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oThe problem occurs with heavy or prolonged exposure to an infected or immunocompromised person. The very young and the very old or debilitated are alsomore susceptible because of decreased host defensesPulmonary TB presents with the classic symptoms of TB: cough with productive, purulent secretions, often with blood streaks.
oOther symptoms include wide temperature variations, malaise, fatigue, wasting, chest pain, and dyspnea. oSweating, including night sweats, is commonLymphatic TB may present initially as unilateral, painless, cervical lymphadenopathy. oTB bacilli can also settle in the genitourinary tract, bones or joints, meninges, gastrointestinal (GI) tract, and pericardium. When these extrapulmonary sites are infected, the symptoms are often vague and difficult to defineGoals of TreatmentThe initial goal of treatment in TB is an accurate diagnosis. oThis requires a practitioner who understands the current guidelines for screening and puts TB high on the differential list forany pulmonary or other illness with vague presenting symptoms. oA second goal is the patient's completion of the recommended therapy, because failure to complete therapy can lead to drug-resistant TB. oFinally, the effectiveness of treatment must be evaluated. Effective treatment of TB is not only intended to treat the sick patient but also to prevent the transmission of M. tuberculosisto the publicPatients who have positive sputum cultures at the beginning of treatmentshould have monthly cultures, and the culture should convert to negative. oA final chest x-ray is needed for documentation of baseline for future films, but the x-ray is not as important as the sputum examinationThe CDC and the Canadian guidelines recommend that threesputum specimens should be obtained if pulmonary involvement is suspectedNucleic acid amplification tests for the diagnosis of TB and to determine drug resistance is sensitive and provides a more rapid result than traditional culture. oBronchoscopy may be necessary to obtain an accurate diagnosis.If presumptive treatment is the only option, the key indicators for response to therapy are the chest x-ray findings. oImprovement should be noted within the first 3 months of therapy. oIf there is no improvement, then either resistance or inaccurate diagnosis must be considered. The CDC recommends that all patients with TB have testing for HIV infection at the time treatment is initiated, if not earlierRational Drug SelectionRisk StratificationoAlthough anyone may become infected with TB, some populations are identified as being at greater risk: children up to age 4 years, the infirm elderly, and immunocompromised patients, including those with HIV infection or AIDS and organ transplant recipients.
Foreign-born people are also at higher riskoIn the United States and Canada, certain populations are identifiedas being at higher risk, specifically medically underserved, low-income populations, including high-risk racial or ethnic minority