Chronic cough, weight loss, night sweats and upper lobe cavitation
Expansion
Pulmonary features
- Cough for over 3 weeks, productive, sometimes with haemoptysis
- Weight loss, night sweats, fever, anorexia, malaise
- Chest radiograph: upper lobe consolidation and cavitation, hilar lymphadenopathy, pleural effusion, or miliary shadowing
Primary infection forms the Ghon focus in the mid or lower zone, which with the draining hilar node makes the Ghon complex. Most heal, leaving latent infection.
Reactivation is characteristically upper lobe, because the apices are the best ventilated and least perfused part of the lung and M. tuberculosis is an obligate aerobe.
Extrapulmonary sites, in rough order of frequency: lymph nodes (scrofula, matted cervical nodes that may discharge), pleura, bone and joint (Pott’s disease of the spine), genitourinary (sterile pyuria), miliary, meningeal, pericardial, gastrointestinal (ileocaecal, mimicking Crohn’s) and adrenal (causing Addison’s).
Risk factors: birth or residence in a high prevalence country, HIV, immunosuppression and anti-TNF therapy, homelessness, prison, injecting drug use, silicosis, diabetes, malnutrition and chronic kidney disease.
Treatment is RIPE: rifampicin and isoniazid for 6 months, pyrazinamide and ethambutol for the first 2, extended to 12 months for central nervous system disease.