The Other TB

How to treat extrapulmonary tuberculosis & protect yourself

• Jason Friesen, BA, NREMT-P
• Jul7 2009 JEMS Vol. 34 No. 7
• 2009 Jul 1

Your pager goes off at 3 a.m., and you immediately recognize the address as being located in a large immigrant neighborhood where calls can get interesting, especially because no one on your shift speaks the language.

As you approach the front door, you’re met by a middle-aged male who’s holding the door open and pointing down a hall. "Sugar" is all he can say, and you and your crew realize that not a lot of difficult history-gathering will be necessary.

You walk through the living room into a back bedroom, past four generations of family members. The room is dark, damp and poorly ventilated. You turn on a lamp as your partner and the fire crew begin assessing the 65-year-old, 200-lb. male, who’s lying in bed.

Within a few moments, your partner calls out the patient’s vitals: respirations 24/min, partially labored but effective and clear bilaterally. Responsive only to pain, localizing, and his eyes are PERL at 3 mm but a little sluggish. Heart rate 110, sinus tach, BP 148/90 and blood sugar 24 mg/dL. Your partner asks the fire crew to prepare an IV bag so he can start a line and administer D50. As the IV is being secured, you turn to a family member.

"Medical problems?" you ask, pointing at the patient.

Luckily, the relative understands enough English, and he smiles, nodding his head.

"Diabetes," he says. Then, he struggles to form the next word. "Tah … Tah … Tah-burr … Tah-burk …"

"Tuberculosis?" 

He smiles and nods his head in agreement. "Tuberculosis! Yes!" Your partner and the fire crew immediately stop what they’re doing.

The fire captain tells you he’s going out to the rig to grab more N95 TB respirators, as your partner pulls out the only mask in   the drug box and secures it to the patient’s face. Another firefighter steps back and offers to help locate the patient’s medications.

Seeing your partner put the mask on the patient, the family member begins to wave his hands and tries to pull the mask off the patient, saying, "Heart tuberculosis! Heart tuberculosis!" He’s quickly pulled back by one of the firefighters, and the mask is readjusted with a proper seal. Efforts are doubled to get the patient—and the crew—out of the poorly ventilated room, and treatment is rendered in the back of the ambulance as the captain begins collecting information to file an exposure report. 

When the patient’s blood sugar is corrected, he becomes alert and oriented, but is still unable to provide any further information on his condition. A thorough search for medications reveals only those related to diabetes and hypertension, none that would be used to treat active TB.

Extrapulmonary TB
Tuberculosis (TB) is a communicable disease contracted via airborne pathogens, in particular mycobacterium tuberculosis   (MTB). According to the World Health Organization, an estimated 9.27 million new cases were reported worldwide in 2007. Although the disease is predominately active in developing nations, areas in developed countries with a high rate of immigration from affected countries present increased risks for TB occurrences.

TB is most commonly encountered in the lungs, but it can involve any organ in the body, particularly among patients who are immuno-compromised. Types of TB that manifest in sites outside the lungs are referred to as extrapulmonary tuberculosis (EPTB) and are often a result of dissemination from the lungs. Although rare, EPTB has been reported to occur in such areas as the lymph nodes, GI tract, abdomen, bones and pericardium, among many others.

The vast majority of all TB occurrences originate in the lungs. Although the primary pathogenic bacteria MTB typically infects pulmonary tissue, it also has the potential to spread via the lymph nodes and/or circulatory system, whereby it may travel to other sites in the body and seed, thus spreading the infection to secondary areas.

Pericardial TB
In the case of pericardial tuberculosis, MTB makes its way to the pericardium and seeds there, where it has the potential to cause a number of further complications, including pericardial effusion, cardiac tamponade and constrictive pericarditis.

Although it’s impossible to diagnose in the prehospital setting, pericardial tuberculosis may present with symptoms similar to pulmonary TB, including rapid weight loss and decreased appetite, malaise, fatigue, increased body temperature at night, night sweats, and a productive cough with or without hemoptysis. Further complications specific to the disease’s infection of the pericardium may include cardiac arrhythmias, chest pain and dyspnea, orthopnea and ankle swelling.

Management
Because EMS providers have virtually no recourse to diagnose and/or treat pericardial tuberculosis, prehospital care consists of both supportive measures for the patient as well as protective precautions for ourselves. If the patient is presenting with chest pain, it may be prudent to treat them with high-flow oxygen, nitrates and IV fluids. Likewise, fluid boluses may be indicated if the patient’s BP is dropping as a result of pericardial effusion or cardiac tamponade.

The number one concern for all providers, however, is the risk for exposure to the tubercle bacilli. First, if available, put a surgical mask on the patient—not an N95, as was done in this case. N95s keep particles from going in, not from coming out. 

Next, several steps should be taken to determine whether or not there has been a significant exposure. To begin with, find out if the patient has been treated for active TB. Your local public health department should have this information readily available, as it is not protected under HIPAA. The Centers for Disease Control and Prevention, in conjunction with the American Thoracic Society and the Infectious Diseases Society of America, has set forth very aggressive guidelines for treating active TB in a decades-long effort to eradicate the disease from the U.S. These guidelines include rigorous treatments with antibiotics, corticosteroids and other drugs, under the auspices of directly observed therapy, which mandates that patients comply with the prescribed drugs and follow-up treatment while under direct professional supervision. 

Likewise, such patient medications as rifampicin, isoniazid, pyrazinamide and sometimes ethambutol are clear indicators that the patient is being treated for active TB. And, as always, patients who are HIV-positive, have AIDS or chronic kidney disease, are homeless and/or alcoholic are also at an increased risk for having active TB. 

Conclusion
Pericardial tuberculosis alone does not present a risk of exposure for prehospital providers because there’s no direct mode of transmission from the pericardium. However, because it is almost always a secondary infection resulting from primary pulmonary TB, patients with pericardial tuberculosis should be treated as though they present with a potential. JEMS

Jason Friesen, BA, NREMT-P, works full time as a paramedic in San Diego, Calif. When not on duty, he’s working to create a non-profit organization to develop EMS in low-income countries. He can be contacted via www.trekmedics.org.  

1. World Health Organization: "Global tuberculosis control: Epidemiology, strategy, financing." www.who.int/tb/publications/global_report/en/  
2. Mayosi BM, Burgess LJ, Doubell AF: "Tuberculous Pericarditis" Circulation. 112(23):3608–3616, 2005. 
3. Sharma SK, Mohan A: "Extrapulmonary tuberculosis." The Indian Journal of Medical Research. 120(4):316–353, 2004. 
4. Jensen PA, Lambert LA, Iademarco MF, et al: "Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005." MMWR. 54(RR-17):1–141, 2005. 
5. "American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: Treatment of Tuberculosis." American Journal of Respiratory and Critical Care Medicine. 167(4):603–662, 2003. 
6. Corey GR, Sexton DJ: "Tuberculous pericarditis." www.uptodate.com/patients/content/topic.do?topicKey=~OQQvvHdI8GPlIbQ     

Read "Infection Protection" from September JEMS at jems.com/journal  

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