Another day, another TB diagnosis. More patients with TB in the hospital than COVID right now. @WHO estimates the COVID-19 pandemic has set us back 12 years in the fight to eliminate TB & expect a 20% increase in deaths. TB can be difficult to diagnose. Here are some thoughts:

Symptoms: TB is an indolent disease & comes on over weeks to months. Often starts with fatigue. Symptoms may come & go in severity. Drenching night sweats, fevers & weight loss should be big red flags. Other symptoms relate to body site affected e.g. cough, haemoptysis, back pain

Investigations: CXR
- Apical changes, cavitation, unil pleural effusion should raise the TB question
- For the love of god SEND A SPUTUM for AFB smear, culture & PCR
- OK to treat for CAP if unsure or worried about sepsis but avoid fluoroquinolones AND chase up the TB question

Discitis, paravertebral collections, potts disease, CSF with high protein, low glucose. Lymphocyte predominance in fluid samples. Cold abscesses. Lymphadenopathy, particularly in the neck. Uveitis (see forthcoming @BTS statement).

Fluid, mass, node - STICK A NEEDLE IN IT and don't put the sample in formalin. Send for smear, culture, possibly PCR. Histology - granuloma, if you're lucky necrotising. If you can't see something to stick your needle in or CXR changes consider CT to look for nodes to sample

Bloods: CRP up but often not high like in bacterial inf. Raised calcium may be seen in disseminated TB. There is almost never a good reason not to test anyone for HIV - do the test.

IGRA - NOT A DIAGNOSTIC TEST FOR ACTIVE TB. May occasionally be used as tiny piece of puzzle

Finally think exposure risk. Hx of TB contact, incidence in countries lived in (no matter how many years ago). Think homelessness & incarceration history. If the signs & symptoms fit- don't let lack of exposure hx distract you from including TB in your differential. SEND CULTURES

A word on healthcare access: Delayed TB diagnosis occurs due to a variety of reasons.
1. People interpret their symptoms in the context of their own lives. Sweats & wt loss experienced with drug use & homelessness. Depression => wt loss. Try to consider this in history taking.

2. People prioritise their health in the context of their needs. Concerns regarding security/ safety (see for example #hostilenvironment & impact on healthcare access for migrants) or need to work to pay bills/ feed self/ family may be prioritised ahead of health concerns.

3. Health systems may be unresponsive or even obstructive: We can dismiss young people's concerns particularly if symptoms non specific as in TB - people know their own bodies, let's trust this. Past poor experiences e.g. racism/ discrimination shape future h/care interactions

Challenges accessing healthcare particularly prevalent this past year with fear of contracting COVID in hospital coupled with limited face to face consultations/ access to x-ray. Social conditions have also been more challenging leading to health being deprioritised.

If we don't think TB then we can miss it resulting in totally avoidable harm and even death. Early diagnosis leads to better outcomes for individuals & reduced transmission. So..
FEVERS, NIGHT SWEATS, WEIGHT LOSS
CHECK A CHEST X-RAY
SEND A TB CULTURE
Chat to your friendly TB team

People