Synopsis
Recognise infectious pulmonary tuberculosis, protect patients and contacts immediately, obtain microbiological confirmation and resistance information, and coordinate specialist multidrug treatment, toxicity monitoring and statutory public-health action.
- Think of pulmonary TB with cough lasting weeks, weight loss, fever, night sweats, haemoptysis or unexplained upper-lobe/cavitary change, especially after exposure or residence in a high-incidence setting.
- Older, immunocompromised and pregnant patients may have atypical or disseminated disease; ask about HIV risk, immunosuppressants, housing, detention, homelessness and prior TB treatment.
- Place potentially infectious pulmonary or laryngeal TB in the locally approved airborne-isolation pathway and involve infection prevention and the specialist TB service immediately.
- Send multiple respiratory specimens for acid-fast microscopy, mycobacterial culture and molecular testing; culture remains essential for species identification and full susceptibility.
- A nucleic-acid result can accelerate diagnosis and rifampicin-resistance assessment but does not replace culture, and a negative smear does not exclude infectious TB.
- Standard drug-susceptible pulmonary TB is usually treated with rifampicin, isoniazid, pyrazinamide and ethambutol for 2 months followed by rifampicin and isoniazid for 4 months, under a specialist weight-banded regimen.
- Check liver risk, vision, neuropathy risk, renal function, pregnancy and interactions before treatment; rifampicin substantially reduces exposure to many medicines including hormonal contraception and anticoagulants.
- Suspected or confirmed active TB is notifiable under applicable UK legislation; identify the nation-specific route, do not wait for culture, and coordinate contact tracing.
Key red flags
Persistent cough, sputum or haemoptysis with weight loss, anorexia, fever and night sweats; radiology may show upper-lobe infiltrates, cavitation, nodules or lymphadenopathy.
Acid-fast bacilli in a respiratory sample plus compatible illness indicates potentially infectious mycobacterial disease; maintain airborne precautions while rapid testing distinguishes TB from NTM.
HIV, transplantation, anti-TNF therapy or other immunosuppression can produce lower-zone, non-cavitary, lymph-node, miliary or extrapulmonary disease with low smear burden.
Previous incomplete treatment, contact with resistant TB, treatment abroad or origin in a high-resistance setting requires rapid molecular resistance assessment and expert regimen design.
Investigation priorities
Identify pulmonary patterns and guide respiratory sampling while assessing severity.
Management branches
Compatible pulmonary illness with epidemiological or radiological concern.
- Use local airborne precautions and appropriate room/respirator arrangements, minimise avoidable transfers and inform infection prevention and the TB team.
- Obtain respiratory samples for smear, culture and molecular testing, plus baseline bloods and HIV testing, without delaying treatment in a severely ill person.
- Notify suspected active TB through the current jurisdictional route and share exposure details with the health-protection team; do not wait for culture confirmation.