Approach to TB in the ED.
TB might be more common than you think: In NY alone, in 2016, 3.9 cases per 100,000 people, 761 cases in NY in 2016.
Reactivation TB is about 90% of active TB in the United States.
Who is at high risk?
Those with no “usual source of care”
ethnic minorities
foreign born
HIV patient
drug users
nursing home patients
homeless patients
prisoners
Why is it often missed?
Non-specific presentation of TB
Cough present: 64%
Cough was chief complaint: 20%
Only 36% had respiratory complaint at triage
What to do if for high suspicion of TB:
Negative pressure isolation room
N95 fitted masks
CXR and rapid HIV
Why HIV test?
HIV increases risk of having reactivation TB
Immunosuppression will give you atypical cxr findings
Looking primarily for active tuberculosis
Confirmatory testing:
PPD: Sensitivity 60-100%
QuantiFERON Gold: Sensitivity 81-96%
Sputum Looking for AFB on smear (Ziehl-Neelson stain)
Variable Sensitivity: 20-60%
High specificity: 90-100%
Culture
Slower results: 7days- 8 weeks
Gold standard: 99% sensitivity
Rapid TB testing/ Cepheid Xpert MTB/RIF PCR assay
Respiratory for assistance in collection
5 ml specimen
Rifampin resistance detection
Supposed to be a 2 hr turnaround
2 negative sputum specimens at least 8 hrs apart: can remove from isolation
Sensitivity about 75-93%
*This is a sample rule out TB protocol that I adapted from Annals of Emergency Medicine October 2016 : http://www.annemergmed.com/article/S0196-0644(16)30920-9/fulltext
