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Tuberculosis

TB

Tuberculosis is a multisystemic disease commonly affecting the lungs.


Presentation

TB presents initially as flu-like symptoms. As the disease progresses, it manifests itself with chronic cough with blood-tinged sputum, fever and night sweats. Patients also complain of weight loss, malaise, retrosternal pain and weakness. There may also be cutaneous lesions. Primary infection usually persists for 7-14 days.

Extrapulmonary tuberculosis most frequently presents with lymphadenitis. It may also cause leukocytosis and anemia, however, the findings are nonspecific. Tuberculous meningitis presents with persistent headache, altered mental status which may progress to coma and low grade fever. Skeletal TB most commonly affects the spine, called Potts disease.

Cough
  • It can be transmitted by coughing, sneezing, spitting and even speaking by a person with an active infection.[symptoma.com]
  • The patient was suspected to have TB after having recurrent episodes of coughing which would improve briefly before her respiratory symptoms returned, which led to her being treated at various healthcare clinics and hospitals.[ncbi.nlm.nih.gov]
  • Coughing or sneezing by infected persons is the most common cause of transmission.[giantmicrobes.com]
  • Symptoms of TB in the lungs may include A bad cough that lasts 3 weeks or longer Weight loss Loss of appetite Coughing up blood or mucus Weakness or fatigue Fever Night sweats Skin tests, blood tests, x-rays, and other tests can tell if you have TB.[medlineplus.gov]
Hemoptysis
  • This report describes the case of a 30-year-old homeless man from Pereira, Colombia with tuberculosis, who presented with massive hemoptysis and associated aneurysm of the left upper lobe (Rasmussen aneurysm).[ncbi.nlm.nih.gov]
  • A 71-year-old man with a history of pulmonary tuberculosis presented with a fungus ball-like shadow in an old cavity and hemoptysis. There was no evidence of aspergillus infection on various examinations.[ncbi.nlm.nih.gov]
  • We report a case of PIMT with hemoptysis. The girl was misdiagnosed with tuberculosis and treated with anti-tuberculous drugs for a long period of time.[ncbi.nlm.nih.gov]
  • Local symptoms of TB vary according to the part affected; acute symptoms include hectic fever, sweats, and emaciation; serious complications include granulomatous erosion of pulmonary bronchi associated with hemoptysis.[fpnotebook.com]
  • This lesion may erode a neighbouring bronchus or blood vessel , causing the patient to cough up blood ( hemoptysis ). Tubercular lesions may spread extensively in the lung, causing large areas of destruction, cavities, and scarring.[britannica.com]
Pleural Effusion
  • We report a 9-year-old girl from Mumbai, India with fever, bilateral pleural effusion, thrombocytopaenia, haemoconcentration and oliguria due to hantavirus infection. She also had associated tuberculosis.[ncbi.nlm.nih.gov]
  • The definitive diagnosis was BTB with pleural effusion. Treatment with a quadruple combinational antituberculous therapy was initiated. Two months later, the patient's chest distress and discomfort significantly decreased.[ncbi.nlm.nih.gov]
  • In some cases the infection may break into the pleural space between the lung and the chest wall, causing a pleural effusion , or collection of fluid outside the lung.[britannica.com]
Productive Cough
  • A 6-year old male infant from the West Region of Cameroon infected with HIV who presented at a local health center with a 10 days history of productive cough associated with nocturnal fever and abdominal pains non responsive to broad spectrum antibiotics[ncbi.nlm.nih.gov]
  • Symptoms include productive cough, fever, weight loss, and malaise. Diagnosis is most often by sputum smear and culture and, increasingly, by rapid molecular-based diagnostic tests.[merckmanuals.com]
  • ., a productive cough, night sweats, fever, weakness or fatigue, weight loss, pain in the chest); and can have a positive tuberculin skin test reaction. 5 Infection Control/Precautions In 2005, the CDC developed guidelines for preventing transmission[ada.org]
  • The CDC has identified the symptoms to be: productive cough, coughing up blood, weight loss, loss of appetite, lethargy/weakness, night sweats, or fever.[osha.gov]
  • Symptoms suggestive of TB include [1] : Productive cough last longer than 3 weeks Weight Loss Fever Night sweats Fatigue Malaise Anorexia Rales could be heard in the lobes of involvement in the lungs Bronchial Breath Sounds Dull chest pain, tightness,[physio-pedia.com]
Chronic Cough
  • TB affecting the lungs presents with chronic cough with sputum, chest pain, fever, night sweats and weight loss. Skeletal TB presents with body aches, musculoskeletal pain and joint pain.[symptoma.com]
  • When to You Call the Doctor Call the doctor if your child: has been in contact with a person who has (or is suspected to have) tuberculosis has persistent fever complains of sweating at night develops a persistent, chronic cough Date reviewed: January[kidshealth.org]
  • Symptoms of TB include a chronic cough with blood-tinged sputum, fever, night sweats, and weight loss.[pih.org]
  • You can also drink the juice of the banana plant stem to relieve symptoms like chronic cough, excess phlegm, excessive perspiration at night with a high fever and so on.[top10homeremedies.com]
  • Specialty Infectious disease , pulmonology Symptoms Chronic cough, fever, blood in the sputum , weight loss [1] Causes Mycobacterium tuberculosis [1] Risk factors Smoking, HIV/AIDS [1] Diagnostic method CXR , culture , tuberculin skin test [1] Similar[en.wikipedia.org]
Fever
  • We report a 9-year-old girl from Mumbai, India with fever, bilateral pleural effusion, thrombocytopaenia, haemoconcentration and oliguria due to hantavirus infection. She also had associated tuberculosis.[ncbi.nlm.nih.gov]
  • After initiation of multidrug TB therapy, her fever and abdominal pain drastically improved.[ncbi.nlm.nih.gov]
  • However, a new persistent fever and confused state developed 1 month after the anti-TB therapy was started.[ncbi.nlm.nih.gov]
  • Tuberculous meningitis presents with persistent headache, altered mental status which may progress to coma and low grade fever. Skeletal TB most commonly affects the spine, called Potts disease.[symptoma.com]
  • Here, we report a 32-year-old female patient who presented with a history of high-grade intermittent fever, cough and painless skin lesions since a month, along with bilateral claw hand (on examination).[ncbi.nlm.nih.gov]
Weight Loss
  • A 50 year male presented with acute onset jaundice, significant weight loss and elevated liver enzymes with clinico-radiological suspicion of cholangiocarcinoma.[ncbi.nlm.nih.gov]
  • A 46-year-old woman who had a recent total abdominal hysterectomy presented with a 1 month history of lower abdominal pain, 1 week of nausea and vomiting as well as decreased urinary output preceded by a year of significant unintentional weight loss.[ncbi.nlm.nih.gov]
  • A 47-year-old HIV-negative man of mixed ethnicity presented with a 2-week history of cough, haemoptysis and unintentional weight loss.[ncbi.nlm.nih.gov]
  • We hereby report a case of a very rare presentation of tuberculosis (TB) in a patient who presented with a dry cough and significant weight loss for 3 months.[ncbi.nlm.nih.gov]
  • TB affecting the lungs presents with chronic cough with sputum, chest pain, fever, night sweats and weight loss. Skeletal TB presents with body aches, musculoskeletal pain and joint pain.[symptoma.com]
Fatigue
  • The diagnosis of miliary TB was made based on the presence of intermittent fever and fatigue; thus, anti-TB treatments (isoniazid, levofloxacin, ethambutol, and pyrazinamide) were started, which led to rapid defervescence and regression of the granular[ncbi.nlm.nih.gov]
  • Fatigue and weight loss may follow. If the disease progresses and cavities form in the lungs, the person might have coughing and the production of saliva, mucus, or phlegm that may contain blood.[kidshealth.org]
  • Symptoms of TB in the lungs may include A bad cough that lasts 3 weeks or longer Weight loss Loss of appetite Coughing up blood or mucus Weakness or fatigue Fever Night sweats Skin tests, blood tests, x-rays, and other tests can tell if you have TB.[medlineplus.gov]
  • Although TB symptoms vary depending on which part of the body the disease infects, symptoms of TB of the lungs typically include: • A bad cough lasting more than two weeks • Coughing up blood or sputum (phlegm from deep in the lungs) • Chest pain, fever, fatigue[giantmicrobes.com]
  • Symptoms include coughing up blood, fatigue, fever, night sweats, chills and loss of appetite. Contact reporter Nicholas Filipas at (209) 546-8257 or [email protected] Follow him on recordnet.com/filipasblog or on Twitter @nicholasfilipas.[recordnet.com]
Weakness
  • You are more likely to get TB if you have a weak immune system.[medlineplus.gov]
  • […] symptoms vary depending on which part of the body the disease infects, symptoms of TB of the lungs typically include: • A bad cough lasting more than two weeks • Coughing up blood or sputum (phlegm from deep in the lungs) • Chest pain, fever, fatigue/weakness[giantmicrobes.com]
  • However, in people with weak immune systems, especially those with HIV (human immunodeficiency virus), or those receiving medicines that suppress the immune system, TB organisms can overcome the body's defenses, multiply, and cause an active disease.[cedars-sinai.edu]
  • […] infect the body, concentrating their effects in the lungs, but they may also spread to the: Brain Kidney Bones Joints Lymph nodes Spine Tuberculosis Symptoms The symptoms of tuberculosis are varied and often include: Weight loss Night sweats Muscle weakness[everydayhealth.com]
Chills
  • […] vary depending on which part of the body the disease infects, symptoms of TB of the lungs typically include: • A bad cough lasting more than two weeks • Coughing up blood or sputum (phlegm from deep in the lungs) • Chest pain, fever, fatigue/weakness, chills[giantmicrobes.com]
  • Symptoms include coughing up blood, fatigue, fever, night sweats, chills and loss of appetite. Contact reporter Nicholas Filipas at (209) 546-8257 or [email protected] Follow him on recordnet.com/filipasblog or on Twitter @nicholasfilipas.[recordnet.com]
  • […] spinal pain, joint damage, meningitis, liver or kidney problems, and heart disorders Signs and symptoms of tuberculosis: Loss of appetite Fatigue Coughing up blood Coughing that lasts three or more weeks Fever Unintentional weight loss Sweats at night Chills[naijafoodtherapy.com]
  • They include: A cough that lasts more than 3 weeks Chest pain Coughing up blood Feeling tired all the time Night sweats Chills Fever Loss of appetite Weight loss If you experience any of these symptoms, see your doctor to get tested.[webmd.com]
  • The rest of the body detects this change, then attempts to adjust to this new temperature by contracting muscles (shivers), making you feel chills.[wikihow.com]
Loss of Appetite
  • We report a case of a 56-year-old Sri Lankan Sinhalese man who presented with pyrexia of known origin with significant loss of weight and loss of appetite. He had mild pallor with mild hepatosplenomegaly.[ncbi.nlm.nih.gov]
  • Symptoms of TB in the lungs may include A bad cough that lasts 3 weeks or longer Weight loss Loss of appetite Coughing up blood or mucus Weakness or fatigue Fever Night sweats Skin tests, blood tests, x-rays, and other tests can tell if you have TB.[medlineplus.gov]
  • […] of appetite, and night sweats Both active and latent TB can be detected by injecting tuberculin under the skin and examining resultant bumps.[giantmicrobes.com]
  • Symptoms include coughing up blood, fatigue, fever, night sweats, chills and loss of appetite. Contact reporter Nicholas Filipas at (209) 546-8257 or [email protected] Follow him on recordnet.com/filipasblog or on Twitter @nicholasfilipas.[recordnet.com]
  • […] of appetite Fatigue Coughing up blood Coughing that lasts three or more weeks Fever Unintentional weight loss Sweats at night Chills Chest pain, or a painful cough or breathing Best Food Diet For Tuberculosis Patient An all-fruit diet for three days.[naijafoodtherapy.com]
Back Pain
  • A 58-year-old Asian woman was referred to our hospital for evaluation of low back pain for 4 years and abdominal pain for 1 month.[ncbi.nlm.nih.gov]
  • For example, tuberculosis of the spine may give you back pain, and tuberculosis in your kidneys might cause blood in your urine.[mayoclinic.org]
  • TB of the spine can cause back pain and leg paralysis. TB of the brain can cause headaches and nausea. You won’t have any symptoms of tuberculosis unless you have active TB. What causes tuberculosis? TB is caused by bacteria.[familydoctor.org]
  • Some of the common reasons to order a chest X-ray test are listed below: Cough Shortness of breath Chest pain Poor oxygenation (hypoxia) Back pain Chest injury Fever From Reviewed on 10/19/2018 Sources: Patient Comments & Reviews CONTINUE SCROLLING FOR[emedicinehealth.com]
  • pain or stiffness Lower-extremity paralysis, in as many as half of patients with undiagnosed Pott disease Tuberculous arthritis, usually involving only 1 joint (most often the hip or knee, followed by the ankle, elbow, wrist, and shoulder) Symptoms of[emedicine.medscape.com]
Night Sweats
  • TB affecting the lungs presents with chronic cough with sputum, chest pain, fever, night sweats and weight loss. Skeletal TB presents with body aches, musculoskeletal pain and joint pain.[symptoma.com]
  • Symptoms of TB in the lungs may include A bad cough that lasts 3 weeks or longer Weight loss Loss of appetite Coughing up blood or mucus Weakness or fatigue Fever Night sweats Skin tests, blood tests, x-rays, and other tests can tell if you have TB.[medlineplus.gov]
  • sweats Both active and latent TB can be detected by injecting tuberculin under the skin and examining resultant bumps.[giantmicrobes.com]
  • ., coughing, fever, night sweats, coughing up blood) and are not infectious to others. It is crucial, however, that persons with LTBI receive treatment, because some persons with LTBI will eventually develop TB disease.[cookcountypublichealth.org]
  • Symptoms of tuberculosis include coughing up blood, night sweats, weight loss and exhaustion. TB Anywhere is TB Everywhere TB is not limited by national boundaries.[aeras.org]
Flank Pain
  • pain, increased frequency, masses or lumps (granulomas) Gastrointestinal TB: difficulty swallowing , nonhealing ulcers, abdominal pain , malabsorption, diarrhea (may be bloody) Miliary TB: many small nodules widespread in organs that resemble millet[medicinenet.com]
  • pain Dysuria Frequent urination In men, a painful scrotal mass, prostatitis, orchitis, or epididymitis Symptoms of gastrointestinal TB are referable to the infected site and may include the following: Nonhealing ulcers of the mouth or anus Difficulty[emedicine.medscape.com]
Headache
  • Tuberculous meningitis presents with persistent headache, altered mental status which may progress to coma and low grade fever. Skeletal TB most commonly affects the spine, called Potts disease.[symptoma.com]
  • TB of the brain can cause headaches and nausea. You won’t have any symptoms of tuberculosis unless you have active TB. What causes tuberculosis? TB is caused by bacteria. The bacteria spread through the air from one person to another.[familydoctor.org]
  • This can cause a lasting or intermittent headache that occurs for weeks. Mental changes also are possible. Liver or kidney problems. Your liver and kidneys help filter waste and impurities from your bloodstream.[mayoclinic.org]
  • The following includes the signs and symptoms of additional types of TB: Skeletal TB (also termed Pott's disease): spinal pain , back stiffness, paralysis is possible TB meningitis : headaches (variable in length but persistent), mental changes, coma[medicinenet.com]
Altered Mental Status
  • Tuberculous meningitis presents with persistent headache, altered mental status which may progress to coma and low grade fever. Skeletal TB most commonly affects the spine, called Potts disease.[symptoma.com]

Workup

Laboratory tests

Screening:

  • Tuberculin skin test (using PPD)
  • Interferon-Gamma release Assay (IGRA): IGRA assays offer certain advantages over tuberculin skin testing [6].

Suspected TB:

  • Acid-fast staining of sputum or other specimens
  • Culture in Lowenstein-Jensen agar
  • Nucleic acid amplification tests
  • Luciferase Assay which can detect drug resistant organisms [2]
  • HIV serology

Imaging

Imaging studies include chest radiography and CT scan which can show pulmonary infiltrates. A biopsy can be performed, but is rarely needed.

Test results

On the basis of clinical evaluation and laboratory test results, TB can be definitively diagnosed. Susceptible individuals should also be screened for latent TB. The goal of testing for latent tuberculosis infection (LTBI) is to identify individuals who are at increased risk for the development of tuberculosis (TB) and therefore would benefit from treatment of LTBI [7].

Pericardial Effusion
  • This paper reports a case of tuberculosis-associated pericardial effusion with dense fibrinous material not causing tamponade in a foreigner presenting with nonspecific symptoms.[ncbi.nlm.nih.gov]
Pyuria
  • Urinary Tract Tuberculosis: A "sterile pyuria" with WBC's present in urine but a negative routine bacterial culture may suggest the diagnosis of renal tuberculosis. Progressive destruction of renal parenchyma occurs if not treated.[library.med.utah.edu]
  • […] radiographic findings, reflecting an inability of the impaired immune response to contain infection.(49) Patients with extrapulmonary TB may present with signs and symptoms specific to the involved site, such as lymphadenopathy, headache, meningismus, pyuria[hivinsite.ucsf.edu]
Pleural Effusion
  • We report a 9-year-old girl from Mumbai, India with fever, bilateral pleural effusion, thrombocytopaenia, haemoconcentration and oliguria due to hantavirus infection. She also had associated tuberculosis.[ncbi.nlm.nih.gov]
  • The definitive diagnosis was BTB with pleural effusion. Treatment with a quadruple combinational antituberculous therapy was initiated. Two months later, the patient's chest distress and discomfort significantly decreased.[ncbi.nlm.nih.gov]
  • In some cases the infection may break into the pleural space between the lung and the chest wall, causing a pleural effusion , or collection of fluid outside the lung.[britannica.com]

Treatment

Medication

Anti-tuberculous chemotherapy is the mainstay of treatment and highly effective. The most commonly used antibiotics used are isoniazid (INH) and rifampicin. The recommended treatment of new-onset pulmonary tuberculosis, as of 2010, is 6 months of a combination of antibiotics containing rifampicin, isoniazid, pyrazinamide, and ethambutol for the first two months [8]. Only rifampicin and isoniazid need to be continued for the last four months.

Directly observed therapy

Patient compliance is generally found to be non satisfactory. To overcome this hurdle, directly observed therapy (DOT) has become an important part of treatment. Individual case management with DOT is very important for facilitating adherence and preventing the development of drug resistance and represents the standard of care in the United States today [9].

Prognosis

TB infection does not always progress to active TB disease, but since both active and latent TB responds well to antituberculous chemotherapy, it has an excellent prognosis. Identification and treatment of latent tuberculosis infection can reduce the risk of development of disease by as much as 90 percent [5].

Etiology

Mycobacterium tuberculosis

The primary causative agent of tuberculosis is the slender, rod-shaped obligate aerobe called Mycobacterium tuberculosis (other mycobacteria can also cause this disease). It is acid-fast due to the high lipid content (up to 60%) of their cell walls. 3 important constituents include [2]:

  • Long-chain fatty acids (C78-C90) called Mycolic acids which contribute to the acid-fastness.
  • Wax D serves to enhance the immune response. 
  • Phosphatides play a role in caseous necrosis.

Transmission

TB is an air-borne infection. It can be transmitted by coughing, sneezing, spitting and even speaking by a person with an active infection. All such actions result in expulsion of infectious aerosol particles or droplets that contain the bacteria which may be inhaled by anyone present in the vicinity. Since the infectious dose of TB is very low, inhalation of as little as 10 organisms can lead to the development of this disease. People in close contact with such a person are particularly at high risk.

Genetics

Many patients are genetically vulnerable to this disease. Polymorphisms in some genes, for example in NRAMP1 gene which encodes the NRAMP1 transmembrane protein that pumps divalent ions out of lysosomes, may result in ineffectual immune response of the host. NRAMP1 may inhibit microbacterial growth by limiting availability of ions needed by the bacteria [3]. So a genetic defect in this gene may make the host vulnerable to TB.

Epidemiology

Incidence

TB is estimated to affect 1.7 billion individuals worldwide with approximately 1.6 million deaths annually. 

Age

Tuberculosis is typically a disease of older people. Immuno-compromised individuals, however, are at risk, irrespective of age.

Sex

The disease is found more in males than in females.

Race

TB is prone to develop in poverty stricken areas and so, in many regions of various third world countries this disease is a common occurrence. It has the highest occurrence in Asians, followed by Hispanics and then African-Americans. 

Sex distribution
Age distribution

Pathophysiology

Mycobacterium tuberculosis enters macrophages by endocytosis mediated by several factors. Once inside, it begins to replicate in the pulmonary airspaces and alveolar macrophages. Despite bacteremia, most patients at this stage are asymptomatic. About 3 weeks after infection, a T-H1 response is mounted that activates macrophages to become bactericidal [4]. The activated T-H1 cells produce Interferon gamma which is critical in containing the infection. NK-1 cells also produce IFN-y. IFN-y enables macrophages to differentiate into epitheloid histiocytes which are characteristic findings of granulomas. Caseous necrosis ensues in an attempt to close off and destroy the bacteria.

The primary formed lesions are 1-1.5 cm areas of inflammation with consolidation called Ghon focus. They begin to caseate and some of the bacteria disseminate into regional lymph nodes. This caseated lesion along with lymph node involvement constitutes the Ghon complex. In subsequent weeks the tubercle bacteria disseminate to the rest of the body via both lymphatic and hematogeneous spread. The Ghon complex undergoes progressive fibrosis turning into calcified lesions called Ranke complex.

All this results in three major effects: Reduced breathing and vital capacity, reduced total respiratory membrane surface area and increased thickness of the respiratory membrane, and lastly, abnormal ventilation-perfusion ratio of the lung.

Prevention

TB can be prevented with the use of BCG vaccine. This vaccine contains a strain of live, attenuated Mycobacterium bovis called bacillus Calmette-Guerin. It can also be prevented by living in well-aired, less crowded quarters and using boiled water and pasteurized milk. The PPD screening test should also be regularly performed in people belonging to susceptible demographics.

Summary

Tuberculosis (TB) is a multisystemic disease commonly affecting the lungs. It is due to an infection by bacteria of the Mycobacteria genus. It is transmitted when people who have an active TB infection cough, sneeze, or otherwise transmit respiratory fluids through the air [1]. It is one of the most common infectious diseases in the world and a source of high infection-associated mortality, second only to HIV. The World Health Organization is still attempting to eradicate the disease from the world and has been quite successful in significantly decreasing the incidence of TB in many developed countries.

Patient Information

Definition

Tuberculosis (TB) is an infectious disease that occurs due to transmission of bacteria from a person with an active TB infection to a healthy individual. Patients that are immune-compromised, for e.g HIV patients, are at higher risk of contracting this disease. 

Cause

TB is most commonly due to an infection by Mycobacterium tuberculosis. Other strains like Mycobacterium bovis may also cause TB. Transmission is through air, like during coughing or sneezing via aerosol droplets containing the infectious particles. 

Signs and symptoms

Signs and symptoms vary according to the type of TB. TB affecting the lungs presents with chronic cough with sputum, chest pain, fever, night sweats and weight loss. Skeletal TB presents with body aches, musculoskeletal pain and joint pain. Tuberculous meningitis presents with headache, altered mental status, fever and sometimes coma.

Diagnosis

Diagnostic evaluation for TB may be initiated in outpatient settings [10]. Patients that are susceptible to this disease should be screened. Diagnosis is made based on history, chest radiography and positive blood/sputum cultures. 

Treatment

Treatment is ideally a quadruple therapy of antibiotics that should be continued for 6 months to prevent recurrence.

References

Article

  1. Konstantinos A. Testing for tuberculosis. Australian Prescriber 33 (1): 12–18, 2010.
  2. Warren Levinson: Review of Medical Microbiology and Immunology. 11th ed. Pa: McGraw Hill, 2010. ISBN 978-0-07-170028-3
  3. Cellier MF, et al. NRAMP1 phagocyte intracellular metal withdrawal defense. Microbes Infect 9:1662, 2007.
  4. Flynn JL, Chan J. Immunology of tuberculosis. Annu Rev Immunol 19:93, 2001.
  5. Comstock GW. How much isoniazid is needed for prevention of tuberculosis among immunocompetent adults? Int J Tuberc Lung Dis 1999; 3:847.
  6. Mazurek GH, Jereb J, Lobue P, Iademarco MF, Metchock B, Vernon A. Guidelines for using the QuantiFERON-TB Gold test for detecting Mycobacterium tuberculosis infection, United States. MMWR Recomm Rep. Dec 16 2005;54:49-55
  7. Mancuso JD, Tribble D, Mazurek GH, et al. Impact of targeted testing for latent tuberculosis infection using commercially available diagnostics. Clin Infect Dis 2011; 53:234.
  8. Lawn SD, Zumla AI. Tuberculosis. Lancet 378 (9785): 57–72. 2 July 2011 doi:10.1016/S0140-6736(10)62173-3. PMID 21420161
  9. Blumberg HM, Burman WJ, Chaisson RE, et al. American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis. Am J Respir Crit Care Med 2003; 167:603.
  10. Taylor Z, Marks SM, Ríos Burrows NM, et al. Causes and costs of hospitalization of tuberculosis patients in the United States. Int J Tuberc Lung Dis 2000; 4:931.

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Last updated: 2018-01-17 10:34