Approach to haemoptysis and pulmonary tuberculosis (incomplete PTB) Flashcards
Differential diagnoses of true haemoptysis
Respiratory
1. Infection - pneumonia, TB, abscess, bronchitis, bronchiectasis, aspergillosis
2. Neoplastic - bronchogenic, metastasis, Kaposi’s sarcoma
3. Vascular - PE, GPA, Goodpasture, HHT, AVM
Cardiac
1. Pulmonary oedema - pink frothy sputum
2. Mitral stenosis
Others
1. Bleeding disorder
2. Anticoagulation
3. Thoracic endometriosis
Differentiate from ENT or UGI bleed
1. Nasopharyngeal carcinoma
2. Oesophageal rupture
3. BGIT causes - PUD, gastric cancer
History taking framework of haemoptysis
A. Characteristics of haemoptysis
B. Associated symptoms
C. Past medical history and medications
D. Family history
E. Social history
A. Characteristics of haemoptysis
Characteristic - site, onset, duration, frequency, previous episodes, colour, quantity
- Site
- ENT bleed: epistaxis
- BGIT: vomit blood (haematemesis), nausea/vomiting/ diarrhoea, epigastic pain, melena
- Respiratory: coughing out blood from airway or lungs - Onset and duration
- Frequency and number of previous episodes
- Colour
- Fresh blood
- Blood clot
- Pink frothy - pulmonary oedema, mitral stenosis
- Brown/rusty/mucopurulent - pneumonia, bronchiectasis
- Black - melanoptysis in pneumoconiosis - Quantity - teaspoon, cups
(volume > 200mL in a day indicates poorer prognosis)
B. Associated symptoms in haemoptysis
Associated symptoms
1. Cough and sputum production
- Acute: infection, pulmonary embolism
- Blood streak: bronchitis
- Chronic purulent: bronchiectasis
2. Dsypnoea - cardiac or respiratory
3. Pleuritic chest pain
4. Fever, rigors, night sweats
- Swinging fever: lung abscess
- Profuse night sweat: tuberculosis
5. Voice hoarseness, dysphagia - bronchogenic ca, enlarged LA in MS
6. Weight loss and anorexia - ca, TB
7. Rash, arthralgia, myalgia - GPA, SLE
8. Other sites of bleeding - GPA, HHT, pulmonary-renal syndrome
9. Leg pain, swelling, erythema - DVT, PE and risks
- Immobility, long travel, recent surgery, malignancy, OCP, prothrombic hereditary states
10. Menstrual history and menstrual pain
C. Past medical history and medications relevant to haemoptysis
D. Family history
Past medical history
1. Recurrent chest infection
- Bronchiectasis, cystic fibrosis, CVID
2. Childhood rheumatic fever - MS
3. Bleeding disorders
4. Malignancy, metastasis and VTE
5. Intracranial haemorrhage (AVM)
6. Gastrointestinal bleeding (AVM, PUD)
7. Chronic liver disease - coagulopathy
8. Immunosuppression and opportunistic infection
Medications
1. Anticoagulation and antiplatelet
2. OCP
3. Recreational drugs - cocaine causing pulmonary haemorrhage and infarct
Family history
1. Lung malignancy
2. Tuberculosis
3. HHT, bleeding disorders and thrombophilia
E. Social history in haemoptysis
- Smoking and betel nut chewing
- Occupational exposure - asbestosis, coal
- Travel history - endemic TB area
Investigations for haemoptysis
- CXR
- CT thorax
- Bronchoscopy
- Sputum - stain and culture, AFB smear culture and PCR, cytology
- FBC - anaemia for blood loss, leukocytosis for infection
- ESR, CRP
- Coagulation panel
- Liver function test
- Renal panel - pulmonary renal syndrome
- CaMgPhos
- D-dimer
- Autoantibodies - ANCA, anti-BGM, SLE panel
- UFEME - red cell cast
Population groups at high risk of tuberculosis
- Endemic regions - Africa, Asia, Eastern Europe
- Low SES - crowded living conditions, homelessness, poor healthcare
- Immunocompromised - HIV, immunosuppressants, chemotherapy
- Healthcare workers
Diagnosis of pulmonary tuberculosis
- CXR - hilar lymphadenopathy, apical consolidation/cavitation, collapse, miliary TB
- AFB smear, culture x2 and PCR x1
Additional tests as indicated:
3. Blood tests including HIV serology
4. CT thorax
5. Bronchoscopy
Additional tests for endemic areas when positive:
6. RIF PCR
7. Whole genome sequencing
How would you treat pulmonary tuberculosis?
Intensive or bacteriocidal phase:
rifampicin (R), isoniazid (H), pyrazinamide (Z) and ethambutol (E) for 2 months
Continuation phase:
rifampicin and isoniazid for 4 months
(Multi-drug resistant, treatment with at least three different drugs should be continued until the sputum culture becomes negative, and then at least two different drugs should be continued for 12-24 months)
Combination drugs for PTB
- Rifater: Rifampicin, Isoniazid and Pyrazinamide
- Voractiv: RHZE
Differing guidelines on treatment of mono-isoniazid resistant PTB
Differing guidelines due to gaps in approach
Some may add fluoroquinolone to NICE regimen, particularly if sensitivities shown a fourth effective oral drug
Meta-analysis suggests extending rifampicin duration > 6 months is more effective
Monitoring of PTB treatment
Pre-treatment and during treatment
1. FBC, RP, LFT - dyscrasias, nephrotoxicity, hepatotoxicity
2. Visual acuity, colour vision, fundoscopy - ethambutol
3. Peripheral neuropathy - isoniazid
4. HIV, Hep B, Hep C
NICE guideline on treatment interruption due to drug-induced hepatotoxicity
- Investigate other causes of acute liver reactions and
- Wait until ALT or AST fall below 2x ULN, bilirubin normalised and hepatotoxic symptoms resolved
(no need to wait for full normalisation of LFT) - Sequentially reintroduce each of the anti-TB drugs at full dose over a period of no more than 10 days
- Start with ethambutol and either isoniazid (with
pyridoxine) or rifampicin
Treatment of TB meningitis
- 2HRZE / 10HR
(NICE guideline recommends minimum of 9 months of treatment) - Corticosteroids (dexa or pred)
Paradoxical reaction during PTB treatment
Worsening PTB disease or enlarging lymph nodes to formation of LN abscess during treatment
Unpredictable
- Anytime: few days to months after the start of anti-TB
- Varying duration and severity
Common in:
- HIV co-infection (TB-IRIS)
- Disseminated TB
Usually resolves with continuing treatment
Can add on corticosteroids to reduce inflammation
Check compliance to medications
Limited value for repeat imaging
Management of known PTB contact
With BCG vaccination:
1. Mantoux test under 35 years old
2. CXR over 35 years old
Without BCG vaccination:
1. Mantoux test, IGRA and CXR
2. Provide BCG vaccination if negative
What are the side effects of tuberculosis medications?
Isoniazid - peripheral neuropathy, hepatitis
Rifampicin - hepatitis, enzyme inducer
Ethambutol - hepatitis, retro-bulbar neuritis
Pyrazinamide - hepatitis
What are the clinical features of old tuberculosis infection?
Apical fibrosis
Thoracoplasty
Pneumonectomy
Lobectomy
Phrenic nerve crush (left supraclavicular scar)
Recurrent pneumothoraces
What is the prevalence of tuberculosis?
2 billion individuals worldwide, with 8 million new diagnoses every year
2021 WHO estimates:
- Asia 59% of cases
- Africa 26% of cases
What are the risk factors for developing tuberculosis?
Immigrant population
Immunocompromised
Elderly patients
Alcoholics
Malnutrition
Homeless individuals
Occupational exposure
What are the acute complications of tuberculosis?
Respiratory: Pneumothorax, Pleural effusion, Empyema, Collapse, ARDS, respiratory failure
Tubulointerstitial nephritis
Tuberculous meningitis
Miliary TB
What are the chronic complications of tuberculosis?
Pulmonary fibrosis
Bronchiectasis
Cor pulmonale
Aspergilloma
Reactivation
What are the past methods of treatment for PTB?
Intended to render affected lungs hypoxic to kill bacteria
- Pneumonectomy
- Thoracoplasty (removal of section of rib to collapse the lung)
- Phrenic nerve crush (supraclavicular fossa scar)
- Iatrogenic pneumothoraces
- Plombage (insertion of inert substance into pleural space to collapse lung)
Examples of non-tuberculous mycobacterium (NTMs)
What NTM is associated with person-to-person transmission
Slow-growing NTMs (SG-NTMs)
1. Mycobacterium avium complex (MAC)
2. Mycobacterium malmoense
3. Mycobacterium kansasii
4. Mycobacterium xenopi
5. Others: marinum, ulcerans
Fast-growing NTMs (FG-NTMs)
1. Mycobacterium abscessus
2. Mycobacterium chelonae
3. Mycobacterium fortuitum
Almost all NTMs are acquired from environmental sources, except mycobacterium abscessus (shown to have increasing person-to-person transmission)
What are the differences between SG-NTMs and FG-NTMs?
Clinical clues for diagnosis of NTMs
- Chronic lung disease
→ MAC, M. kansasii (SG-NTMs) - Rapidly progressive lung disease
→ M. abscessus (FG-NTMs) - Cutaneous exposure (fish, water)
→ M. marinum - Painless ulcer with undermined edges
→ M. ulcerans - Post-surgical or nosocomial infection
→ M. abscessus, M. fortuitum
Diagnostic criteria for NTM-pulmonary disease
2 clinical criteria (both must be satisfied):
1. Pulmonary symptoms or progression of nodular or cavitary opacities on CXR or HRCT multifocal bronchiectasis with multiple small nodules
2. Appropriate exclusion of other diagnoses
Microbiological criteria (1 criteria sufficient):
1. Positive culture at least two separate expectorated sputum samples;
(if results are non-diagnostic, consider repeat sputum acid-fast bacillus (AFB) smears and cultures.
2. Positive culture from at least one BAL
3. Transbronchial or other lung biopsy with:
- Mycobacterial histopathological features (granulomatous inflammation or AFB)
- Positive culture for NTM (sputum/BAL/biopsy)
Susceptibility testing for NTMs and its treatment
Treatment regimens should be
continued for a minimum of 12 months after culture conversion
Tuberculin Skin Test (TST) is also known as the Mantoux test,
- Used to detect latent tuberculosis infection (LTBI) and assess TB exposure.
Technique:
1. Injection of 0.1 mL of purified protein derivative (PPD) intradermally
2. Measure induration (not erythema) after 48–72 hours.
Interpretation of tuberculin skin test
Considerations:
1. Overwhelming TB Disease/severe disseminated TB (e.g., miliary TB) can paradoxically suppress TST response due to immune exhaustion.
2. BCG Vaccination – Can cause a mild positive TST but typically <10 mm unless recent.
3. Non-Tuberculous Mycobacteria (NTM) Infection – Can cause minor reactivity.
Treatment for latent PTB
NICE guidelines (choice of either 1):
1. 3 months of isoniazid (with pyridoxine) and rifampicin
- younger than 35 years if hepatotoxicity is a concern
2. 6 months of isoniazid (with pyridoxine)
- if interactions with rifamycin are a concern (in HIV treatment; or transplant patient)
Offer testing for HIV and hepatitis B and C before commencing treatment for latent TB.
