Clinical characteristics, diagnostic approaches and treatment of extrapulmonary tuberculosis (TB).
| Localisation of tuberculosis | Clinical presentation | Diagnostic tests | Best way of isolating M. tuberculosis (in single organ involvement) | Treatment | |
| Pericarditis | Effusive | Vital emergency (risk of tamponade) Febrile subacute pericarditis | Echocardiography Chest radiography, Pericardial fluid | AFB smear and cultures in pericardial biopsy>pericardial fluid | Pericardiotomy Consider corticosteroids |
| Constrictive | Progressive dyspnoea and right heart failure | Echocardiography Right heart catheterisation | Pericardial biopsy | Pericardiectomy | |
| Miliary | Vital emergency, subacute or fulminant febrile multiple organ failure and respiratory distress | Chest radiography – computed tomography scan of thorax Lumbar puncture if involvement of the CNS is suspected | Sampling of involved organs, Sputum smear and culture, Blood cultures for M. tuberculosis | Immediate treatment start Empiric treatmen Regimen and duration adapted to involved organs | |
| Meningitis and encephalitis | Vital emergency, subacute febrile meningitis | Computed tomography scan or MRI of brain, CSF | PCR and GeneXpert in CSF>>AFB smear and cultures in CSF | Injectable route administration, Empiric treatment, Consider corticosteroids, Treatment extension to 12 months recommended, Paradoxical reaction may occur | |
| Brain tuberculoma | Asymptomatic,
seizures | Computed tomography scan of brain, MRI of brain | Needle biopsy of the lesion (usually not necessary if TB can be diagnosed on sputum or other specimens) | Consider toxoplasmosis if HIV Consider corticosteroids Treatment extension to 12 months recommended Avoid surgery Paradoxical reaction may occur | |
| Spinal arachnoiditis | Varying combinations of spinal cord, meninges and nerve roots affections | Spinal MRI CSF | In the absence of meningitis: biopsy of the spinal lesion (usually not necessary if TB can be diagnosed on sputum or other specimens) | Consider corticosteroids Treatment extension to 12 months recommended Consider surgery if treatment failure | |
| Ocular tuberculosis | Uveitis, especially posterior uveitis, is the most common form of intraocular tuberculosis | The diagnosis is often empiric and response to antituberculous treatment may be the only definitive evidence of intraocular TB | |||
| Peripheral lymphadenitis | Progressive cold and painless swelling of a group of lymph nodes +/− Scrofuloderma | Ultrasound of lymph node, biopsy for pathology EBUS-TBNA +/− EUS-FNA for mediastinal or abdominal lymph nodes | Fine needle biopsy of the lymph node (culture>GeneXpert>PCR>AFB smear) | Consider extension of treatment to 9 months Paradoxical reaction may occur | |
| Pott's Disease | Chronic back pain, Alderman's gait, complications (gibbus, para or tetraparesia, paravertebral or iliopsoas abscess) | Spine radiography Spine MRI | Computed tomography scan guided biopsy of the lesion (usually not necessary if TB can be diagnosed on sputum or other specimens) | Treatment extension to 12 months recommended | |
| Tuberculous arthritis | Progressive painful but cold swelling of a joint | Joint radiography Joint MRI | Synovial biopsy | ||
| Osteomyelitis | Progressive, depends on the involved bone | Bone MRI or computed tomography scan | Fine needle aspiration of a cold abscess Tissue biopsy of a bone lesion | Consider surgery | |
| Peritoneal | Slowly growing ascites | Paracentesis | Peritoneal biopsy by laparoscopy>paracentesis | Injectable route administration in case of occlusion or severe vomiting | |
| Liver | Subacute abdominal pain, fever, jaundice | Ultrasound of abdomen Computed tomography scan or MRI of abdomen | Liver biopsy | Injectable route administration in case of occlusion or severe vomiting | |
| Intestinal | Subacute abdominal pain, diarrhoea, bleeding, fever | Computed tomography scan of abdomenColonoscopy | Intestinal biopsy | Injectable route administration in case of occlusion or severe vomiting | |
| Urinary tract | Dysuria, low back pain, aseptic pyuriaGlomerulonephritis | Computed tomography scan of abdomen | Renal or bladder biopsy>urine AFB smear and cultures | Surgery on case-by-case basis | |
| Male genital tract | Chronic orchi-epididymitis | Ultrasound | Biopsy of involved structure | Surgery on case-by-case basis | |
| Female genital tract | Infertility Chronic salpingitis or endometritis | Hysterosalpingram | Biopsy of involved structures Culture of menstrual fluid | Surgery on case-by-case basis | |
| Upper respiratory tract | Depending on the involved structure | Computed tomography scan Nasofibroscopy | Biopsy of involved structures | ||
| Adrenal gland | Adrenal gland insufficiency (Addison disease) | Computed tomography scan or MRI of abdomen Blood cortisol levelACTH stimulation test | Supplementation with hydrocortisone | ||
| Cutaneous tuberculosis | Various presentations | Skin biopsy for pathology, AFB smear, PCR and culture |
Clinicians should always look for concomitant pulmonary tuberculosis to facilitate a diagnosis and because of its implications for isolation of the patient, protective measures and contact tracing. CNS: central nervous system.