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Extrapulmonary tuberculosis

Key sources
The following summarized guidelines for the evaluation and management of extrapulmonary tuberculosis are prepared by our editorial team based on guidelines from the French Society of Infectious Diseases (SPLIF 2023), the European Bone and Joint Infection Society (EBJIS 2023), the U.S. Preventive Services Task Force (USPSTF 2023), the Canadian Thoracic Society (CTS 2022), the World Health Organization (WHO 2022; 2021; 2020; 2017), the Neurocritical Care Society (NCS 2020), the European Association of Nuclear Medicine (EANM/ESNR/ESCMID 2019), the Infectious Diseases Society of America (IDSA/ATS/CDC 2017; 2016), the Infectious Diseases Society of America (IDSA 2015; 2008), the European Society of Cardiology (ESC/EACTS 2015), and the British Thoracic Society (BTS 2010).
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Guidelines

1.Screening and diagnosis

Screening for latent tuberculosis: as per USPSTF 2023 guidelines, obtain screening for latent tuberculosis infection in populations at increased risk.
B
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2.Diagnostic investigations

Specimen collection, general principles: make every effort to collect clinical samples for both mycobacteriologic (AFB smear, culture, NAAT) and histopathologic tests.
E

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  • Specimen collection (bone and joint)

  • Fluid specimen analysis (general principles)

  • Fluid specimen analysis (pleural fluid)

  • Fluid biomarkers

  • Acid-fast bacilli smear (general principles)

  • Acid-fast bacilli smear (pleural fluid)

  • Acid-fast bacilli smear (synovial fluid)

  • Mycobacterial culture (general principles)

  • Mycobacterial culture (pleural fluid)

  • Mycobacterial culture (synovial fluid)

  • Nucleic acid amplification testing

  • Blood/skin tests

  • Testing for pulmonary tuberculosis

3.Diagnostic procedures

Tissue biopsy, general principles: perform a histological examination of specimens collected from sites of suspected extrapulmonary tuberculosis.
B

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  • Tissue biopsy (pleural biopsy)

  • Tissue biopsy (synovial biopsy)

4.Medical management

Setting of care: as per WHO 2017 guidelines, consider offering the following treatment administration options in patients on tuberculosis treatment:
community- or home-based directly observed treatment over health facility-based directly observed treatment or unsupervised treatment
C
directly observed treatment administered by trained lay providers or health-care workers over directly observed treatment administered by family members or unsupervised treatment
C
video-observed treatment over directly observed treatment when the video communication technology is available and can be appropriately organized and operated by healthcare providers and patients.
C

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  • Management of tuberculous lymphadenitis (antimycobacterial therapy)

  • Management of tuberculous lymphadenitis (surgery/drainage)

  • Management of pleural tuberculosis (antimycobacterial therapy)

  • Management of pleural tuberculosis (adjunctive corticosteroids)

  • Management of pleural tuberculosis (thoracentesis)

  • Management of tuberculous pericarditis (antimycobacterial therapy)

  • Management of tuberculous pericarditis (adjunctive corticosteroids)

  • Management of tuberculous pericarditis (intrapericardial urokinase)

  • Management of tuberculous pericarditis (pericardiectomy)

  • Management of tuberculous meningitis (antimycobacterial therapy)

  • Management of tuberculous meningitis (adjunctive corticosteroids)

  • Management of abdominal tuberculosis

  • Management of genitourinary tuberculosis

  • Management of bone and joint tuberculosis (antimycobacterial therapy)

  • Management of bone and joint tuberculosis (surgery)

  • Management of ocular tuberculosis

  • Management of skin tuberculosis

  • Management of disseminated tuberculosis

  • Management of tuberculoma (antimycobacterial therapy)

  • Management of tuberculoma (adjunctive corticosteroids)

5.Specific circumstances

Patients with human immunodeficiency virus infection: as per WHO 2022 guidelines, initiate ART as early as possible (within the first 8 weeks) following the initiation of antituberculosis treatment in all patients with HIV infection and drug-resistant tuberculosis requiring second-line antituberculosis drugs, irrespective of the CD4 cell count.
B

6.Patient education

Patient support: as per WHO 2017 guidelines, provide health education and counseling on the disease and treatment adherence in patients receiving tuberculosis treatment.
B
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