Clinical Manual for Management of the HIV-Infected ... - myCME.com

6–66 | Clinical Manual for Management of the HIV-Infected Adult/2006
S: Subjective
Persons with TB generally describe an illness lasting
several weeks to months, associated with systemic features
such as high fever, night sweats, loss of appetite,
and weight loss. These symptoms may be nonspecific, but
should raise the possibility of TB.
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Pulmonary TB causes a chronic productive cough,
sometimes with hemoptysis; shortness of breath
occurs late in the disease.
TB adenitis causes enlargement of the lymph nodes
(usually asymmetric involvement in 1 region) which
may suppurate and drain but usually are not painful,
hot, or erythematous.
TB meningitis causes headache, gradual change
in mental status, and sometimes cranial nerve
abnormalities such as double vision or decreased
hearing.
Disseminated TB may occur with only systemic
manifestations such as fever, sweats, and weight loss,
with no localizing features.
Risks for TB include known previous contact with an
active case, previous positive result of a tuberculin skin
test (TST, also known as a purified protein derivative
test [PPD]), exposure in congregate settings (such as
homeless shelters and prisons, but also health care facilities),
or travel or residence in countries with high rates
of endemic TB. In the United States, persons with active
or past substance use disorders and persons of color
are more likely than others to have had TB exposure.
O: Objective
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Measure vital signs, including oxygen saturation.
Measure weight; compare with previous values.
Perform thorough physical examination with
particular attention to the lungs, heart, abdomen,
lymph nodes, and neurologic system.
Systemic signs of chronic disease and inflammation are
common, including fever, night sweats (which may occur
without awareness of the high fever that precedes
them), and weight loss.
In patients with pulmonary TB, the breath sounds may
be normal or focally abnormal; tachypnea and hypoxia
occur only with extensive lung damage.
Extrapulmonary TB may present with focal adenopathy
without local signs of inflammation, but perhaps with a
draining sinus.
TB meningitis causes subacute or chronic symptoms,
with neck stiffness and changes in mental status, with or
without cranial nerve palsies caused by inflammation at
the base of the brain or increased intracranial pressure.
Pericardial disease can be associated with the pain and
friction rub of pericarditis or signs of pericardial tamponade.
Patients with disseminated TB may have diffuse adenopathy
and hepatic or splenic enlargement.
A: Assessment
The differential diagnosis of TB is extensive and
depends in part on the degree of immunosuppression
(as indicated by the CD4 cell count) of the individual.
It includes a broad range of bacterial, mycobacterial,
viral, and fungal infections in addition to noninfections
causes. A partial differential diagnosis of pulmonary TB
includes:
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Bacterial pneumonia
Pulmonary Mycobacterium pneumonia
(nontuberculous)
Pneumocystis jiroveci pneumonia (PCP)
Cryptococcus neoformans pneumonia/pneumonitis
Pulmonary Kaposi sarcoma
Toxoplasma pneumonitis
Disseminated histoplasmosis
Disseminated coccidioidomycosis
Cytomegalovirus pneumonia
Bronchogenic carcinoma
Non-Hodgkin lymphoma
Influenza
Pulmonary embolus
Chronic obstructive pulmonary disease
Reactive airway disease
Congestive heart failure
Lactic acidosis