Reactivation pulmonary tuberculosis, common in adolescents and typical in adults, usually is confined to apical segments of upper lobes or superior segments of lower lobes. There is usually little lymphadenopathy and no extrathoracic infection because of established hypersensitivity. This is a manifestation of a secondary expansion of infection at a site seeded years previously during primary infection. Advanced disease is associated with cavitation and endobronchial spread of bacilli. Symptoms include fever, night sweats, malaise, and weight loss. A productive cough and hemoptysis often herald cavitation and bronchial erosion.
Miliary tuberculosis refers to widespread hematogenous dissemination to multiple organs. The lesions are of roughly the same size as a millet seed, from which the name miliary is derived. Miliary tuberculosis is characterized by fever, general malaise, weight loss, lymphadenopathy, night sweats, and hepatosplenomegaly. Diffuse bilateral pneumonitis is common, and meningitis may be present. The chest radiograph reveals bilateral miliary infiltrates, showing overwhelming infection. The TST may be nonreactive as a result of anergy. Liver or bone marrow biopsy is useful for the diagnosis.
Tuberculous meningitis most commonly occurs in children under 5 years old and often within 6 months of primary infection. Tubercle bacilli that seed the meninges during the primary infection replicate, triggering an inflammatory response. This condition may have an insidious onset, initially characterized by low-grade fever, headache, and subtle personality change. Progression of the infection results in basilar meningitis with impingement of the cranial nerves and is manifested by meningeal irritation and, eventually, increased intracranial pressure, deterioration of mental status, and coma. Computed tomography (CT) scans show hydrocephalus, edema, periventricular lucencies, and infarctions. Cerebrospinal fluid (CSF) analysis reveals pleocytosis (50 to 500 leukocytes/mm3), which early in the course of disease may be either lymphocytes or polymorphonuclear leukocytes. Glucose is low, and protein is significantly elevated. Acid-fast bacilli are not detected frequently in the CSF by either routine or fluorescent staining procedures. Although culture is the standard for diagnosis, PCR for M. tuberculosis is useful to confirm meningitis.
Skeletal tuberculosis results from either hematogenous seeding or direct extension from a caseous lymph node. This is usually a chronic disease with an insidious onset that may be mistaken for chronic osteomyelitis caused by Staphylococcus aureus. Radiographs reveal cortical destruction. Biopsy and culture are essential for proper diagnosis. Tuberculosis of the spine, Pott’s disease, is the most common skeletal site followed by the hip as well as fingers and toes (dactylitis).
Other forms of tuberculosis include abdominal tuberculosis that occurs from swallowing infected material. This is a relatively uncommon complication in developed nations where dairy herds are inspected for bovine tuberculosis. Tuberculous peritonitis is associated with abdominal tuberculosis and presents as fever, anorexia, ascites, and abdominal pain. Urogenital tuberculosis is a late reactivation complication and is rare in children. Symptomatic illness presents as dysuria, frequency, urgency, hematuria, and sterile pyuria.