Tuberculosis differential diagnosis, Pthisiology

In the following presentation, we go through many lung conditions which may come across as tuberculosis. Very useful to keep in mind where pulmonary diseases are prevalent, especially armenia and India

1. Name: Sheba Roymon​ Pthisiology​ University of Traditional Medicine, Armenia Tuberculosis differential diagnosis

2. Causes of lung cavities | Differentiating Features | Differentiating radiological findings | Diagnosis confirmation Pulmonary tuberculosis must be distinguished from other cavitary lung lesions. Differential Diagnosis

3. Disease Findings Bacterial pneumonia Sudden onset of symptoms, such as high fever, cough, purulent sputum, chest pain, leukocytosis, chest X-ray shows consolidation. Bronchogenic carcinoma may be asymptomatic, usually at older ages (> 50 years old), cough, hemoptysis, weight loss Brucellosis Fever, anorexia, night sweats, malaise,back pain , headache, and depression. History of exposure to infected animal Hodgkin lymphoma Fever, night sweats, pruritus, painless adenopathy, mediastinal mass Mycoplasmal pneumonia Gradual onset of dry cough, headache, malaise, sore throat. Diffuse bilateral infiltrates on chest X-ray. Sarcoidosis Non-caseating granulomas in lungs and other organs, bilateral hilar lymphadenopathy, mostly in African American females. Pulmonary Tuberculosis

4. Malignancy (Primary lung cancer) Elderly male or female Chronic smokers Presents with a low-grade fever, absence of leukocytosis, systemic complaints weight loss, fatigue Absence of predisposing factors that lead to gastric content aspiration, no response to antibiotics within 10 days Hemoptysis is commonly associated with bronchogenic carcinoma A coin-shaped lesion with thick wall(>15mm) is seen on CXR with less ground glass opacities Bronchoalveolar lavage cytology shows malignant cells Biopsy of lung

5. HISTÓRIA Necrotizing Pneumonia Any age group Acute, fulminant life threating complication of previous infection >100.4 °F fever, with hemodynamic instability Worsening pneumonia-like symptoms CXR shows multiple cavitary lesions Pleural effusion and empyema are common findings CBC is positive for the causative organism

6. Granulomatosis with Polyangiitis & Rheumatic disease Women are more commonly affected than man Kidneys are also involved Upper respiratory tract symptoms , perforation of nasal septum, chronic sinusitis, otitis media, mastoiditis. Lower respiratory tract symptoms, hemoptysis, cough, dyspnea. Renal symptoms, hematuria, red cell casts Pulmonary nodules with cavities and infiltrates are a frequent manifestation of CXR Positive for P-ANCA Biopsy of the affected tissue shows necrotizing granulomas Elderly females of 40-50 age group Manifestation of rheumatoid arthritis Presents with other systemic symptoms including symmetric arthritis of the small joints of the hands and feet and morning stiffness are common manifestations. Pulmonary nodules with cavitation are present in the upper lobe (Caplan syndrome) on Xray. Positive for both rheumatoid factor and anti-cyclic citrullinated peptide antibody.

7. Sarcoidosis More common in African-American females Often asymptomatic except for enlarged lymph nodes Associated with restrictive lung disease Erythema nodosum Lupus pernio (skin lesions on face resembling lupus) Bell palsy Epithelioid granulomas containing microscopic Schaumann and asteroid bodies On CXR bilateral adenopathy and coarse reticular opacities are seen. CT of the chest demonstrates extensive hilar and mediastinal adenopathy Additional findings on CT include fibrosis (honeycomb, linear, or associated with bronchial distortion), pleural thickening, and ground-glass opacities. Biopsy of lung reveals non-caseating granuloma

8. Langerhans cell Histiocytosis Exclusively occurs in smokers, with a peak age of onset 20-40 years Clinical presentation is variable, but symptoms usually include months of dry cough, fever, night sweats, and weight loss Skin is involved in 80% of the cases, scaly erythematous rash is typical Thin-walled cystic cavities are the common radiographic manifestation, seen in over 50% of patients on either CXR or CT scans. Biopsy of the lung

9. Of tuberculosis and non-tuberculous mycobacterial infections The family of non-tuberculous mycobacteria (NTM) consists of about 170 species of mycobacteria pulmonary diseases in humans are mostly caused by species of M. avium complex (MAC), M. kansasii, and M. abscessus Human infections due to NTM are primarily acquired from the environment Compared to TB, the clinical presentation of NTM is heterogeneous and complicated by underlying co-morbid conditions, such as DM, COPD, and CF Clinical symptoms, in combination with the presence of pulmonary nodular or cavitary opacities on the radiograph, or multifocal bronchiectasis, and dispersed multiple small nodules on HRCT scan, are indicative of active NTM disease Various biochemical tests, including niacin accumulation test, arylsulfatase test, nitrate reduction, catalase estimation, and growth in MacConkey agar media, are commonly used for NTM species identification One of the vital biochemical tests used routinely in clinical laboratories to discriminate Mtb from NTM is the p-nitro benzoic acid test (PNB)

10. A quick Immunochromatographic test (ICT) kit, called SD Bioline TB Ag MPT64 RAPID® The ICT kit detects MPT 64 antigen, present only in Mtb isolates Another method for NTM species identification is HPLC, in which mycolic acids, a peculiar type of cell wall fatty acids found in mycobacteria, are analyzed There are two forms of NTM lung disease. The less progressive form is sometimes called nodular bronchiectasis The other more progressive form of NTM lung disease is called cavitary disease symptoms include: cough, fatigue, shortness of breath (dyspnea), coughing up of blood (hemoptysis), excessive mucus (sputum) production, fever, night sweats, loss of appetite, and unintended weight loss. Wheezing and chest pain may also occur

11. bacterial infection caused by actinomyces species, especially Actinomyces israelii Detection of ‘sulphur’ granules by gram or histologic staining is the principal method of direct detection of Actinomyces The usual presentation is now an indolent, slowly progressive pneumonia with fever, weight loss, cough, sputum and chest pain Parenchymal patterns of pulmonary actinomycosis include a peripheral pulmonary nodule, mass or consolidation, all of which may or may not be cavitary or multifocal Bronchial infection may occur from aspiration of a foreign body contaminated with Actinomyces organisms Actinomycosis

12. Blastomycosis Blastomycosis is a pulmonary disease caused by inhaling spores of the dimorphic fungus Blastomyces dermatitidis . Occasionally, the fungi spread hematogenously, causing extrapulmonary disease. Symptoms result from pneumonia or from dissemination to multiple organs, most commonly the skin. Symptoms include a productive or dry hacking cough, chest pain, dyspnea, fever, chills, and drenching sweats. Pleural effusion occurs occasionally Pulmonary blastomycosis is manifested on chest x-rays as focal or diffuse infiltrates that sometimes fan out from the hilum

13. Tularemia Tularemia is a zoonotic disease caused by Francisella tularensis that can be transmitted to humans when they handle rabbits, receive tick bites, consume contaminated water, or inhale aerosolized particles Pulmonary tularemia is a subacute or chronic infection that presents with fever, cough, weight loss, and mediastinal lymphadenopathy that mimics tuberculosis, lymphoma, or sarcoidosis Pulmonary tularaemia classically presents with a flu-like illness with fever, headache, fatigue, joint pain, nausea or diarrhoea, often with respiratory symptoms as cough, dyspnoea and chest pain here are few recent studies on radiological findings in pulmonary tularaemia with older studies typically describing infiltrates and hilar adenopathy on chest radiography enlarged hilar and/or mediastinal lymph nodes to be the most common finding on computed tomography (CT) scan of the chest. The World Health Organization (WHO) guideline states that the diagnosis of tularaemia should be based on serological tests, molecular detection or culture

14. Hidradenitis suppurativa Hidradenitis suppurativa (HS), also called acne inversa, is a chronic inflammatory skin condition that affects apocrine gland-bearing skin in the axillae, groin, and under the breasts. It is characterised by persistent or recurrent boil-like nodules and abscesses that culminate in a purulent discharge, sinuses, and scarring. Pulmonary involvement manifests as cavitations Leishmaniasis Multiple nodules in both the lungs with paratracheal lymphadenopathies Leprosy Leprosy is a chronic, progressive bacterial infection caused by the bacterium Mycobacterium leprae . It primarily affects the nerves of the extremities, the skin, the lining of the nose, and the upper respiratory tract. Leprosy is also known as Hansen’s disease. Chest X-ray reveals a large cavity with a mass filled opacity confined to left upper zone and fibrotic changes in right upper zone Computed tomography of thorax revealed fibro-consolidation with cavitation in anterior segment of left upper lobe with fibrotic nodule in anterior and posterior segment of right upper lobe

15. Syphilis The clinical presentation of pulmonary syphilis varies and includes cough, hemoptysis, dyspnea and chest pain . Some patients have no respiratory symptoms. Tracheobronchial syphilis affects limited sections of the airways; if it is severe, subsequent healing and fibrosis can lead to distortion of bronchus and adjacent lung. Luetic pneumonia is chronic and involves both the airspace and interstitium. The disease tends to attack the middle and lower lobes of the lungs. Microscopically, a heavy inflammatory infiltrate of histiocytes, plasma cells and lymphocytes may be seen, as well as small foci of necrosis. Typical gummata have a centre of pale grey or yellow dry necrosis encased by a fibrous capsule from which irregular strands of fibrotic lung extend into and distort the surrounding tissue. These gummata can cause necrosis of the alveolar wall and destruction of elastic tissue, erode into adjacent bronchi and lead to cavitation

16. Syringoma Malignant chondroid syringoma, previously called "mixed tumor of the skin of the salivary gland type"is a fairly uncommon type of sweat gland tumor

17. Resources Tuberculosis differential diagnosis - wikidoc What are the differential diagnoses for Tuberculosis (TB)? [Differential diagnosis of pulmonary tuberculosis] - PubMed Necrotic pulmonary nodules in secondary syphilis Concomittant pulmonary tuberculosis and borderline leprosy with type-II lepra reaction in single patient Visceral Leishmaniasis with Massive Pulmonary Involvement: A Case Report | International Journal of Infection | Full Text Pulmonary manifestations of pyoderma gangrenosum: 2 cases and a review of the literature Pulmonary tularaemia: a differential diagnosis to lung cancer | European Respiratory Society Blastomycosis - Infectious Diseases - MSD Manual Professional Edition An overview of thoracic actinomycosis: CT features Nontuberculous Mycobacterial Lung Disease - NORD (National Organization for Rare Disorders) Learn about Nontuberculous Mycobacteria (NTM) | American Lung Association Tuberculosis and Nontuberculous Mycobacterial Disease - Brigham and Women's Hospital Of tuberculosis and non-tuberculous mycobacterial infections – a comparative analysis of epidemiology, diagnosis and treatment | Journal of Biomedical Science | Full Text

18. Thankyou!