Physical Exam

Patients may demonstrate a fever, weight loss,

adventitial sounds and cervical
lymphadenopathy.

Tuberculosis
Friday, September 26, 2014

7:06 PM

History of Present Illness

Patients can present with cough,
hemoptysis, fever, weight loss and night
sweats.

Labs and Diagnostics

Patients suspected of tuberculosis can
have an intradermal PPD (purified
protein derivative) placed on their
forearm and observed for a reaction.
The examiner of the reaction should look
for and measure induration or firmness
around the site as opposed to erythema.
The induration is a result of infiltrates of
T lymphocytes and monocytes and
resultant edema and fibrin deposition
due to increased vascular permeability in
response to cytokines produced by CD4+
T cells as well as tissue damage induced
by the products of macrophages
activated by the T cells.
A positive test depends upon the risk factors
of the patient.
An induration < 5 mm is considered
normal.
An induration between 5-10 mm is
abnormal in patients with HIV, patients
taking steroids, patients with abnormal
calcifications on x-ry, organ transplant
recipients, and those with close contact
with patients with active tuberculosis.
Induration 10-15 mm is considered
abnormal in patients who have
immigrated within the past 5 years, are
prisoners, healthcare workers, are
alcoholic or diabetic.
Induration > 15 mm is considered
positive in anyone.

Figure: PPD Placement and Rxn

PPD contains tuberculins that in patients

who have been exposed to TB, will
develop a delayed type hypersensitivity
reaction which occurs within 24-48
hours. The delay is a result of the time it
takes for circulating effector T
lymphocytes to respond to the antigen at
that site in the skin.

Management
Tuberculosis is treated with multi-drug regimens
to minimize the development of resistance. This
includes medications such as isoniazid, rifampin,
pyrazinamide, ethambutol and streptomycin.
Risk Factors

Figure: Langerhans
Giant Cell in Center
in Horseshoe or
Arciform Pattern

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A biopsy of lymph nodes may

reveal apical caseating granulomas with
Langhans giant cells which have multiple
nuclei and are arranged like a horseshoe. The
granulomas will typically have central caseous
necrosis with large cells surrounding the necrosis
with abundant pale cytoplasms termed
large epithelioid macrophages.
These macrophages have been activated by CD4
+ lymphocytes to kill the bug.

Discussion
When a patient is exposed to the organism, the body activates its cell-mediated immune system since Mycobacterium tuberculosis is a facultative
intracellular organism that survives and multiplies in macrophages. The TH1 response involves activating specific CD4+ lymphocytes by
antigen-presenting cells, followed by interferon gamma and IL-2 mediated activation of macrophages and cytotoxic T lymphocytes. This walls off
the organism and creates the caseating granulomas made of epithelioid cells, the Langhans multinucleated giant cells, fibrobl asts and collagen.
Patients being treated with immunosuppressants have a higher likelihood of contracting the disease.
Pott's disease refers to tuberculosis that has infected the spine.
Pathology

Classically with sub

pleural along with
hilar lymph node

Mycobacterium

Necrosis in
center of
granulomas

Epitheloid
Histocytes

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