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Tuberculosis case history

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"tuberculosis"[MeSH Terms] AND "diagnosis"[MeSH Terms]

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WHO tuberculosis screening symptoms diagnosis guideline 2025

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Tuberculosis Case History Format

1. Identification Data

  • Name:
  • Age / Sex:
  • Address:
  • Occupation:
  • Date of admission:
  • Date of examination:
  • Informant and reliability:

2. Chief Complaints

Example:
  • Cough with expectoration for 1 month
  • Fever, mainly evening rise, for 3 weeks
  • Loss of weight and appetite for 1 month
  • Night sweats for 2 weeks
  • Hemoptysis, if present, with duration and approximate quantity

3. History of Present Illness

Describe symptoms in chronological order.
Cough
  • Onset, duration, progressive/static
  • Dry or productive
  • Quantity, color, odor of sputum
  • Any blood in sputum
  • Relation to posture, exertion, day or night
Fever
  • Duration and pattern: low-grade, intermittent, evening rise
  • Chills, rigors, sweating
  • Response to antipyretics
Constitutional symptoms
  • Loss of appetite
  • Weight loss
  • Fatigue, weakness
  • Night sweats
Respiratory symptoms
  • Breathlessness
  • Chest pain, especially pleuritic pain
  • Wheeze
  • Hoarseness of voice
Features suggesting extrapulmonary TB
  • Headache, vomiting, altered sensorium, seizures: CNS TB
  • Neck swelling: tuberculous lymphadenitis
  • Back pain or deformity: spinal TB
  • Abdominal pain, distension, altered bowel habits: abdominal TB
  • Joint pain/swelling
  • Dysuria, hematuria, infertility: genitourinary TB
Negative history
  • No previous similar illness or anti-tubercular treatment, if applicable
  • No known diabetes, HIV infection, chronic kidney or liver disease
  • No history suggestive of malignancy or another chronic lung disease
Pulmonary TB commonly presents with cough, fever, night sweats, anorexia, weight loss, and sometimes hemoptysis. It may be extrapulmonary in 10% to 25% of cases. Textbook of Family Medicine, 9e, p. 298.

4. History of Contact

Ask specifically:
  • Contact with a known TB patient, especially at home
  • Duration and closeness of contact
  • History of cough among family members
  • Overcrowding, poor ventilation
  • Recent travel, hostel/prison/shelter residence
  • Exposure to silica dust, mining, healthcare work

5. Past History

  • Previous TB or anti-tubercular treatment
  • Previous treatment completion, interruptions, or treatment failure
  • Diabetes mellitus
  • HIV status or recurrent infections
  • Chronic liver disease, renal disease
  • Previous hospitalizations or blood transfusions
  • Any prior chest radiograph or sputum test results

6. Drug, Allergy, and Personal History

  • Current medications, especially immunosuppressants or steroids
  • Drug allergy
  • Smoking: pack-years
  • Alcohol use
  • Injection drug use
  • Nutrition and dietary history
  • Bowel and bladder habits
  • Sleep disturbance due to cough or fever

7. Family History

  • Similar symptoms or diagnosed TB in household contacts
  • Diabetes, HIV, or chronic respiratory disease in family members

8. Socioeconomic History

  • Housing, ventilation, crowding
  • Occupation and dust exposure
  • Financial barriers to nutrition or treatment adherence
  • Availability of family support and access to a TB program

Examination

General Physical Examination

  • General condition, consciousness, nutritional status
  • Temperature, pulse, blood pressure, respiratory rate, oxygen saturation
  • Pallor, icterus, cyanosis, clubbing
  • Lymphadenopathy, especially cervical and supraclavicular nodes
  • Pedal edema
  • Weight, height, BMI

Respiratory System Examination

Inspection
  • Chest shape, symmetry, movement
  • Supraclavicular hollowing, intercostal retractions
  • Prominent veins or scars
Palpation
  • Tracheal position
  • Chest expansion
  • Tactile vocal fremitus
Percussion
  • Dullness over consolidation, effusion, or collapse
  • Hyperresonance if pneumothorax
Auscultation
  • Bronchial breath sounds
  • Crackles, especially upper-zone crepitations
  • Increased vocal resonance
  • Amphoric breath sounds or cavernous breathing in cavitary disease
  • Pleural rub if pleurisy

Systemic Examination

  • CNS: signs of meningitis or focal deficit
  • Abdomen: hepatosplenomegaly, ascites, abdominal mass
  • Spine and joints: tenderness, deformity, restricted movement
  • Genitourinary examination if symptoms indicate

Investigations

  1. Sputum examination
    • Acid-fast bacilli smear microscopy
    • Nucleic acid amplification test, such as Xpert MTB/RIF or another WHO-recommended rapid molecular test
    • Mycobacterial culture and drug-susceptibility testing when indicated
  2. Chest radiograph
    • Upper-lobe infiltrates or cavities are typical of reactivation TB.
    • Primary disease can show consolidation and lymphadenopathy.
    • A normal chest radiograph does not exclude TB, particularly in people with HIV. Textbook of Family Medicine, 9e, p. 298.
  3. Baseline tests before treatment
    • Complete blood count
    • ESR or CRP
    • Liver and renal function tests
    • HIV test, with consent and counseling
    • Blood glucose
    • Pregnancy test where relevant
    • Visual acuity and color vision assessment if ethambutol is planned
  4. If extrapulmonary TB is suspected
    • FNAC/biopsy of lymph node
    • Pleural fluid analysis and biopsy
    • CSF examination and neuroimaging
    • Ultrasound or CT abdomen
    • MRI spine
    • Site-specific biopsy for histology, AFB testing, molecular testing, culture, and drug susceptibility
WHO recommends systematic screening of high-risk groups, including household contacts and people living with HIV, and supports the use of symptom screening, chest radiography, and rapid molecular tests in appropriate settings. See the WHO TB screening guidance and WHO rapid-diagnostics guidance.

Example Case Summary

A 32-year-old male construction worker presented with productive cough for 1 month, low-grade evening fever for 3 weeks, night sweats, anorexia, and unintentional weight loss of 5 kg over 1 month. He had two episodes of scanty hemoptysis. There was a history of close household contact with a person receiving treatment for pulmonary tuberculosis. He had no previous TB treatment, diabetes, or known HIV infection. Examination showed low BMI, low-grade fever, and right upper-zone crackles with bronchial breath sounds. Chest radiograph showed a right upper-lobe cavity. Sputum molecular testing detected Mycobacterium tuberculosis and should be assessed for rifampicin resistance.
Provisional diagnosis: Bacteriologically confirmed pulmonary tuberculosis, pending drug-susceptibility results.

Important Clinical Notes

  • A positive tuberculin skin test or interferon-gamma release assay supports TB infection but does not diagnose active TB by itself.
  • Assess for drug resistance, HIV, diabetes, liver disease, pregnancy, and prior TB treatment before finalizing therapy.
  • Suspected infectious pulmonary TB needs prompt infection-control measures and notification/referral according to local public-health requirements.
  • Treatment regimen and duration must follow the current national TB program or specialist advice, especially for rifampicin-resistant or multidrug-resistant TB.

Treatment

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"Tuberculosis"[MeSH Terms] AND "Drug Therapy"[MeSH Terms]

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WHO consolidated guidelines tuberculosis treatment drug susceptible tuberculosis 2025

Treatment of Tuberculosis

Treatment depends on whether TB is drug-susceptible, drug-resistant, latent, or extrapulmonary. Confirm disease with a rapid molecular test and obtain drug-susceptibility results whenever possible before finalizing the regimen.

1. Drug-susceptible pulmonary TB

Standard 6-month regimen

  • Intensive phase, first 2 months:
    H + R + Z + E
    Isoniazid + Rifampicin + Pyrazinamide + Ethambutol
  • Continuation phase, next 4 months:
    H + R
    Isoniazid + Rifampicin
Written as: 2HRZE/4HR
This is the usual first-line regimen for newly diagnosed drug-susceptible TB. Treatment should be weight-based and administered under the national TB program with adherence support. The 2025 WHO guidance retains 2HRZE/4HR as a strongly recommended standard regimen for drug-susceptible pulmonary TB. See the WHO treatment guideline.

2. Alternative shorter regimen

In eligible patients with drug-susceptible pulmonary TB, WHO also recommends a 4-month regimen using:
  • Rifapentine
  • Isoniazid
  • Pyrazinamide
  • Moxifloxacin
Eligibility, availability, HIV antiretroviral interactions, pregnancy status, and local program policy must be checked before using it. The conventional 6-month regimen remains an appropriate alternative.

3. Pyridoxine supplementation

Give pyridoxine (vitamin B6) with isoniazid, particularly in patients who are:
  • Malnourished
  • Pregnant or breastfeeding
  • Diabetic
  • Living with HIV
  • Alcohol-dependent
  • Having renal failure
  • At risk of peripheral neuropathy

4. Monitoring during treatment

At each visit assess:
  • Fever, cough, hemoptysis, appetite, weight, and adherence
  • Adverse drug effects
  • Sputum smear/culture or molecular follow-up according to local protocol
  • Drug-susceptibility results
  • HIV status and diabetes control
Important adverse effects
DrugImportant toxicity
IsoniazidHepatitis, peripheral neuropathy
RifampicinHepatitis, orange discoloration of body fluids, major drug interactions
PyrazinamideHepatitis, hyperuricemia, arthralgia
EthambutolOptic neuritis, impaired visual acuity or red-green color discrimination
Check liver tests when clinically indicated or in patients with liver disease, alcohol use, HIV, pregnancy/postpartum state, or symptoms of hepatitis. Check baseline and follow-up vision if ethambutol is used.

5. Infection control and supportive care

  • Advise cough etiquette, good ventilation, and mask use while infectious.
  • Evaluate household and close contacts for TB disease and TB infection.
  • Notify and coordinate treatment with the local tuberculosis program.
  • Provide nutrition support, smoking cessation, and management of diabetes, HIV, or other comorbidities.
  • A patient with smear-positive pulmonary TB is generally much less infectious after effective therapy, but isolation decisions should follow local public-health guidance and clinical response. Textbook of Family Medicine, 9e, p. 298.

6. Drug-resistant TB

If molecular testing shows rifampicin resistance, or there is prior TB treatment, treatment failure, or contact with drug-resistant TB:
  • Do not continue a routine first-line regimen without expert review.
  • Obtain full drug-susceptibility testing.
  • Refer to a TB specialist/national drug-resistant TB program.
  • Use an all-oral, WHO-recommended regimen selected according to resistance pattern, previous drugs, disease severity, and drug availability.
Drug-resistant TB commonly involves bedaquiline-based regimens, but the exact regimen must be individualized and managed by a specialist because toxicity and interactions can be substantial. Recent evidence continues to evaluate bedaquiline and linezolid-containing regimens for multidrug-resistant TB, including PMID 40172415.

7. Latent TB infection

Latent TB means a positive TST or IGRA without evidence of active disease. Rule out active TB before starting preventive therapy. Preferred shorter preventive options may include:
  • 3 months once-weekly isoniazid plus rifapentine
  • 3 months daily isoniazid plus rifampicin
  • 4 months daily rifampicin
  • 6 to 9 months isoniazid when shorter regimens are unsuitable
The exact choice depends on age, HIV medicines, pregnancy, resistance exposure, and local program recommendations.

Case-sheet treatment plan wording

“Patient will be started on weight-band based anti-tubercular therapy after confirmation of drug-susceptible pulmonary tuberculosis: intensive phase with isoniazid, rifampicin, pyrazinamide, and ethambutol for 2 months, followed by isoniazid and rifampicin for 4 months, with pyridoxine supplementation, adherence support, adverse-effect monitoring, contact tracing, and follow-up sputum/drug-susceptibility assessment according to national TB program guidelines.”

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WHO 2025 tuberculosis treatment 2HRZE 4HR drug susceptible

Tuberculosis Treatment: Viva Questions and Answers

1. What is the standard treatment for new drug-susceptible pulmonary TB?

2HRZE/4HR, given daily.
  • Intensive phase, 2 months: H + R + Z + E
    Isoniazid, Rifampicin, Pyrazinamide, Ethambutol
  • Continuation phase, 4 months: H + R
    Isoniazid and Rifampicin
Total duration is usually 6 months.

2. Expand HRZE.

  • H: Isoniazid
  • R: Rifampicin
  • Z: Pyrazinamide
  • E: Ethambutol

3. Why are four drugs used initially?

To:
  • Rapidly reduce bacillary load
  • Prevent emergence of drug resistance
  • Cover possible initial resistance until drug-susceptibility results are available
  • Treat bacilli in different metabolic states and sites

4. What is the usual adult daily dose?

Approximate weight-based daily doses:
  • Isoniazid: 5 mg/kg, maximum 300 mg/day
  • Rifampicin: 10 mg/kg, maximum 600 mg/day
  • Pyrazinamide: 20-25 mg/kg/day
  • Ethambutol: 15-20 mg/kg/day
In practice, use national TB program weight-band fixed-dose combinations.

5. Why is pyridoxine given with isoniazid?

Isoniazid can cause peripheral neuropathy by interfering with pyridoxine metabolism. Therefore, give pyridoxine (vitamin B6), particularly in diabetes, HIV, malnutrition, pregnancy, alcohol dependence, chronic kidney disease, and pre-existing neuropathy.

6. What are the important adverse effects of first-line anti-TB drugs?

DrugImportant adverse effects
IsoniazidHepatitis, peripheral neuropathy, lupus-like syndrome
RifampicinHepatitis, orange-red body fluids, flu-like syndrome, drug interactions
PyrazinamideHepatotoxicity, hyperuricemia, arthralgia
EthambutolOptic neuritis, reduced visual acuity, red-green color blindness

7. Which drug causes orange discoloration of urine?

Rifampicin. It can turn urine, tears, saliva, and sweat orange-red. It may stain soft contact lenses.

8. Which anti-TB drug causes peripheral neuropathy?

Isoniazid. Prevent with pyridoxine.

9. Which anti-TB drug causes optic neuritis?

Ethambutol. Ask about blurring of vision and impaired red-green color discrimination. Stop the drug and urgently assess if visual symptoms occur.

10. Which anti-TB drug causes hyperuricemia?

Pyrazinamide, and it can cause arthralgia or precipitate gout.

11. Which drugs are hepatotoxic?

Isoniazid, rifampicin, and pyrazinamide. Evaluate promptly if nausea, vomiting, abdominal pain, jaundice, dark urine, or marked fatigue develops.

12. How do you monitor a patient on treatment?

  • Clinical improvement: fever, cough, appetite, weight
  • Treatment adherence
  • Sputum follow-up as per national protocol
  • Drug-susceptibility results
  • Adverse effects, especially hepatitis, neuropathy, and visual symptoms
  • Liver function tests when indicated
  • HIV testing and blood glucose assessment
  • Contact tracing and screening of household members

13. What is DOT?

Directly Observed Therapy means observing or supporting the patient to take anti-TB drugs to improve adherence and reduce treatment failure, relapse, and resistance.

14. What is MDR-TB?

Multidrug-resistant TB is TB resistant to at least:
  • Isoniazid, and
  • Rifampicin

15. What is rifampicin-resistant TB?

TB with resistance to rifampicin, with or without resistance to other anti-TB drugs. It requires evaluation under a drug-resistant TB program.

16. What should be done if rifampicin resistance is detected?

  • Obtain complete drug-susceptibility testing.
  • Refer to a TB specialist or drug-resistant TB program.
  • Use an individualized WHO/national-program recommended all-oral regimen.
  • Do not manage it with the routine 6-month first-line regimen alone.

17. Is steroid therapy used in TB?

Steroids are used as adjuncts in selected forms, especially:
  • Tuberculous meningitis
  • Tuberculous pericarditis
They are not routinely required in uncomplicated pulmonary TB.

18. How is extrapulmonary TB treated?

Most forms are treated with the same first-line regimen as pulmonary TB. However, duration may be longer in some situations, particularly:
  • TB meningitis
  • Bone and joint TB
  • Spinal TB
Follow local/national guidelines and specialist advice.

19. How is latent TB different from active TB?

  • Latent TB infection: Patient has TB infection but no symptoms, no infectivity, and no evidence of active disease.
  • Active TB disease: Symptomatic or clinically/radiologically/microbiologically evident disease that needs multidrug treatment.
Always exclude active TB before starting latent-TB preventive treatment.

20. One-line viva answer

“A newly diagnosed drug-susceptible pulmonary TB patient is treated with daily 2HRZE/4HR: isoniazid, rifampicin, pyrazinamide, and ethambutol for 2 months, followed by isoniazid and rifampicin for 4 months, along with pyridoxine, adherence support, adverse-effect monitoring, and assessment for drug resistance.”
The WHO 2025 consolidated recommendations retain daily 2HRZE/4HR as the standard 6-month regimen for new drug-susceptible pulmonary TB. Some eligible patients may receive specific shorter rifapentine-moxifloxacin regimens under program guidance. See the WHO treatment recommendations.

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"Tuberculosis"[MeSH Terms] AND "Diagnosis"[MeSH Terms]

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WHO tuberculosis diagnosis rapid molecular test Xpert 2025 guidelines

Tuberculosis Investigations: Viva Questions and Answers

1. What are the investigations for suspected pulmonary TB?

  1. Sputum examination
    • AFB smear microscopy
    • Rapid molecular test, for example Xpert MTB/RIF or Xpert Ultra
    • Mycobacterial culture
    • Drug-susceptibility testing
  2. Chest X-ray
  3. Baseline blood investigations
    • CBC
    • ESR/CRP
    • Liver function tests
    • Renal function tests
    • Blood glucose
    • HIV test after consent
    • Pregnancy test where applicable
  4. Tests for extrapulmonary TB, based on site involved:
    • FNAC/biopsy
    • Pleural fluid examination
    • CSF analysis
    • USG/CT/MRI as appropriate

2. What is the most important initial test?

A WHO-recommended rapid molecular test on sputum, such as Xpert MTB/RIF Ultra, is preferred where available because it detects Mycobacterium tuberculosis and identifies rifampicin resistance rapidly.

3. What does Xpert MTB/RIF detect?

It detects:
  • DNA of Mycobacterium tuberculosis complex
  • Mutations associated with rifampicin resistance
Results are available within hours. WHO recognizes rapid molecular testing as central to modern TB diagnosis. See the WHO diagnostic guideline.

4. What is the role of sputum AFB smear microscopy?

It detects acid-fast bacilli in sputum.
Advantages
  • Cheap, quick, widely available
  • Helps assess infectiousness
Limitations
  • Less sensitive than molecular tests and culture
  • Cannot reliably distinguish TB from nontuberculous mycobacteria
  • Does not provide complete drug-susceptibility information

5. What stain is used for AFB?

  • Ziehl-Neelsen stain
  • Auramine-rhodamine fluorescent stain may also be used

6. Why are mycobacteria called acid-fast?

Their cell wall contains mycolic acid, so after staining with carbol fuchsin, they resist decolorization by acid-alcohol.

7. What is the gold-standard test for TB diagnosis?

Mycobacterial culture is the reference standard because it confirms viable organisms and permits drug-susceptibility testing.

8. What are the culture methods?

  • Solid culture: Lowenstein-Jensen medium
  • Liquid culture: MGIT system
Liquid culture is faster, while solid culture may take several weeks.

9. How many sputum samples should be sent?

Send sputum samples according to the local/national TB program. Traditionally, multiple samples were used. Textbook practice describes submitting sputum for AFB smear and culture, plus at least one specimen for nucleic-acid amplification testing. Goldman-Cecil Medicine, “Respiratory Specimen Testing.”

10. What if the patient cannot produce sputum?

  • Induced sputum
  • Bronchoscopy with bronchoalveolar lavage, if needed
  • Gastric aspirate in children
  • Test a sample from the involved extrapulmonary site, such as lymph-node aspirate, pleural fluid, CSF, or tissue biopsy

11. What are the chest X-ray findings in pulmonary TB?

Typical findings include:
  • Upper-lobe infiltrates
  • Cavitary lesions, especially in reactivation TB
  • Fibrosis and volume loss
  • Hilar/mediastinal lymphadenopathy, more common in primary TB
  • Miliary nodules in disseminated TB
  • Pleural effusion
A chest X-ray supports diagnosis but does not confirm TB.

12. Can a normal chest X-ray exclude TB?

No. It does not exclude TB, especially in early disease or in people living with HIV.

13. What is the role of CT chest?

CT is more sensitive than X-ray for:
  • Small cavities
  • Tree-in-bud nodules
  • Mediastinal lymph nodes
  • Miliary disease
  • Complications such as bronchiectasis or pleural disease
It is not routinely necessary if sputum molecular testing gives a diagnosis.

14. What is the role of ESR?

ESR may be raised but is nonspecific. It cannot diagnose TB and should not be used alone to monitor response.

15. What is the role of Mantoux test?

The Mantoux test detects previous sensitization to TB antigens.
A positive result may indicate:
  • TB infection
  • Past TB
  • BCG vaccination
  • Exposure to nontuberculous mycobacteria
It cannot differentiate active TB from latent TB infection.

16. What is IGRA?

Interferon-gamma release assay is a blood test that detects immune sensitization to TB-specific antigens.
Examples:
  • QuantiFERON-TB Gold
  • T-SPOT.TB
It is mainly useful in evaluating latent TB infection and does not confirm active TB.

17. What is CBNAAT?

Cartridge-Based Nucleic Acid Amplification Test is the common programmatic term for Xpert MTB/RIF testing. It detects TB DNA and rifampicin resistance.

18. What baseline tests are done before anti-TB treatment?

  • Weight for weight-band drug dosing
  • CBC
  • Liver and renal function tests when indicated
  • Blood glucose
  • HIV test
  • Pregnancy test if relevant
  • Visual acuity and red-green color vision testing before ethambutol
  • Hepatitis evaluation when indicated

19. What is drug-susceptibility testing?

It determines whether the organism is susceptible or resistant to anti-TB drugs, especially rifampicin and isoniazid. It is essential in previously treated patients, treatment failure, contact with drug-resistant TB, or rifampicin resistance detected on a molecular test.

20. One-line viva answer

“In suspected pulmonary tuberculosis, I will send sputum for rapid molecular testing such as CBNAAT/Xpert MTB-RIF, AFB smear microscopy, culture, and drug-susceptibility testing; obtain a chest X-ray; and perform baseline tests including HIV testing, blood glucose, liver and renal function tests before treatment.”
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