Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Tuberculosis

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In one line

·M. tuberculosis is a slow-moving bacteria that hides inside immune cells, causing lung sickness and sometimes spreading to other organs.

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Normal physiology

·Alveolar macrophages (cleanup cells in the tiny air sacs of the lungs) normally capture and kill breathed-in bacteria. When M. tuberculosis is inhaled, macrophages eat the bacteria and build granulomas—tiny walled-off bunkers made of immune cells—to trap any bacteria they cannot kill. The bacteria stay alive but dormant inside these granulomas, and you feel healthy. This balance is called latent TB, and about 90% of infected people stay in this latent state for life.

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What goes wrong

·The break is that macrophages cannot kill M. tuberculosis because the bacteria have a thick, waxy coat (made of mycolic acid) that protects them from the acid and enzymes inside the macrophage. Instead of dying, the bacteria multiply slowly inside the macrophages. The body builds granulomas to trap them, but the granulomas only contain the bacteria—they do not kill them. If your immune system weakens, the granuloma walls crumble, the bacteria escape and multiply, and you get active TB.

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Hallmark signs

·Cough that lasts three weeks or longer
·Coughing up blood or rust-colored coughed-up mucus (sputum) (hemoptysis)
·Fever, often with chills
·Drenching night sweats
·Unintentional weight loss and loss of appetite
·Fatigue and general weakness
·Chest pain, especially with deep breathing or coughing
·Cavities (holes) visible on chest X-ray

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Red flags · escalate now

·Coughing up blood (hemoptysis)
·Severe trouble breathing or shortness of breath at rest
·Confusion, stiff neck, or severe headache (signs of meningitis)
·Rapid weight loss (more than 10% of body weight in weeks)
·Known contact with someone who has active TB and new symptoms

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Workup

·Coughed-up mucus (Sputum) acid-fast bacilli (AFB) smear — 3 separate morning samples
·Coughed-up mucus (Sputum) mycobacterial culture (solid or liquid media)
·Nucleic acid amplification test (NAAT), such as GeneXpert MTB/RIF
·Chest X-ray (posteroanterior and lateral views)
·Tuberculin skin test (TST, Mantoux test) or interferon-gamma release assay (IGRA, such as QuantiFERON)
·HIV test (fourth-generation antigen/antibody or RNA if acute infection suspected)
·Complete blood count (CBC) with differential
·Red blood cell (Erythrocyte) sedimentation rate (ESR) or C-reactive protein (CRP)

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Treatment

·RIPE regimen: rifampin, isoniazid, pyrazinamide, ethambutol — all four drugs daily for the first 2 months (intensive phase)
·Continuation phase: rifampin plus isoniazid daily (or 3 times per week) for 4 more months after the first 2 months
·Pyridoxine (vitamin B6) 25–50 mg daily, given with isoniazid
·Airborne isolation (negative-pressure room, N95 respirators for staff) until coughed-up mucus (sputum) AFB smears are negative on 3 consecutive samples (usually after 2 weeks of treatment)
·Directly observed therapy (DOT): a healthcare worker or trained observer watches the patient swallow every dose
·Latent tuberculosis infection (LTBI) treatment: isoniazid daily for 6–9 months, OR rifampin daily for 4 months, OR isoniazid + rifapentine weekly for 3 months (3HP regimen) — for people with positive TST/IGRA but no active disease
·Drug-resistant TB regimen (for rifampin-resistant or multidrug-resistant TB): bedaquiline, linezolid, fluoroquinolone (levofloxacin or moxifloxacin), plus 1–2 additional agents for 18–20 months

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NCLEX trap

·Latent TB infection (positive skin test, no symptoms, clear chest X-ray) is treated with one drug — isoniazid or rifampin — for months. Active tuberculosis (cough, fever, lung cavities, feeling sick) needs four drugs at once (RIPE) for 2 months, then two drugs for 4 more months. They are completely different stages and need different treatment.
·Feeling better does not mean the bacteria are dead. Macrophages (the white blood cells that eat germs) still cannot kill all the TB bacteria hiding inside cells and lung cavities. If you stop early, the surviving bacteria wake up stronger and become resistant to the drugs. You must finish the full 6 months (or longer for drug-resistant strains) to cure the infection.
·Isoniazid can damage nerves and cause tingling, numbness, or burning in the hands and feet (peripheral neuropathy). Pyridoxine (vitamin B6) prevents this nerve damage. Always give pyridoxine along with isoniazid — especially in pregnant women, people with diabetes, people who drink alcohol, and anyone with HIV.
·Tuberculosis spreads through tiny droplets that float in the air when a person with active lung TB coughs, sneezes, or talks. Put the patient in a negative-pressure room (air flows in and is filtered before leaving) and anyone entering must wear an N95 mask. Keep these precautions until the patient has taken effective medicine for at least 2 weeks AND coughed-up mucus (sputum) smears turn negative for acid-fast bacilli.
·Tuberculosis spreads by bacteria floating in the air — it does not matter whether there is blood in the coughed-up mucus (sputum) or not. Any person with active pulmonary TB who is coughing can spread the infection. Airborne isolation is required until coughed-up mucus smears are negative, which usually happens about 2 weeks after starting the right four-drug treatment.
·Using one or two drugs lets resistant bacteria survive and multiply — that is how multi-drug-resistant TB (MDR-TB) starts. Active tuberculosis always requires four drugs for the first 2 months (rifampin, isoniazid, pyrazinamide, ethambutol — called RIPE), then two drugs (rifampin and isoniazid) for 4 more months. No shortcuts, even if symptoms disappear early.

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