If a patient has any of the following, consider him a ‘Tuberculosis Suspect’:
- Cough for more than 3 weeks
- Coughing blood
- Pain in the chest for more than 3 weeks
- Fever for more than 3 weeks
All these can be due to other diseases but sputum must be tested for MBT if any are present. Cough and sputum is very common everywhere. Much of this is due to acute respiratory infections and lasts only a week or two. In many countries there is also much chronic cough due to chronic bronchitis (sometimes called ‘Chronic Obstructive Pulmonary Disease’ – COPD or other names). This is mostly due to tobacco smoking, but may also occur from atmospheric pollution (either due to cooking or heating fires or in some places to industrial pollution).
As we shall see, certain additional symptoms may suggest tuberculosis. However, often this is not obvious: the only way to make sure is to examine the sputum for ТВ in everyone who has had a cough for more than 3 weeks. Here some guidelines are presented to how for the diagnosis of pulmonary tuberculosis. These include:
(The number of plus (+) sign show which symptoms are most important.)
General Symptoms:
++ Loss of weight
++ Fewer and sweating
+ Loss of appetite
+ Tiredness
Respiratory Symptoms
+++ Cough
+++ Sputum
++ Blood-spitting
+ Breathlessness
+ Chest wall pain
+ Localized wheeze
+ Frequent colds
It is important to remember that all the symptoms could be due to other illnesses. One of the most important signs, which should make to think of possible tuberculosis, is that the symptoms have come on gradually over weeks or months. This applies particularly to the general symptoms of illness: loss of weight, loss of appetite, tiredness or fever.
Cough, of course, is a common symptom after acute respiratory infections. It is also common in smokers. It is common in some areas where the houses or huts have no chimneys and the houses are often full of smoke – especially in cold climates or cold weather when fires may be used for heating as well as cooking. Both tobacco and domestic smoke lead to chronic bronchitis. Cough may come on gradually in a patient with lung cancer, which is becoming commoner in countries with increasing cigarette smoking. Bronchiectasis is common in some countries: the patient may have had a chronic cough with purulent sputum since childhood. However, if a patient has had a cough for more than 3 weeks you must get his sputum examined for ТВ to make sure the cough is not due to tuberculosis. There is nothing in the sputum which itself suggests tuberculosis: it may be mucoid, purulent or contain blood. In tuberculosis, blood in the sputum may vary from a few spots to a sudden coughing of a large amount of blood. Occasionally this blood loss is so great that the patient quickly dies, usually from asphyxia due to aspirated blood. If there is a blood in the sputum you must always examine this sputum for MBT.
Pain in the chest is not uncommon in tuberculosis. Sometimes it is just a dull ache. Sometimes it is worse on breathing in (due to pleurisy). Sometimes it is due to muscle strain from coughing.
Breathlessness in tuberculosis is due to extensive disease in the lungs, or to pleural effusion complicating the lung tuberculosis. Occasionally the patient has a localized wheeze. This is due to local tuberculous bronchitis or to pressure of a lymph node on a bronchus. Moist pronounced rales are heard at presence of inflammatory and destructive changes in lungs. Sometimes the patient seems to have developed an acute pneumonia. But the pneumonia may not get better with routine antibiotics. The cough and fever may persist. The patient remains ill. If you question him closely, you may find that he has had cough and loss of weight for weeks or months before the pneumonia came on. Sometimes the patient says that for months he has had one cold after another. Question him carefully. The colds may be just that a chronic cough has got repeatedly worse. Remember that, in an older smoker, cough and loss of weight, which come on gradually, may be due to lung cancer. However, you must check for tuberculosis by examining the sputum.
Women who develop tuberculosis may lose their menstruation (amenorrhea).
Physical signs.
Often these do not help much. But do examine the patient carefully. The pathognomic signs could be revealed.
- General condition. Sometimes this may be good, in spite of advanced disease. But the patient may be obviously ill. He may be very thin, with obvious loss of weight. He may be pale or have a flush due to fever.
- Fever. This can be of any type. There may be only slight rise of temperature in the evening. The temperature may be high or irregular. Often there is no fever.
- Pulse is usually raised in proportion to fever.
- Finger clubbing. You may find this, especially in a patient with extensive disease. Remember that clubbing is common with lung cancer and with chronic unspecific diseases of breath organs.
- Examination of chest. Often there are no abnormal signs. The commonest is fine crepitations (crackles) in the upper part of one or both lungs. These are heard particularly on taking a deep breath after coughing. Later there may be dullness to percussion or even bronchial breathing in the upper part of both lungs. Occasionally there is a localized wheeze due to local tuberculous bronchitis or pressure by a lymph node on a bronchus.
In chronic tuberculosis, with much fibrosis (scarring) the scarring may pull of the mediastinum organs the trachea or the heart over to one side. At any stage the physical signs of pleural effusion may be present.
However, often you will find nothing abnormal in the chest.