Review
Acute Forms of Tuberculosis in Adults

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Abstract

Although typically considered a chronic disease, tuberculosis (TB) has protean acute manifestations, the major forms of which are reviewed in this article. The pathogenesis of acute TB, although still incompletely understood, may be related to both epidemiologic and genetic host factors. Miliary TB manifests as a nonspecific clinical syndrome with a high mortality rate. The most well-known form of acute TB is meningitis, characterized by fever, nuchal rigidity, and a lymphocytic pleocytosis of the cerebrospinal fluid. Acute abdominal TB may present with obstruction or less commonly as perforated viscus or peritonitis. Critically ill patients may have acute respiratory distress syndrome, shock, or disseminated intravascular coagulopathy. The spectrum of disease makes diagnosis of acute TB difficult unless clinical suspicion of disease is high, but the high mortality mandates its consideration. Early initiation of therapy is crucial to optimize clinical outcome.

Section snippets

Pathophysiology and Risk Factors

Once Mycobacterium tuberculosis is inhaled into the lungs, a series of immunologic events leads to 3 possible outcomes: eradication, primary infection, or latent infection. Acute TB can arise as a primary disease or from reactivation of latent infection. Primary infection in most individuals is asymptomatic or mild; acute symptomatic disease requiring medical attention develops in only 3% to 10%.1 Latent TB affects approximately one third of the world's population, all of whom are potentially

Miliary Disease

Two well-defined entities exist at either end of the spectrum of miliary TB: acute miliary TB and nonreactive TB. Acute miliary TB has a severe, rapidly progressive course, usually after acute infection in young adults, and is characterized by caseating granulomas with few organisms, frequently resulting in negative acid-fast bacilli (AFB) stains and cultures. Nonreactive TB usually occurs in older adults with disease reactivation. AFB cultures are frequently positive, and the pathologic

Meningitis

Meningitis is probably the most well-described acute presentation of TB. Clinical syndromes range from mimicking typical bacterial meningitis to a nonspecific, subacute illness characterized by fever and headache. Typically occurring in the fourth decade of life, meningitis seems to more commonly affect men.8, 15, 16, 17, 18 When tested, 43% to 65% of patients are HIV infected and have an average CD4 count less than 200.8, 15, 16

The median duration of symptoms ranges from 12 to 29 days in most

Abdominal Disease

Abdominal TB generally occurs during the third and fourth decades of life and is more common in women.26 Between one tenth and one third of abdominal TB cases are acute, with an average duration of symptoms of 1 to 2 weeks.26, 27 Acute forms most commonly manifest in 3 clinical syndromes, often as surgical emergencies: peritonitis or acute abdomen (15%), obstruction (66%), and perforation (17%).26, 27, 28, 29 Gastrointestinal TB most commonly involves the ileocecal area, perhaps because of the

Acute Tuberculosis in the Critical Care Setting

The above manifestations of acute TB may progress in severity requiring care in an intensive care unit in 1% to 3% of cases.31 Pulmonary TB is most common among these conditions to require critical care, with a resultant hospital mortality of 25% to 33%, and approaching 70% for those requiring mechanical ventilation (Figure 1).32, 33 Mechanical ventilation, adult respiratory distress syndrome, sepsis, acute renal failure, pancreatitis, and secondary nosocomial pneumonia are independent risk

Conclusions

During the last 2 decades, TB has reemerged in the developing and developed world. The recent development of extensively resistant strains of M. tuberculosis concerns clinicians, field workers, and the public health community. Despite improved methods, the diagnosis of acute TB is frequently made postmortem. The increasing number of immunocompromised individuals is expanding the population at risk for acute TB. Although these acute presentations are rare, the morbidity from TB is significant,

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  • Cited by (0)

    Funding: The study was partly supported by the Emory Medical Care Foundation (M.K.L.).

    Conflict of Interest: The authors have no conflict of interest.

    Authorship: All authors had access to the data and a role in writing the article.

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