Extrapulmonary tuberculosis — MSF Tuberculosis

What this guideline says

GMJ summary

This MSF clinical guideline section addresses extrapulmonary tuberculosis (EPTB), which accounts for approximately 16% of global TB cases. EPTB occurs when M. tuberculosis spreads from a pulmonary focus to other organs, most commonly lymph nodes, meninges, bones and joints, kidneys, genital organs and the abdominal cavity. Young children, HIV-infected persons and malnourished patients are at higher risk due to relative immunodeficiency.

The guideline emphasises that patients with EPTB may also have concurrent pulmonary TB, which should always be sought. It provides detailed clinical presentations for eight forms of EPTB: lymph node TB (the most common, particularly in Africa and Asia), tuberculous meningitis (a medical emergency most common in children under 2 years), bone and joint TB (including spinal TB/Pott’s disease), urogenital TB, abdominal TB, pleural effusion, pericardial effusion and cutaneous TB.

Diagnosis relies on clinical presentation combined with specimen collection and testing where possible. The guideline notes specific diagnostic clues for each form, such as cold painless lymph nodes that soften and fistulise, subacute meningitis with cranial nerve palsies, chronic mono-arthritis with joint destruction, and pyuria unresponsive to antibiotics in urogenital TB. Lymph nodes typically disappear within 3 months of treatment, though paradoxical reactions may occur without requiring treatment changes.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Approximately 16% of global TB cases are extrapulmonary; young children, HIV-infected persons and malnourished patients are at higher risk
2. Always search for concurrent pulmonary TB when EPTB is diagnosed or suspected; up to 40% of bone and joint TB patients have concurrent PTB
3. Lymph node TB presents as cold, painless adenopathy (usually bilateral or single) that evolves chronically towards softening and fistulisation; nodes typically disappear within 3 months of treatment
4. TB meningitis is a medical emergency most common in children under 2 years and HIV-infected persons; any delay results in irreversible neurological sequelae or death
5. Spinal TB (Pott's disease) most frequently affects the thoracic spine; localised back pain may precede radiological anomalies by several months, and missed diagnosis can result in paralysis
6. Tuberculous pleural effusion is often asymptomatic if less than 300 ml; shortness of breath and chest pain occur with large effusions
7. Urogenital TB diagnosis is suspected when pyuria and haematuria do not respond to antibiotics for urinary infection
8. Paradoxical reactions in lymph node TB (appearance of abscesses, fistulas or other lymph nodes) may occur at treatment initiation but do not require treatment changes

From the guideline

Verbatim

“TB meningitis is a serious form of TB that affects the meninges. It is most common in children under 2 years and in HIV-infected persons. It is a medical emergency. Any delay in diagnosis or treatment will result in irreversible neurological sequelae or death.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

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