Comprehensive Insights into Extrapulmonary Tuberculosis: From Genitourinary System to Bones and Joints
In this article we’ll discuss Tuberculosis of the genitourinary system, Tuberculous peripheral lymphadenopathy, Tuberculosis of the intestines, peritoneum and mesenteric glands, Tuberculosis of the skin and subcutaneous tissue, Tuberculosis of the eye, Tuberculosis of the (inner) (middle) ear, Tuberculosis of adrenal glands, Tuberculosis of other specified organs and Tuberculosis of bones and joints.
1. Tuberculosis of the genitourinary system
Tuberculosis (TB) of the genitourinary system is a type of extrapulmonary Tuberculosis that affects the kidneys, bladder, and urethra when bacilli migrate to the renal system via blood circulation or the lymph system from an original infection by Mycobacterium tuberculosis (rarely Mycobacterium bovis); the infection can remain dormant for long periods but eventually activate and infect the involved organ system.
1.1 Symptoms
A patient with genitourinary TB can experience;
- frequent voiding;
- dysuria;
- pyuria;
- back pain;
- flank pain;
- abdominal pain;
- night sweats;
- fever; and
- weight loss.
The formation of granulomas or tuberculomas (tuberculous “tumors”) can result in fibrosis (thickened and scarred connective tissue), leading to obstruction due to stricture or stenosis (narrowing of a tubular structure).
1.2 Diagnosis
Providers diagnose the condition based on blood tests, tuberculin skin tests, and previous Tuberculosis or active disease history. Intravenous urography, MRI, or CT may detect granulomas or tuberculomas. Definitive diagnosis is made by tissue biopsy or abscess samples for acid–fast bacilli (AFB).
1.3 Treatment
Treatment includes standard antituberculous chemotherapy with isoniazid, rifampin, rifabutin, pyrazinamide, and ethambutol; other drugs may be tried if these drugs are ineffective. The provider may perform surgery to treat abscesses, tuberculomas, fistulas, and strictures or obstructions.
2. Tuberculous peripheral lymphadenopathy
Tuberculous lymphadenopathy, also known as Tuberculous adenitis, is a common type of extrapulmonary Tuberculosis that affects the lymph nodes in the upper and lower extremities and axillary and inguinal areas due to direct infection by Mycobacterium tuberculosis (rarely Mycobacterium bovis) or extension of pulmonary Tuberculosis.
2.1 Symptoms
A patient with tuberculous peripheral lymphadenopathy can experience enlarged lymph nodes, which usually grow with time, are hard to fluctuate, and may have draining sinuses along with typical symptoms of TB such as night sweats, fever, and weight loss.
Obstruction of lymph flow can cause severe swelling (lymphedema) with skin thickening and fissures of the extremities; untreated, it can lead to elephantiasis, a disfiguring disease with extreme swelling and skin that looks like wrinkled leather.
2.2 Diagnosis
Providers diagnose the condition based on blood tests, tuberculin skin tests, and previous Tuberculosis or active disease history. Definitive diagnosis is made by tissue biopsy or abscess samples for acid–fast bacilli (AFB).
2.3 Treatment
Treatment includes standard antituberculous chemotherapy with isoniazid, rifampin, rifabutin, pyrazinamide, and ethambutol; other drugs may be tried if these drugs are ineffective. Massage may be used to improve lymph flow, and antidiuretics may improve water loss. Surgery may be performed for diagnosis or treatment.
3. Tuberculosis of intestines, peritoneum and mesenteric glands
Tuberculosis (TB) of the intestines, peritoneum, and mesenteric glands is a common complication of pulmonary Tuberculosis, especially among immune–compromised patients, that occurs when the Mycobacterium bacilli migrate through the bloodstream or lymph system and lodges in the area and form granulomas (inflammatory masses of cells), which can remain dormant for long periods but eventually activate and infect the structures.
3.1 Symptoms
A patient with TB of the intestines, peritoneum (the membrane lining the abdominal cavity), and mesenteric glands (lymph glands that receive lymph fluid from the intestines) can experience;
- abdominal swelling;
- tenderness;
- rectal bleeding;
- constipation;
- ascites (abnormal collection of fluid in the abdomen);
- weight loss;
- bowel obstruction or perforation;
- fever;
- cough; and
- malaise (fatigue).
3.2 Diagnosis
Providers diagnose the condition based on a history of pulmonary Tuberculosis and laboratory analysis of sputum, gastric washings, peritoneal fluid, and biopsy.
Providers may perform upper and lower endoscopy and ultrasound– or CT–guided fine needle aspiration of the peritoneum (also called paracentesis when performed on the peritoneum) to obtain specimens for laboratory analysis for acid–fast bacilli and culture. Chest X–ray may diagnose concurrent pulmonary TB, and a barium enema can reveal tuberculous changes in the colon wall.
Ultrasound and CT scans can reveal ascites, thickening, and soft tissue densities in the peritoneum and omentum (part of the peritoneum near the stomach) and help distinguish peritoneal TB from carcinomatosis (widespread cancer).
3.3 Treatment
The provider may perform emergent exploratory laparotomy for biopsy of the peritoneum or mesentery and/or colon resection and anastomosis to treat a bowel perforation, stricture, or obstruction followed by treatment with standard antituberculous chemotherapy with isoniazid, rifampin, rifabutin, pyrazinamide, and ethambutol.
4. Tuberculosis of skin and subcutaneous tissue
Tuberculosis (TB) of the skin and subcutaneous tissue is an uncommon type of extrapulmonary Tuberculosis that can occur as a complication from an original infection by Mycobacterium tuberculosis (rarely Mycobacterium bovis), direct introduction of the bacterium into the skin due to trauma or injury, or rarely vaccination with the Bacille Calmette–Guérin (BCG) vaccine. Immune–compromised patients are at the most risk of developing this condition.
Tuberculosis of skin and subcutaneous tissue is also known as:
- Erythema induratum, tuberculous
- Lupus excedens
- Lupus vulgaris NOS
- Lupus vulgaris of eyelid
- Scrofuloderma
- Tuberculosis of external ea
4.1 Symptoms
A patient with TB of skin and subcutaneous tissue can experience tender, warm, scaly plaques that release pus from the margins on light pressure, along with symptoms of TB such as night sweats, fever, and weight loss.
4.2 Diagnosis
Providers diagnose the condition based on blood tests, tuberculin skin tests, and previous Tuberculosis or active disease history. Definitive diagnosis is made by skin biopsy or tissue cultures for acid–fast bacilli (AFB).
4.3 Treatment
Treatment includes standard antituberculous chemotherapy with isoniazid, rifampin, rifabutin, pyrazinamide, and ethambutol; other drugs may be tried if these drugs are ineffective.
5. Tuberculosis of the eye
Tuberculosis of the eye is a rare manifestation of extrapulmonary Tuberculosis (TB) resulting from reactivation of the bacilli lodged in the area from an original infection by Mycobacterium tuberculosis and rarely by Mycobacterium bovis or by direct introduction of the bacteria through an open wound.
5.1 Symptoms
A patient with TB of the eye can experience;
- lid abscess or inflammation of external structures of the eye (blepharitis, conjunctivitis;
- interstitial keratitis and/or scleritis);
- granulomatous masses involving the sebaceous (oil) glands inside the lid (atypical chalazion);
- discharge of mucus and pus.
Intraocular manifestations include inflammation of the uvea, iris, and ciliary body (iridocyclitis) and choroid and retina (retinochoroiditis or chorioretinitis) as well as granulomatous changes within the iris, cornea, choroid, and even the optic nerve. Ocular Tuberculosis is complicated to diagnose and often inconclusive.
5.2 Diagnosis
Providers diagnose the condition based on PCR of blood serum and/or intraocular fluid, a tuberculin skin test, and previous history of Tuberculosis or active disease. Ocular imaging studies (such as fluorescein or indocyanine green angiography, ocular coherence tomography [OCT], and ocular ultrasound) or biomicroscopy (combined slit lamp and microscopic examination) are of little use in primary diagnosis of TB. Still, they may help diagnose uveitis complications.
5.3 Treatment
Treatment includes antituberculous chemotherapy with isoniazid, rifampin, rifabutin, pyrazinamide, and ethambutol; topical, periocular, intraocular, and systemic steroids may relieve inflammation.
6. Tuberculosis of (inner) (middle) ear (Tuberculous otitis media)
Tuberculosis of (inner) (middle) ear, also known as Tuberculous otitis media, is a rare manifestation of extrapulmonary Tuberculosis resulting from reactivation of the bacilli lodged in the area from an original infection by Mycobacterium tuberculosis and rarely by Mycobacterium bovis or by direct introduction of the bacteria through the Eustachian tube.
6.1 Symptoms
A patient with other TB of the inner or middle ear can experience symptoms similar to suppurative otitis media, that is;
- painless ear discharge (otorrhea);
- tympanic membrane (eardrum) perforations;
- hearing loss;
- facial nerve paralysis; and
- swollen or enlarged lymph nodes (lymphadenopathy) in the neck;
- fever; and
- weight loss.
6.2 Diagnosis
Providers diagnose the condition based on blood tests, tuberculin skin tests, and previous Tuberculosis or active disease history. A CT scan may show opacification of the middle ear. A definitive diagnosis is made by culture results and histological analysis for acid–fast bacilli.
6.3 Treatment
Treatment includes antituberculous chemotherapy with isoniazid, rifampin, rifabutin, pyrazinamide, and ethambutol; other drugs may be tried if these drugs are ineffective. In severe cases of bony sequestration, surgical therapy is indicated.
7. Tuberculous Addison’s disease (Tuberculosis of adrenal glands)
Tuberculosis (TB) of the adrenal glands, also known as Tuberculous Addison’s disease, is a rare manifestation of extrapulmonary Tuberculosis resulting from reactivation of the bacilli lodged in the area that migrated through the blood from an original infection by Mycobacterium tuberculosis and rarely by Mycobacterium bovis.
7.1 Symptoms
A patient with TB of the adrenal glands can experience;
- weakness;
- fatigue;
- anorexia;
- nausea;
- vomiting;
- skin hyperpigmentation;
- fever; and
- weight loss.
7.2 Diagnosis
Providers diagnose the condition based on blood tests, a tuberculin skin test, and previous history of Tuberculosis or active disease. A CT scan may show bilateral adrenal enlargement, calcifications, and atrophy. A definitive diagnosis is made by biopsy.
7.3 Treatment
Treatment includes antituberculous chemotherapy with isoniazid, rifampin, rifabutin, pyrazinamide, and ethambutol; other drugs may be tried if these drugs are ineffective. At times, adjunctive steroid therapy may be employed to prevent adrenal crisis.
8. Tuberculosis of other specified organs
Tuberculosis (TB) of other specified organs is caused by Mycobacterium tuberculosis, which enters through the respiratory system; the bacilli (rod–shaped bacterium) migrate to other organ systems through the lymph system or blood circulation and form granulomas (inflammatory masses of cells), which can remain dormant for long periods but eventually rupture and infect the involved organ.
8.1 Symptoms
A patient with TB of other specified organ systems experiences various symptoms depending on the organ system involved.
The formation of granulomas or tuberculomas (tuberculous “tumors”) can result in fibrosis (thickened and scarred connective tissue), leading to obstruction due to stricture or stenosis (narrowing of a tubular structure).
The patient may experience other typical symptoms of TB, such as night sweats, fever, weight loss, and pain and inflammation in the organ system affected.
8.2 Diagnosis
Providers diagnose the condition based on blood tests, tuberculin skin tests, and previous Tuberculosis or active disease history. MRI or CT may detect granulomas or tuberculomas.
8.3 Treatment
Treatment includes standard antituberculous chemotherapy, starting with isoniazid, rifampin, rifabutin, pyrazinamide, and ethambutol for two months, followed by longer-term (9–12 months) isoniazid, rifabutin, and rifampin for maintenance; other drugs may be tried if these drugs are ineffective. At times, adjunctive steroid therapy helps treat symptoms of swelling and inflammation. The provider may perform surgery to treat abscesses, tuberculomas, and strictures or obstructions.
9. Tuberculosis of bones and joints
Tuberculosis of the bones and joints is a type of extrapulmonary Tuberculosis resulting from reactivation of the bacilli lodged in the area from an original infection by Mycobacterium tuberculosis and rarely by Mycobacterium bovis or by direct introduction of the bacteria through an open wound.
9.1 Symptoms
A patient with bone or joint Tuberculosis can experience;
- local pain;
- tenderness;
- inflammation; and
- stiffness of the affected anatomy.
9.2 Diagnosis
Providers diagnose the condition based on a tuberculin skin test and previous history of Tuberculosis or active disease. MRI or CT can detect tuberculous osteomyelitis and arthritis. A definitive diagnosis is made by biopsy.
8.3 Treatment
Treatment includes antituberculous chemotherapy with isoniazid, rifampin, rifabutin, pyrazinamide, and ethambutol; other drugs may be tried if these drugs are ineffective. In severe cases, surgical therapy is indicated.
