Diagnosis of Tuberculosis Disease
When Should You Suspect Tuberculosis (TB)?
TB is a disease caused by Mycobacterium tuberculosis. TB disease should be suspected in persons who have the following symptoms:
- Unexplained weight loss
- Loss of appetite
- Night sweats
If TB disease is in the lungs (pulmonary), symptoms may include:
- Coughing for longer than 3 weeks
- Hemoptysis (coughing up blood)
- Chest pain
If TB disease is in other parts of the body (extrapulmonary), symptoms will depend on the area affected.
How Do You Evaluate Persons Suspected of Having TB Disease?
A complete medical evaluation for TB includes the following:
1. Medical History
Clinicians should ask about the patient’s history of TB exposure, infection, or disease. It is also important to consider demographic factors (e.g., country of origin, age, ethnic or racial group, occupation) that may increase the patient’s risk for exposure to TB or to drug-resistant TB. Also, clinicians should determine whether the patient has medical conditions, especially HIV infection, that increase the risk of latent TB infection progressing to TB disease.
2. Physical Examination
A physical exam can provide valuable information about the patient’s overall condition and other factors that may affect how TB is treated, such as HIV infection or other illnesses.
3. Test for TB Infection
The Mantoux tuberculin skin test (TST) or the TB blood test can be used to test for M. tuberculosis infection. Additional tests are required to confirm TB disease. The Mantoux tuberculin skin test is performed by injecting a small amount of fluid called tuberculin into the skin in the lower part of the arm. The test is read within 48 to 72 hours by a trained health care worker, who looks for a reaction (induration) on the arm.
The TB blood test measures the patient’s immune system reaction to M. tuberculosis.
4. Chest Radiograph
A posterior-anterior chest radiograph is used to detect chest abnormalities. Lesions may appear anywhere in the lungs and may differ in size, shape, density, and cavitation. These abnormalities may suggest TB, but cannot be used to definitively diagnose TB. However, a chest radiograph may be used to rule out the possibility of pulmonary TB in a person who has had a positive reaction to a TST or TB blood test and no symptoms of disease.
5. Diagnostic Microbiology
The presence of acid-fast-bacilli (AFB) on a sputum smear or other specimen often indicates TB disease. Acid-fast microscopy is easy and quick, but it does not confirm a diagnosis of TB because some acid-fast-bacilli are not M. tuberculosis. Therefore, a culture is done on all initial samples to confirm the diagnosis. (However, a positive culture is not always necessary to begin or continue treatment for TB.) A positive culture for M. tuberculosis confirms the diagnosis of TB disease. Culture examinations should be completed on all specimens, regardless of AFB smear results. Laboratories should report positive results on smears and cultures within 24 hours by telephone or fax to the primary health care provider and to the state or local TB control program, as required by law.
6. Drug Resistance
For all patients, the initial M. tuberculosis isolate should be tested for drug resistance. It is crucial to identify drug resistance as early as possible to ensure effective treatment. Drug susceptibility patterns should be repeated for patients who do not respond adequately to treatment or who have positive culture results despite 3 months of therapy. Susceptibility results from laboratories should be promptly reported to the primary health care provider and the state or local TB control program.
- American Thoracic Society (ATS) and CDC. Diagnostic standards and classification of tuberculosis in adults and children.(PDF) Am J Respir Crit Care Med 2000; 161.
- ATS, CDC, and Infectious Diseases Society of America. Treatment of tuberculosis. MMWR 2003; 52 (No. RR-11).
- Centers for Disease Control and Prevention. Guidelines for the investigation of contacts of persons with infectious tuberculosis and Guidelines for using the QuantiFERON®-TB Gold test for detecting Mycobacterium tuberculosis infection, United States. MMWR 2005; 54 (No. RR-15).
- Updated Guidelines for the Use of Nucleic Acid Amplification Tests in the Diagnosis of Tuberculosis. MMWR 2009;58(1)