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Diagnosis of pulmonary tuberculosis in HIV-uninfected adults

Author
John Bernardo, MD
Section Editor
C Fordham von Reyn, MD
Deputy Editor
Elinor L Baron, MD, DTMH

INTRODUCTION

More than two billion people (about one-third of the world population) are estimated to be latently infected with Mycobacterium tuberculosis [1]. In 2015, approximately 10.4 million individuals became ill with tuberculosis (TB), and 1.8 million died [2]. Prompt diagnosis of active TB facilitates timely therapeutic intervention and minimizes community transmission [3,4].

The diagnosis of pulmonary TB in HIV-uninfected adults will be reviewed here. Issues related to diagnosis of tuberculosis HIV-infected patients and children are discussed separately, as are issues related to the clinical manifestations and treatment of TB. (See "Epidemiology, clinical manifestations, and diagnosis of tuberculosis in HIV-infected patients" and "Tuberculosis disease in children", section on 'Diagnosis' and "Clinical manifestations and complications of pulmonary tuberculosis" and "Treatment of drug-susceptible pulmonary tuberculosis in HIV-uninfected adults".)

OVERVIEW

General diagnostic approach — The diagnosis of pulmonary tuberculosis (TB) should be suspected in patients with relevant clinical manifestations (cough >2 to 3 weeks' duration, lymphadenopathy, fevers, night sweats, weight loss) and relevant epidemiologic factors (history of prior TB infection or disease, known or possible TB exposure, and/or past or present residence in or travel to an area where TB is endemic) (table 1) [3]. Patients being evaluated for pulmonary tuberculosis who pose a public health risk for transmission should be admitted and isolated with airborne precautions. (See "Tuberculosis transmission and control", section on 'Clinical triaging'.)

The diagnosis of pulmonary tuberculosis is definitively established by isolation of M. tuberculosis from a bodily secretion (eg, culture of sputum, bronchoalveolar lavage or pleural fluid) or tissue (pleural biopsy or lung biopsy) [5]. Additional diagnostic tools include sputum acid-fast bacilli (AFB) smear and nucleic acid amplification (NAA) testing; positive NAA test (with or without AFB smear positivity) is considered sufficient for diagnosis of tuberculosis (algorithm 1). Radiographic studies are important supportive diagnostic tools [3].

The approach to diagnosis of tuberculosis begins with a history and physical examination to assess the patient's risk for TB (table 1). Patients meeting clinical criteria should undergo chest radiography; if imaging suggests TB of the lungs or airways, three sputum specimens (obtained via cough or induction at least eight hours apart and including at least one early-morning specimen) should be submitted for AFB smear, mycobacterial culture, and NAA testing (algorithm 1) [1,3,6].

                      

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