respir Med. 84 (2): 155–6. PMID 2371439.
- ↑ 17.0 17.1 Kowal LE, Goodman LR, Zarro VJ, Haskin ME (1983). "CT diagnosis of broncholithiasis". J Comput Assist Tomogr. 7 (2): 321–3. PMID 6833568.
- ↑ 18.0 18.1 Conces DJ, Tarver RD, Vix VA (1991). "Broncholithiasis: CT features in 15 patients". AJR Am J Roentgenol. 157 (2): 249–53. doi:10.2214/ajr.157.2.1853800. PMID 1853800.
- ↑ Fraser, Richard (1994). Synopsis of diseases of the chest. Philadelphia: W.B. Saunders. ISBN 0721636691.
- ↑ 20.0 20.1 Song JW, Im JG, Shim YS, Park JH, Yeon KM, Han MC (1998). "Hypertrophied bronchial artery at thin-section CT in patients with bronchiectasis: correlation with CT angiographic findings". Radiology. 208 (1): 187–91. doi:10.1148/radiology.208.1.9646812. PMID 9646812.
- ↑ Ramakantan R, Bandekar VG, Gandhi MS, Aulakh BG, Deshmukh HL (1996). "Massive hemoptysis due to pulmonary tuberculosis: control with bronchial artery embolization". Radiology. 200 (3): 691–4. doi:10.1148/radiology.200.3.8756916. PMID 8756916.
- ↑ 22.0 22.1 Im JG, Kim JH, Han MC, Kim CW (1990). "Computed tomography of esophagomediastinal fistula in tuberculous mediastinal lymphadenitis". J Comput Assist Tomogr. 14 (1): 89–92. PMID 2299003.
- ↑ Fraser, Richard (1994). Synopsis of diseases of the chest. Philadelphia: W.B. Saunders. ISBN 0721636691.
- ↑ Mönig SP, Schmidt R, Wolters U, Krug B (1995). "Esophageal tuberculosis: a differential diagnostic challenge". Am J Gastroenterol. 90 (1): 153–4. PMID 7801924.
- ↑ Larrieu AJ, Tyers GF, Williams EH, Derrick JR (1980). "Recent experience with tuberculous pericarditis". Ann Thorac Surg. 29 (5): 464–8. PMID 7377888.
- ↑ Agrons GA, Markowitz RI, Kramer SS (1993). "Pulmonary tuberculosis in children". Semin Roentgenol. 28 (2): 158–72. PMID 8516692.
- ↑ Leung AN, Müller NL, Pineda PR, FitzGerald JM (1992). "Primary tuberculosis in childhood: radiographic manifestations". Radiology. 182 (1): 87–91. doi:10.1148/radiology.182.1.1727316. PMID 1727316.
- ↑ Choyke PL, Sostman HD, Curtis AM, Ravin CE, Chen JT, Godwin JD; et al. (1983). "Adult-onset pulmonary tuberculosis". Radiology. 148 (2): 357–62. doi:10.1148/radiology.148.2.6867325. PMID 6867325.
- ↑ Hopewell PC (1995). "A clinical view of tuberculosis". Radiol Clin North Am. 33 (4): 641–53. PMID 7610236.
- ↑ 30.0 30.1 30.2 Atasoy C, Fitoz S, Erguvan B, Akyar S (2001). "Tuberculous fibrosing mediastinitis: CT and MRI findings". J Thorac Imaging. 16 (3): 191–3. PMID 11428422.
- ↑ 31.0 31.1 Kushihashi T, Munechika H, Motoya H, Hamada K, Satoh I, Naitoh H; et al. (1995). "CT and MR findings in tuberculous mediastinitis". J Comput Assist Tomogr. 19 (3): 379–82. PMID 7790546.
- ↑ Johnson TM, McCann W, Davey WN (1973). "Tuberculous bronchopleural fistula". Am Rev Respir Dis. 107 (1): 30–41. PMID 4683320.
- ↑ Hulnick DH, Naidich DP, McCauley DI (1983). "Pleural tuberculosis evaluated by computed tomography". Radiology. 149 (3): 759–65. doi:10.1148/radiology.149.3.6647852. PMID 6647852.
- ↑ Müller NL (1993). "Imaging of the pleura". Radiology. 186 (2): 297–309. doi:10.1148/radiology.186.2.8421723. PMID 8421723.
- ↑ Schmitt WG, Hübener KH, Rücker HC (1983). "Pleural calcification with persistent effusion". Radiology. 149 (3): 633–8. doi:10.1148/radiology.149.3.6647839. PMID 6647839.
- ↑ Kuhlman JE, Singha NK (1997). "Complex disease of the pleural space: radiographic and CT evaluation". Radiographics. 17 (1): 63–79. doi:10.1148/radiographics.17.1.9017800. PMID 9017800.
- ↑ Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID http://dx.doi.org/10.1148/radiology.175.1.2315473 Check
|pmid=
value (help). - ↑ Im JG, Chung JW, Han MC (1993). "Milk of calcium pleural collections: CT findings". J Comput Assist Tomogr. 17 (4): 613–6. PMID 8331232.
- ↑ Song JW, Im JG, Goo JM, Kim HY, Song CS, Lee JS (2000). "Pseudochylous pleural effusion with fat-fluid levels: report of six cases". Radiology. 216 (2): 478–80. doi:10.1148/radiology.216.2.r00jl09478. PMID 10924573.
- ↑ Ridley N, Shaikh MI, Remedios D, Mitchell R (1998). "Radiology of skeletal tuberculosis". Orthopedics. 21 (11): 1213–20. PMID 9845453.
- ↑ Sharif HS, Morgan JL, al Shahed MS, al Thagafi MY (1995). "Role of CT and MR imaging in the management of tuberculous spondylitis". Radiol Clin North Am. 33 (4): 787–804. PMID 7610245.
- ↑ 42.0 42.1 Lee G, Im JG, Kim JS, Kang HS, Han MC (1993). "Tuberculosis of the ribs: CT appearance". J Comput Assist Tomogr. 17 (3): 363–6. PMID 8491894.
- ↑ 43.0 43.1 Adler BD, Padley SP, Müller NL (1993). "Tuberculosis of the chest wall: CT findings". J Comput Assist Tomogr. 17 (2): 271–3. PMID 8454753.
- ↑ Glicklich M, Mendelson DS, Gendal ES, Teirstein AS (1990). "Tuberculous empyema necessitatis. Computed tomography findings". Clin Imaging. 14 (1): 23–5. PMID 2322879.
- ↑ 45.0 45.1 Roviaro GC, Sartori F, Calabrò F, Varoli F (1982). "The association of pleural mesothelioma and tuberculosis". Am Rev Respir Dis. 126 (3): 569–71. PMID 7125345.
- ↑ 46.0 46.1 Iuchi K, Aozasa K, Yamamoto S, Mori T, Tajima K, Minato K; et al. (1989). "Non-Hodgkin's lymphoma of the pleural cavity developing from long-standing pyothorax. Summary of clinical and pathological findings in thirty-seven cases". Jpn J Clin Oncol. 19 (3): 249–57. PMID 2681886.
- ↑ 47.0 47.1 47.2 Minami M, Kawauchi N, Yoshikawa K, Itai Y, Kokubo T, Iguchi M; et al. (1991). "Malignancy associated with chronic empyema: radiologic assessment". Radiology. 178 (2): 417–23. doi:10.1148/radiology.178.2.1987602. PMID 1987602.
- ↑ Hillerdal G, Berg J (1985). "Malignant mesothelioma secondary to chronic inflammation and old scars. Two new cases and review of the literature". Cancer. 55 (9): 1968–72. PMID 3978576.