Synopsis
Recognise tuberculosis across lung, lymph node, meninges, spine, pleura, pericardium and other organs; secure culture and resistance evidence; start site-specific multidrug and adjunctive treatment; and coordinate infection control, notification and completion through a specialist TB service.
- Pulmonary TB creates transmission risk; extrapulmonary TB may present through lymph nodes, pleura, meninges, spine, abdomen, genitourinary tract, pericardium or disseminated organ disease.
- Use epidemiology as probability, not a gate: exposure, residence in a high-incidence setting, immune suppression, homelessness, detention and previous treatment matter, but disease can occur without a disclosed classic risk.
- For suspected pulmonary TB, NICE recommends multiple deep-cough sputum specimens for smear and culture, preferably three with one early-morning sample; add rapid molecular identification and resistance testing.
- An acid-fast smear identifies mycobacteria, not M tuberculosis. Maintain the protective pathway until molecular and culture evidence distinguishes TB from NTM.
- For lymph-node, pleural, meningeal, bone or other disease, plan unfixed tissue or fluid for mycobacterial culture and molecular testing as well as a separate histology specimen.
- Drug-susceptible TB without central-nervous-system involvement usually receives 2 months of rifampicin, isoniazid, pyrazinamide and ethambutol, followed by 4 months of rifampicin and isoniazid; add pyridoxine for people at increased neuropathy risk.
- Central-nervous-system TB uses the same four-drug first 2 months followed by rifampicin and isoniazid for 10 further months, plus high-dose corticosteroid tapered over 4 to 8 weeks.
- Rifampicin induces many metabolic pathways; isoniazid, rifampicin and pyrazinamide can injure liver; ethambutol can damage optic nerve; renal impairment changes pyrazinamide and ethambutol dosing.
- In England, TB notification is routine within 3 days unless the case is urgent, such as suspected MDR disease, a healthcare worker or a cluster; notify on suspicion and use the current nation-specific route.
Key red flags
Weeks of cough, weight loss, fever, night sweats or haemoptysis accompany upper-zone, nodular or cavitary change, especially with exposure or epidemiological risk.
Subacute headache, fever, neck stiffness, cranial neuropathy, confusion or reduced consciousness may coexist with hyponatraemia and requires urgent CSF, neuroimaging and treatment planning.
Persistent focal back pain, constitutional illness, vertebral destruction, deformity, weakness or sphincter change raises spinal infection and possible cord compression.
Fever, weight loss, cytopenia, organomegaly, diffuse micronodules or multi-organ abnormalities in pregnancy or immune suppression can signal haematogenous spread.
Previous incomplete or failing treatment, contact with resistant TB, prior therapy abroad or origin from a high-resistance setting requires rapid molecular resistance testing and expert regimen design.
Investigation priorities
Find pulmonary disease, cavitation, nodes, miliary spread and a safe route to sample.
Management branches
Symptoms and imaging make pulmonary or laryngeal tuberculosis credible.
- Place the patient in the locally approved airborne pathway, minimise unnecessary movement and involve infection prevention and the specialist TB team.
- Send multiple respiratory samples for smear, molecular testing and culture plus baseline safety tests; begin treatment before culture when the clinical diagnosis is strong or illness is life threatening.
- Report suspected active TB through the current national route and telephone urgently when resistance, healthcare work or a possible cluster raises immediate public-health concern.