Summary of clinical presentations of tuberculosis — MSF Tuberculosis — Médecins Sans Frontières 2026

MSFClinical guideline (chapter)Current edition

From Tuberculosis › Chapter 2: Clinical presentation · Médecins Sans Frontières, Current online edition, 2026

MSF guidance on recognising pulmonary, extrapulmonary and disseminated TB in HIV-infected and non-HIV patients.

In one sentenceMSF guidance describes clinical presentations of TB at multiple anatomical sites, emphasising that HIV co-infection modifies symptoms (more fever/weight loss, less cough/haemoptysis in pulmonary TB) and requires exclusion of cryptococcal meningitis.

Issuer: Médecins Sans Frontières
Edition: Current online edition, 2026
Audience: Clinicians and healthcare workers managing tuberculosis patients in resource-limited settings
Evidence: Expert consensus based on MSF field experience
Reviewed: 21 Oct 2026 · GMJ

Read the original on MSF Whole guideline (PDF)

Summary by GMJ Guidelines Desk•Reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD•Record updated 21 Oct 2026•Next check Apr 2027

What this guideline says

GMJ summary

This section from the MSF Tuberculosis guideline systematically describes the clinical presentations of tuberculosis at different anatomical sites, with particular attention to how HIV co-infection modifies disease manifestations. It covers pulmonary TB, disseminated miliary TB, lymph node TB, TB meningitis, bone and joint TB, urogenital TB, abdominal TB, and effusions (pleural and pericardial).

The guidance emphasises that HIV-infected patients often present atypically: fever and weight loss are more common and pronounced in pulmonary TB, whilst cough and haemoptysis may be less common due to reduced inflammation and cavity formation. Disseminated miliary TB in HIV patients may be confused with severe wasting in advanced HIV disease, and M. tuberculosis can sometimes be isolated from blood cultures. For TB meningitis in HIV patients, cryptococcal meningitis must be ruled out by performing antigen tests on serum and cerebrospinal fluid.

The document provides practical differential diagnoses for HIV patients, noting that persistent generalised lymphadenopathy, lymphoma, carcinomatous metastases and Kaposi sarcoma are common alternative causes of lymphadenopathy. In high TB-HIV prevalence settings, TB is the most likely aetiology of serious effusions.

Key points

For clinicians — doses and thresholds as stated in the guideline

Pulmonary TB: prolonged cough (> 2 weeks), with or without sputum production, weight loss, anorexia, fatigue, shortness of breath, chest pain, moderate fever, night sweats, haemoptysis
In HIV patients with pulmonary TB: fever and weight loss more common and pronounced; cough and haemoptysis may be less common due to less inflammation and cavity formation
Lymph node TB: most often cervical region, non-inflammatory painless node > 2 cm, chronic (> 4 weeks), with possible fistulisation
Disseminated miliary TB: non-specific symptoms (high fever, headache, weight loss), deterioration over days or weeks, simultaneous involvement of multiple organs, high risk of meningitis in children
TB meningitis: subacute and insidious onset with headache, irritability, fever, altered consciousness; in HIV patients, rule out cryptococcal meningitis by performing antigen test on serum and CSF
Urogenital TB (renal): urinary symptoms with few constitutional symptoms; suspected when no response to antibiotics for urinary infection
Pleural effusion: pleuritic chest pain and dyspnoea; pericardial effusion: chest pain, dyspnoea, lower limb oedema or ascites, pericardial friction rub
In high TB-HIV prevalence settings, TB is the most likely aetiology of serious effusions

Clinical presentations and considerations for HIV-infected persons

Table extracted from the guideline

Sites	Clinical presentations	Considerations for HIV patients
Pulmonary TB	Prolonged cough (> 2 weeks), with or without sputum production. Weight loss, anorexia, fatigue, shortness of breath, chest pain, moderate fever, night sweats, haemoptysis.	Fever and weight loss more common and pronounced. Cough and haemoptysis may be less common (less inflammation and cavity formation). See algorithm, Chapter 5.
Disseminated miliary TB	Non-specific symptoms: high fever, headache, weight loss. Deterioration over days or weeks. Simultaneous involvement of multiple organs. High risk of meningitis in children. Miliary findings on CXR.	May be confused with severe wasting in advanced HIV disease. M. tuberculosis sometimes isolated from blood cultures.
Lymph node TB	Most often in cervical region. Non-inflammatory, painless node > 2 cm, chronic (> 4 weeks); fistulisation possible.	HIV infection can cause persistent generalised lymphadenopathy (PGL). PGL lymph nodes are painless, and symmetrical. Posterior cervical or epitrochlear nodes are often involved. Other common causes of lymphadenopathy include: lymphoma, carcinomatous metastases, Kaposi sarcoma.
TB meningitis	Subacute, insidious. Headache, irritability, fever, altered consciousness. Meningeal syndrome usually present.	Rule out cryptococcal meningitis: perform antigen test on serum and CSF.
Bone and joint TB	Monoarthritis with joint destruction and little or no pain. Deformity of the spine (Pott's disease).	Multifocal disease more common.
Urogenital TB	Renal: urinary symptoms, few constitutional symptoms; suspected when no response to antibiotics for urinary infection. Non-specific gynaecological symptoms, infertility or epididymitis with scrotal pain.
Abdominal TB	Ascites (may mask weight loss). Abdominal mass, pain, diarrhoea.	PTB more frequently associated.
Effusions	Pleural: pleuritic chest pain, dyspnoea. Pericardial: chest pain, dyspnoea, lower limb oedema or ascites, pericardial friction rub.	Serious effusions are common. TB is the most likely aetiology in high TB-HIV prevalence settings.

Source: Médecins Sans Frontières, Summary of clinical presentations of tuberculosis — MSF Tuberculosis. Reproduced in summary form.

From the guideline

Verbatim

“Rule out cryptococcal meningitis: perform antigen test on serum and CSF.”

— Médecins Sans Frontières, Summary of clinical presentations of tuberculosis — MSF Tuberculosis, Table 2.3, TB meningitis row (2026)

Editor’s perspective

Why this matters for Georgia and the region

Prof. Giorgi Pkhakadze, MD, MPH, PhD

Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration

As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute, I recognise this MSF guidance as essential for Georgian clinicians managing TB in our context of moderate TB burden and emerging HIV co-infection. The most critical recommendation for our setting is the two-week cough threshold for pulmonary TB screening and the mandate to perform cryptococcal antigen testing in all HIV-infected patients with meningitis, given that Georgia's laboratory network has expanded such capacity in recent years. The implementation challenge will be ensuring that primary care physicians maintain adequate suspicion for extrapulmonary TB presentations, particularly lymph node and bone TB, which may be under-recognised in our ambulatory care settings where patients often present late. This guidance complements Georgia's national TB programme protocols and should inform continuing medical education for both infectious disease specialists and general practitioners.

ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 21 Oct 2026

Applicability

Georgia and the South Caucasus

This guidance is highly relevant for Georgia and the South Caucasus region, where TB remains endemic and HIV co-infection, though lower than in sub-Saharan Africa, is an emerging concern particularly amongst vulnerable populations. Georgian clinicians should be alert to atypical presentations in HIV-infected patients and maintain a high index of suspicion for extrapulmonary TB. National TB programmes in the region should ensure that diagnostic algorithms incorporate cryptococcal antigen testing capacity for HIV patients presenting with meningitis, and that clinical training emphasises the modified symptomatology of TB in immunocompromised patients. The guidance’s emphasis on prolonged cough (> 2 weeks) as a screening criterion aligns with Georgian national TB protocols.

Questions this guideline answers

Quick answers

How does HIV infection change the presentation of pulmonary TB?

In HIV-infected patients, fever and weight loss are more common and pronounced, whilst cough and haemoptysis may be less common due to less inflammation and cavity formation. This atypical presentation can delay diagnosis.

What is the key diagnostic consideration for TB meningitis in HIV patients?

Cryptococcal meningitis must be ruled out by performing antigen tests on both serum and cerebrospinal fluid, as it is a common alternative diagnosis in HIV-infected patients presenting with meningitis symptoms.

How long should a cough persist before considering pulmonary TB?

A prolonged cough lasting more than 2 weeks, with or without sputum production, should prompt consideration of pulmonary TB, particularly when accompanied by weight loss, fever, night sweats or haemoptysis.

What distinguishes TB lymphadenopathy from HIV-related persistent generalised lymphadenopathy?

TB lymph nodes are most often in the cervical region, non-inflammatory, painless, larger than 2 cm, chronic (> 4 weeks) and may fistulise. HIV-related persistent generalised lymphadenopathy nodes are painless, symmetrical, and often involve posterior cervical or epitrochlear nodes.

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Same guideline

Clinical presentation of tuberculosis in HIV-infected persons — MSF TuberculosisChapter 2: Clinical presentation
Disseminated or miliary tuberculosis — MSF TuberculosisChapter 2: Clinical presentation
Extrapulmonary tuberculosis — MSF TuberculosisChapter 2: Clinical presentation
Pulmonary tuberculosis — MSF TuberculosisChapter 2: Clinical presentation

Summary of clinical presentations of tuberculosis — MSF Tuberculosis

What this guideline says

Key points

Clinical presentations and considerations for HIV-infected persons

From the guideline