📌 Part 1 — Introduction (Chapter 1)

Concept-Based + Exam-Ready Notes

🧠 1.1 What is EPTB?

• Extra-pulmonary TB (EPTB) is TB involving any organ outside the lungs (e.g., pleura, lymph nodes, abdomen, bones, CNS).
• Terminology aligns with standard definitions used by national & international TB programmes.

📊 1.2 Epidemiology in Sri Lanka

• Sri Lanka is classified as a low TB burden country.
• Annually ~8,000–9,000 total TB cases are notified.
• About 23–27% of these are EPTB.
• Over the past decade (2013–2022), the proportion of EPTB has remained ≈25% but notification rates have dropped over time.
• Most common EPTB sites historically:
1. Peripheral lymph nodes
2. Pleural TB
3. Spinal TB
• EPTB proportion is higher in persons with HIV (globally: 40–68% of TB in HIV vs ≈15–20% without).

🌍 1.3 Transmission of TB (context)

• TB is an airborne infection spread via droplet nuclei expelled when someone with pulmonary TB coughs, sneezes, etc.
• EPTB itself is generally not considered infectious, but patients often need evaluation for coexisting pulmonary TB because lung disease can be present even if symptoms are minimal.

👩‍⚕️ 1.4 Why this guideline was updated

• Original EPTB guideline in Sri Lanka was published in 2013.
• Since then, there have been major advances in diagnosis and management of EPTB (including new molecular tests and evidence for site-specific management).
• The 2024 update was developed to provide current evidence-aligned guidance for clinicians managing EPTB across body organs and age groups.
• The guideline integrates WHO recommendations and specialty input from national experts in pulmonology, radiology, microbiology, pathology, surgery and paediatrics.

🧑‍⚕️ 1.5 Why EPTB matters

• Delay in diagnosis leads to worse outcomes and potential disability (e.g., neurological or skeletal).
• Symptoms vary widely by organ involved; therefore clinical suspicion must be high.
• The guideline aims to standardize EPTB care, improve outcomes and support Sri Lanka’s TB elimination goals (aligned with the End TB Strategy).

📍 Quick exam/reflex points from Intro

• EPTB = TB outside lungs but look always for coexisting PTB.
• ≈25% of TB in Sri Lanka is EPTB.
• Common sites: lymph nodes, pleura, spine.
• Higher probability of EPTB in HIV.
• Delay in diagnosis worsens outcomes.

Part 2 — Classification of Extra-Pulmonary Tuberculosis (Chapter 2)

(From the 2024 Sri Lanka NPTCCD EPTB Guideline — structured, exam-ready)

National Programme for Tuberculosis Control and Chest Diseases

2.1 Why classification matters (guideline logic)

• EPTB presents with organ-specific symptoms, needs site-specific diagnostics, and sometimes different treatment durations.
• A clear classification helps clinicians suspect early, choose the right specimen, and avoid delays/misdiagnosis.

2.2 Anatomical classification of EPTB

The guideline groups EPTB by organ/system involved:

1. Peripheral lymph node TB
2. Pleural TB
3. Bone and joint TB (including spinal TB)
4. Central nervous system TB
• TB meningitis
• Intracranial tuberculoma
5. Abdominal TB
• Peritoneal
• Intestinal
• Solid organ involvement (e.g., liver, spleen)
6. Genitourinary TB
7. Breast TB
8. Upper airway TB (larynx, nasopharynx, middle ear)
9. Ocular TB
10. Cutaneous TB
11. Cardiac TB (pericardial TB)
12. Disseminated TB (multi-site involvement without pulmonary focus)

Exam anchor: Lymph node TB is the most common form of EPTB in Sri Lanka.

2.3 Microbiological classification

• Bacteriologically confirmed EPTB
• Mycobacterium tuberculosis detected by:
• AFB smear
• Culture
• Molecular tests (NAAT/Xpert) from extrapulmonary specimens
• Clinically diagnosed EPTB
• Compatible clinical + radiological features
• Histology suggestive of TB
• Microbiology negative or specimen unobtainable
• Decision made by a specialist

Key guideline principle:

Failure to get microbiological proof does NOT exclude EPTB.

2.4 Drug-resistance classification (applies to EPTB too)

• Drug-susceptible EPTB
• Rifampicin-resistant EPTB
• Multidrug-resistant (MDR) EPTB
• Pre-XDR / XDR EPTB

Resistance classification follows the same definitions as pulmonary TB, but diagnosis is harder because EPTB is often paucibacillary.

2.5 Clinical severity grouping

Used implicitly to guide urgency and duration:

• Non-severe EPTB
• Lymph node TB
• Uncomplicated pleural TB
• Severe EPTB
• TB meningitis
• Spinal TB with neurological deficit
• Pericardial TB with tamponade
• Disseminated TB

Severity influences treatment duration, need for steroids, and referral urgency.

2.6 Programmatic classification (public-health view)

• EPTB without pulmonary involvement
• Usually not infectious
• Still needs contact tracing to identify the source case
• EPTB with concomitant pulmonary TB
• Managed as pulmonary TB for infection control
• Household contacts screened as PTB contacts

2.7 High-yield exam/reflex lines

• EPTB is classified by anatomical site + microbiological confirmation + drug resistance.
• Lymph node TB is the commonest EPTB in Sri Lanka.
• Clinical diagnosis is acceptable when microbiology is negative or not feasible.
• Always assess for co-existing pulmonary TB, regardless of EPTB site.

Part 3 — Clinical Features of Extra-Pulmonary Tuberculosis (Chapter 3)

(Sri Lanka NPTCCD EPTB Guideline 2024 — logic-based, site-wise)

National Programme for Tuberculosis Control and Chest Diseases

3.1 General clinical principles (apply to all EPTB)

• EPTB often presents with chronic, slowly progressive symptoms.
• Constitutional symptoms may or may not be present:
• Low-grade fever
• Weight loss
• Night sweats
• Malaise
• Symptoms are site-specific → hence TB may mimic malignancy, autoimmune disease, or other infections.
• Absence of pulmonary symptoms does NOT exclude TB.
• Always actively look for co-existing pulmonary TB even if extrapulmonary features dominate.

3.2 Site-specific clinical features (EXAM + WARD USE)

A. Peripheral Lymph Node TB (Commonest EPTB)

• Painless, slowly enlarging lymph nodes
• Common sites:
• Cervical (most common)
• Supraclavicular
• Axillary
• Inguinal
• Nodes may be:
• Firm initially
• Later matted
• May become fluctuant → sinus formation
• Overlying skin:
• Usually normal early
• Later inflamed, discharging sinus
• Systemic symptoms: variable
• Important mimic: lymphoma, metastatic cancer

Exam reflex: Painless cervical lymphadenopathy + chronic course → think TB.

B. Pleural TB

• Acute or subacute onset
• Symptoms:
• Fever
• Pleuritic chest pain
• Dyspnoea
• Dry cough
• Signs:
• Reduced breath sounds
• Dullness to percussion
• Effusion usually:
• Unilateral
• Moderate to large
• Systemic symptoms may be prominent

Exam reflex: Young patient + unilateral exudative pleural effusion + fever → TB until proven otherwise.

C. Bone & Joint TB

Includes spinal and non-spinal disease.

Spinal TB (Pott disease)

• Persistent back pain (earliest symptom)
• Local tenderness
• Gibbus deformity (late)
• Neurological features if cord compression:
• Weakness
• Sensory loss
• Bladder/bowel dysfunction

Peripheral joint TB

• Monoarthritis
• Pain, swelling, reduced range of movement
• Minimal redness (cold joint)

Exam reflex: Chronic monoarthritis without erythema → TB arthritis.

D. Central Nervous System TB

Includes TB meningitis and intracranial tuberculoma.

TB Meningitis

• Subacute onset (days–weeks)
• Fever
• Headache
• Vomiting
• Altered consciousness
• Cranial nerve palsies (esp. VI)
• Seizures (late)

Tuberculoma

• Features of space-occupying lesion:
• Headache
• Seizures
• Focal neurological deficits

Exam reflex: Subacute meningitis with cranial nerve palsy → TB meningitis until proven otherwise.

E. Abdominal TB

Can involve peritoneum, intestine, lymph nodes, solid organs.

• Abdominal pain
• Fever
• Weight loss
• Altered bowel habits
• Ascites
• Abdominal mass
• Intestinal obstruction (late)

Exam reflex: Young patient + chronic abdominal pain + ascites + weight loss → think TB.

F. Genitourinary TB

• Dysuria
• Frequency
• Sterile pyuria
• Hematuria
• Flank pain
• Infertility (late complication)

Exam reflex: Sterile pyuria = genitourinary TB until proven otherwise.

G. Pericardial TB

• Fever
• Chest pain
• Dyspnoea
• Signs of pericardial effusion:
• Raised JVP
• Muffled heart sounds
• Tamponade features in severe cases

H. Other sites (briefly listed in guideline)

• Breast TB → lump, sinus, mimics carcinoma
• Ocular TB → uveitis, visual disturbance
• Cutaneous TB → nodules, ulcers
• Upper airway TB → hoarseness, dysphagia
• Disseminated TB → multi-system involvement

3.3 Red flags (urgent referral)

• Neurological deficits
• Altered consciousness
• Spinal tenderness with weakness
• Pericardial tamponade
• Intestinal obstruction

3.4 Exam-critical summary

• EPTB symptoms are organ-specific and often insidious.
• Lymph node TB = commonest form.
• TB meningitis and spinal TB are medical emergencies.
• Always search for pulmonary TB, regardless of EPTB presentation.

Part 4 — Diagnostic Approach to Extra-Pulmonary TB (Chapter 4)

(Sri Lanka NPTCCD EPTB Guideline 2024 — step-by-step, exam + ward logic)

National Programme for Tuberculosis Control and Chest Diseases

4.1 Core diagnostic principle (memorize this)

• EPTB diagnosis = clinical suspicion + appropriate specimen + microbiology/histology ± imaging.
• Do NOT wait for microbiology if the site is critical (e.g., CNS, spinal cord) — start treatment on strong clinical grounds.

4.2 Always exclude or detect co-existing Pulmonary TB

• Mandatory step in ALL EPTB cases.
• Why:
• Infection control
• Contact tracing
• Program classification
• How:
• Symptom screen
• Chest X-ray
• Sputum for AFB / molecular test if any respiratory symptoms or abnormal CXR

Exam reflex: EPTB ≠ no PTB — always look.

4.3 Specimen-first logic (choose the RIGHT sample)

General rules

• Get tissue/fluid from the site of disease whenever possible.
• Prefer invasive sampling over empiric treatment if safe and feasible.
• Yield depends more on specimen quality than on test type.

Specimen handling (high-yield, practical)

• For microbiology (AFB, culture, Xpert): send in 0.9% normal saline
• For histology: send in formalin
• Do NOT put microbiology samples in formalin (kills bacilli → false negatives).
• If delay in transport:
• Store at 2–8 °C
• Use triple-layer packaging

4.4 Microbiological tests (what each test gives you)

AFB smear

• Rapid
• Low sensitivity in EPTB (paucibacillary)
• A positive smear = definitive TB

Culture (gold standard)

• Recommended for all EPTB specimens where feasible
• Allows:
• Confirmation
• Drug susceptibility testing
• Liquid culture ≈ faster; solid culture slower

Molecular tests (Xpert / NAAT)

• Detects:
• MTB
• Rifampicin resistance
• Useful for many extrapulmonary specimens
• A negative result does NOT exclude EPTB

Exam reflex: Culture is gold standard; Xpert is rapid but not exclusionary.

4.5 Histopathology (very important in EPTB)

• Findings suggestive of TB:
• Caseating granulomas
• Epithelioid cells
• Langhans giant cells
• AFB may be absent even with typical granulomas.
• Histology + clinical context = acceptable basis for diagnosis.

4.6 Imaging — supportive, not diagnostic

Role of imaging

• Identify disease extent
• Guide biopsy
• Detect complications
• Monitor response (selected cases)

Common imaging by site

• Lymph nodes: Ultrasound / CT
• Pleura: CXR, ultrasound
• Spine: MRI (best)
• CNS: MRI brain with contrast
• Abdomen: Ultrasound / CT

Exam reflex: Imaging supports diagnosis; tissue confirms it.

4.7 Baseline investigations (recommended)

• Full blood count
• ESR / CRP
• Liver function tests
• Renal function
• Fasting blood sugar
• HIV testing (recommended for all TB patients)

4.8 When diagnosis is “clinical EPTB”

Diagnosis can be made without microbiological confirmation if:

• Compatible clinical features
• Supportive imaging / histology
• Other diagnoses reasonably excluded
• Decision by specialist

This is explicitly allowed in the guideline.

4.9 Common diagnostic pitfalls (exam favorites)

• Treating empirically without trying to obtain specimens
• Assuming EPTB is non-TB malignancy without biopsy
• Ignoring co-existing pulmonary TB
• Misinterpreting paradoxical reaction as treatment failure
• Using negative Xpert to exclude EPTB

4.10 One-page diagnostic algorithm (mental flow)

1. Suspect EPTB (site-specific symptoms)
2. Look for PTB (CXR ± sputum)
3. Obtain site-specific specimen
4. Send for AFB + culture + Xpert ± histology
5. If critical site → start treatment early
6. Reassess response and revise if no improvement

Exam lock

• EPTB diagnosis is often clinical + supportive evidence.
• Culture is gold standard but treatment should not wait in severe disease.
• Normal CXR does not exclude EPTB.

Part 5 — Site-Specific Investigations in EPTB (Chapter 5)

(Sri Lanka NPTCCD EPTB Guideline 2024 — what to sample, how to test, common traps)

National Programme for Tuberculosis Control and Chest Diseases

5.1 Peripheral Lymph Node TB

Best specimen

• Excision biopsy (preferred)
• FNAC acceptable if excision not feasible

Tests to send

• Microbiology: AFB smear + culture + Xpert (specimen in 0.9% saline)
• Histology: granulomas/caseation (specimen in formalin)

Imaging

• Ultrasound (size, necrosis, guide biopsy)

Common pitfalls

• Relying on FNAC cytology alone without culture
• Incision & drainage instead of aspiration (leads to sinus)

Exam lock

• Excision biopsy gives highest yield in lymph node TB.

5.2 Pleural TB

Best specimen

• Pleural fluid (thoracentesis)
• Pleural biopsy if fluid studies non-diagnostic

Tests

• Pleural fluid:
• AFB smear (low yield)
• Culture (important)
• Xpert (supportive)
• Histology (biopsy): granulomas

Imaging

• CXR (effusion)
• Ultrasound (guide tap)
• CT if complicated

Special note

• Empyema → drainage + ATT; often needs surgical input

Exam lock

• Pleural fluid smear often negative; biopsy increases yield.

5.3 Bone & Joint TB (including Spine)

Best specimen

• CT/MRI-guided biopsy from lesion
• Abscess aspirate if present

Tests

• AFB smear + culture + Xpert
• Histology

Imaging

• MRI = investigation of choice (cord compression, abscess)
• X-ray may be normal early

Urgent flags

• Neurological deficit → do not delay treatment

Exam lock

• MRI spine is best for spinal TB.

5.4 Central Nervous System TB

A. TB Meningitis

Specimen

• CSF (large volume improves yield)

CSF profile (typical)

• Lymphocytic pleocytosis
• High protein
• Low glucose

Tests

• AFB smear (low sensitivity)
• Culture
• Xpert (useful but negative ≠ exclude)

Imaging

• MRI brain (basal enhancement, hydrocephalus, infarcts)

Rule

• Start ATT early if strong suspicion — do not wait for confirmation

Exam lock

• Subacute meningitis + lymphocytic CSF + low glucose → TB meningitis.

5.5 Abdominal TB

Specimens

• Ascitic fluid
• Intestinal/mesenteric node biopsy
• Peritoneal biopsy (laparoscopy)

Tests

• AFB smear + culture + Xpert
• Histology

Imaging

• Ultrasound
• CT abdomen (nodes, thickened bowel, ascites)

Exam lock

• Laparoscopy with biopsy has high diagnostic yield.

5.6 Genitourinary TB

Specimens

• Early morning urine (multiple samples)
• Tissue biopsy if needed

Tests

• AFB smear + culture + Xpert

Clue

• Sterile pyuria is a classic pointer

5.7 Pericardial TB

Specimens

• Pericardial fluid
• Pericardial biopsy (if required)

Tests

• AFB smear + culture + Xpert
• Histology

Imaging

• Echocardiography (effusion, tamponade)
• CT/MRI if constriction suspected

Exam lock

• Pericardial TB can progress to constrictive pericarditis.

5.8 Ocular / Cutaneous / Breast TB (overview)

• Diagnosis often clinical + histology
• Microbiological confirmation difficult
• Manage with specialist input

5.9 Universal specimen rules (repeat once — exam favourite)

• Microbiology → 0.9% saline
• Histology → formalin
• Store 2–8 °C if delay
• Triple-layer transport

5.10 Quick recall table (mental)

• Lymph node → excision biopsy
• Pleura → fluid + biopsy
• Spine → MRI + biopsy
• CNS → CSF + MRI
• Abdomen → laparoscopy biopsy
• GU → early morning urine

Part 6 — Differential Diagnosis of Extra-Pulmonary TB (Chapter 6)

(Sri Lanka NPTCCD EPTB Guideline 2024 — site-wise mimics + how to separate)

National Programme for Tuberculosis Control and Chest Diseases

6.1 Why differentials matter (guideline logic)

• EPTB mimics many diseases (malignancy, autoimmune, other infections).
• Misdiagnosis leads to delayed TB treatment or unnecessary surgery/chemotherapy.
• Guideline stresses systematic exclusion of common mimics before labeling “clinical EPTB”.

6.2 Site-wise differentials (EXAM + WARD READY)

A. Peripheral Lymph Node Disease

TB vs:

• Lymphoma (Hodgkin / Non-Hodgkin)
• Metastatic carcinoma
• Sarcoidosis
• Reactive lymphadenitis
• Toxoplasmosis

Clues favoring TB

• Painless, matted nodes
• Caseating granulomas on histology
• Sinus formation (late)

Clues favoring malignancy

• Hard, fixed nodes
• B symptoms with abnormal blood counts
• Atypical cells on biopsy

B. Pleural Effusion

TB vs:

• Malignancy (lung, breast)
• Parapneumonic effusion
• Pulmonary embolism
• Connective tissue disease

Clues favoring TB

• Young patient
• Subacute fever
• Unilateral exudative effusion
• Lymphocyte-predominant fluid

C. Bone & Joint Disease

TB vs:

• Pyogenic osteomyelitis
• Metastatic disease
• Degenerative spine disease
• Brucellosis

Clues favoring TB

• Chronic course
• Minimal redness (“cold” abscess)
• Vertebral body involvement with disc space narrowing (late)
• Paraspinal abscess on MRI

D. CNS Disease

TB meningitis vs:

• Viral meningitis
• Bacterial meningitis
• Fungal meningitis
• Carcinomatous meningitis

Clues favoring TB meningitis

• Subacute onset
• Lymphocytic CSF
• Low CSF glucose
• Basal meningeal enhancement on MRI

Tuberculoma vs:

• Brain tumor
• Neurocysticercosis
• Abscess

E. Abdominal Disease

TB vs:

• Crohn disease
• GI malignancy
• Lymphoma
• Chronic liver disease (ascites)

Clues favoring TB

• Young patient
• Constitutional symptoms
• Ascites with peritoneal thickening
• Ileocecal involvement

F. Genitourinary Disease

TB vs:

• Recurrent UTI
• Renal stones
• Bladder carcinoma

Key clue

• Sterile pyuria (very high yield)

G. Pericardial Disease

TB vs:

• Viral pericarditis
• Malignancy
• Uremic pericarditis
• Autoimmune disease

Clues favoring TB

• Fever + weight loss
• Large effusion
• Constrictive features over time

H. Breast TB

TB vs:

• Breast carcinoma
• Pyogenic abscess
• Granulomatous mastitis

Clue

• Sinus tract + chronic lump

6.3 Guideline-emphasized diagnostic approach

• Never rely on response to ATT alone to confirm diagnosis.
• If diagnosis uncertain:
• Re-biopsy
• Repeat cultures
• Reassess for malignancy
• Multidisciplinary input (surgery, radiology, pathology) is encouraged.

6.4 Exam reflex lines

• TB is the great mimicker in extrapulmonary disease.
• Histology + microbiology are key to exclude malignancy.
• Sterile pyuria → GU TB until proven otherwise.
• Subacute meningitis + low CSF glucose → TB meningitis.

Part 7 — Special Diagnostic Situations in EPTB (Chapter 7)

(Sri Lanka NPTCCD EPTB Guideline 2024 — how diagnosis changes in key populations)

National Programme for Tuberculosis Control and Chest Diseases

7.1 Children

Why different

• Children often have paucibacillary disease → low yield on smear/Xpert.
• Symptoms may be non-specific and progress faster at critical sites.

Diagnostic approach

• Strong clinical suspicion is essential.
• Obtain specimens where feasible (node biopsy, CSF, bone aspirate).
• Imaging is crucial (US/MRI/CT by site).
• Microbiology may be negative → clinical diagnosis acceptable.
• Always assess nutrition status and HIV.

Exam lock

• In children, a negative microbiology does NOT exclude EPTB.

7.2 Pregnancy

Key principles

• Pregnancy does not protect against EPTB.
• Diagnosis should not be delayed due to pregnancy.

Investigations

• Use site-specific sampling as usual.
• Avoid ionizing radiation in 1st trimester where possible:
• Prefer ultrasound and MRI.
• CXR only if essential (with shielding).

Program emphasis

• Maternal TB → risk to mother and fetus → early diagnosis is safer than delay.

Exam lock

• Suspected TB in pregnancy must still be investigated promptly.

7.3 People Living with HIV (PLHIV)

Why important

• Higher proportion of EPTB in HIV.
• More atypical presentations.
• Faster progression and higher mortality.

Diagnostic features

• Sites often involved:
• Lymph nodes
• CNS
• Disseminated TB
• Microbiological yield may be higher due to higher bacillary load in advanced disease.
• Always test HIV status in EPTB.

Caution

• High risk of paradoxical reactions (IRIS) after starting ART.

Exam lock

• EPTB is commoner and more severe in HIV.

7.4 Elderly

Why tricky

• Atypical symptoms
• Multiple comorbidities
• TB may mimic:
• Malignancy
• Degenerative disease
• Chronic inflammatory disorders

Diagnostic emphasis

• Low threshold for biopsy.
• Imaging + histology often more helpful than microbiology alone.

7.5 Immunosuppressed (non-HIV)

Includes:

• Long-term steroids
• Transplant recipients
• Malignancy / chemotherapy
• Biologic agents

Key points

• Higher risk of:
• Disseminated TB
• Severe EPTB
• Early aggressive investigation recommended.
• Multiple sites may be involved.

7.6 Recurrent or Non-resolving EPTB

Guideline warning

• If no improvement after starting ATT:
• Do not immediately label as treatment failure
• Consider:
• Wrong diagnosis
• Drug resistance
• Poor adherence
• Paradoxical reaction
• Alternative pathology (malignancy)

Action

• Re-evaluate diagnosis
• Repeat biopsy/culture if needed
• Specialist review mandatory

7.7 Exam-critical summary

• Children → clinical diagnosis often needed
• Pregnancy → don’t delay diagnosis
• HIV → more EPTB, more severe, atypical
• Elderly/immunosuppressed → TB mimics malignancy
• Poor response ≠ failure → reassess carefully

Part 8 — Treatment of Extra-Pulmonary TB (Chapter 16)

(Sri Lanka NPTCCD EPTB Guideline 2024 — regimen logic, site-wise durations, exam locks)

National Programme for Tuberculosis Control and Chest Diseases

8.1 Core treatment principle (memorize)

• Drug-susceptible EPTB is treated with the same first-line drugs as PTB.
• Duration is site-dependent (this is where exams test you).

8.2 Standard first-line regimen (DS-TB)

• Intensive phase: 2 months — H + R + Z + E (HRZE)
• Continuation phase: 4 months — H + R (HR)
• Total: 6 months (for most EPTB)

Rule: Daily dosing, weight-band based, under program supervision.

8.3 Site-specific durations (HIGH-YIELD TABLE IN WORDS)

A. Lymph Node TB

• Total duration: 6 months (2HRZE + 4HR)
• Notes:
• Nodes may increase in size during treatment (paradoxical reaction).
• This does not mean treatment failure.
• Surgery usually not required.

Exam lock: TB lymphadenitis → 6 months ATT.

B. Pleural TB

• Total duration: 6 months
• Notes:
• Same regimen as pulmonary TB.
• TB empyema requires drainage + ATT.

Exam lock: Pleural TB → 6 months ATT.

C. Peritoneal / Intestinal TB

• Total duration: 6 months
• Notes:
• Monitor for obstruction.
• Surgery only for complications.

D. Pericardial TB

• Total duration: 6 months
• Notes:
• Monitor for constriction.
• Drainage if tamponade.

Exam lock: Pericardial TB → 6 months (same as PTB).

E. Bone & Joint TB

• Total duration: 9–12 months
• 2 months HRZE
• 7–10 months HR
• Spinal TB: usually at the longer end of duration.
• Notes:
• Immobilization may be required.
• Surgery only if neurological deficit, instability, or abscess not responding.

Exam lock: Bone/joint TB needs prolonged therapy (≥9 months).

F. Central Nervous System TB

TB meningitis

• Total duration: 12 months
• 2 months HRZE
• 10 months HR
• Adjunctive steroids: Recommended (reduce mortality & sequelae).

Tuberculoma

• Duration similar to TB meningitis (often prolonged).

Exam lock: TB meningitis → 12 months + steroids.

G. Other EPTB sites

• Breast TB, ocular TB, cutaneous TB, upper airway TB:
• Usually 6 months, unless complications.
• Decision individualized with specialist input.

8.4 When to EXTEND treatment

The guideline allows extension if:

• CNS involvement
• Bone/joint disease
• Poor clinical response
• Immunosuppression
• Severe or complicated disease

Do not extend just because imaging lags behind clinical recovery.

8.5 Role of surgery in EPTB

• Diagnostic: biopsy, decompression
• Therapeutic: only for complications
• Spinal cord compression
• TB empyema
• Intestinal obstruction
• Surgery never replaces ATT.

8.6 Monitoring response

• Clinical improvement is primary:
• Symptom relief
• Weight gain
• Radiology: supportive, may improve slowly
• Microbiology: limited role in EPTB follow-up

8.7 Common mistakes (exam traps)

• Giving 6 months for TB meningitis ❌
• Extending treatment only due to residual lymph node enlargement ❌
• Stopping drugs early when symptoms improve ❌
• Delaying ATT waiting for culture in CNS disease ❌

8.8 One-glance exam reflex

• Most EPTB → 6 months
• Bone/joint → 9–12 months
• TB meningitis → 12 months + steroids
• Same drugs as PTB

Part 9 — Paradoxical Reaction & IRIS in EPTB (Chapter 15)

(Sri Lanka NPTCCD EPTB Guideline 2024 — recognize, don’t mislabel as failure)

National Programme for Tuberculosis Control and Chest Diseases

9.1 What is a Paradoxical Reaction (PR)?

• Clinical or radiological worsening after starting effective anti-TB therapy, despite initial improvement or adequate adherence.
• Represents an exaggerated inflammatory immune response to mycobacterial antigens—not drug failure.

9.2 When does PR usually occur?

• Typically 2–12 weeks after starting ATT.
• Can occur later, especially in:
• Lymph node TB
• CNS TB
• Pleural TB
• HIV-infected patients (overlaps with IRIS)

9.3 Common manifestations (site-wise)

• Lymph node TB:
• Nodes increase in size, become fluctuant, or new nodes appear.
• Pleural TB:
• Effusion increases or re-accumulates after initial drainage.
• CNS TB:
• Worsening headache, focal deficits, new tuberculomas, hydrocephalus.
• Bone/joint TB:
• Increased pain or swelling despite microbiologic response.

Exam anchor: Worsening after starting treatment ≠ treatment failure.

9.4 Paradoxical Reaction vs Treatment Failure (KEY DIFFERENTIATION)

Think PR if:

• Good adherence
• Initial clinical response
• No evidence of drug resistance
• Cultures (if available) turning negative or already negative

Think failure if:

• Persistent/worsening symptoms without any initial improvement
• Poor adherence
• Drug resistance detected
• Alternative diagnosis emerges

9.5 IRIS (Immune Reconstitution Inflammatory Syndrome)

• Occurs in HIV patients after starting ART.
• Two forms:
• Unmasking IRIS: TB becomes clinically apparent after ART.
• Paradoxical IRIS: Known TB worsens after ART initiation.

Risk factors

• Low baseline CD4
• High antigen burden
• Early ART initiation

9.6 Management of PR / IRIS

• Continue ATT unchanged (do NOT stop or switch drugs).
• Exclude other causes first:
• Non-adherence
• Drug resistance
• Secondary infection
• Malignancy
• Supportive care:
• Analgesia
• Drainage if required (e.g., tense nodes, effusions)
• Corticosteroids:
• Indicated for:
• CNS involvement
• Severe airway compromise
• Severe IRIS
• Use short courses, taper carefully.

Program rule: Steroids treat inflammation—not TB—so ATT must continue.

9.7 What NOT to do (exam traps)

• ❌ Do not label PR as MDR-TB without evidence
• ❌ Do not stop rifampicin
• ❌ Do not extend treatment just because nodes persist
• ❌ Do not operate unless there’s a complication

9.8 Exam reflex lines

• PR = inflammatory worsening after starting ATT
• Common in lymph node & CNS TB
• Manage with reassurance ± steroids
• ATT must be continued unchanged

✅ Next part: Part 10 — Contact Tracing & Public Health Aspects in EPTB (Chapter 17)

This part explains why contacts are traced even when EPTB is “non-infectious.”

Say “next” when ready.

Part 10 — Contact Tracing & Public Health Aspects in EPTB (Chapter 17)

(Sri Lanka NPTCCD EPTB Guideline 2024 — program logic + exam rules)

National Programme for Tuberculosis Control and Chest Diseases

10.1 Why do contact tracing in EPTB? (core logic)

• EPTB is usually not infectious, but the source of infection often is.
• Contact tracing aims to:
• Find an undiagnosed pulmonary TB source case
• Prevent ongoing transmission
• Strengthen TB surveillance and elimination

Key idea: EPTB patient is a “sentinel” — not the transmitter.

10.2 Who should be traced?

• Household contacts of all EPTB patients.
• Close contacts based on:
• Living arrangements
• Prolonged indoor exposure
• Caregiver roles

10.3 What is done during contact tracing?

Step-by-step (program workflow)

1. Symptom screening of contacts
2. If symptomatic → evaluate for active TB
• CXR
• Sputum for AFB / molecular test
3. If active TB detected → start full ATT

10.4 Important distinction: EPTB vs PTB contacts

❌ What is NOT recommended for EPTB contacts

• No routine testing for TB infection (LTBI)
• No TB preventive therapy (TPT) for contacts only exposed to EPTB

✅ What IS recommended

• Active TB case finding only

Exam lock:

TPT is recommended for contacts of pulmonary TB — NOT for EPTB contacts.

10.5 If EPTB patient ALSO has pulmonary TB

• Manage contacts as PTB contacts
• This includes:
• Screening for active TB
• LTBI evaluation where indicated
• TPT according to national policy

10.6 Notification & reporting

• All TB cases (including EPTB) are notifiable.
• Notification enables:
• Contact tracing
• Treatment outcome monitoring
• National TB statistics

10.7 Role of the clinician (practical responsibilities)

• Ensure:
• Accurate diagnosis classification (EPTB vs EPTB+PTB)
• Timely notification
• Referral to chest clinic / MOH for contact tracing
• Educate patient:
• Why contacts are screened
• That EPTB itself is usually non-infectious

10.8 Common exam traps

• ❌ Giving INH prophylaxis to EPTB contacts
• ❌ Assuming EPTB requires no public health action
• ❌ Missing a pulmonary source case in the household

10.9 One-glance exam reflex

• EPTB → contact tracing YES
• EPTB contacts → active TB screening ONLY
• TPT → only for PTB contacts
• EPTB + PTB → manage as PTB

Part 11 — Follow-up, Monitoring & Treatment Outcomes in EPTB (Final Core Chapter)

(Sri Lanka NPTCCD EPTB Guideline 2024 — how to judge response, avoid false failure)

National Programme for Tuberculosis Control and Chest Diseases

11.1 Core principle of follow-up

• Clinical response is the primary indicator of success in EPTB.
• Microbiological follow-up is limited or not possible in most EPTB sites.
• Imaging improves slowly and may lag behind clinical recovery.

Exam anchor: Do not use radiology alone to decide treatment success or failure.

11.2 What to monitor during treatment

A. Clinical parameters (MOST IMPORTANT)

• Symptom improvement:
• Pain reduction
• Fever resolution
• Improved function (neurology, mobility, breathing)
• Weight gain
• Return of appetite
• Healing of sinuses / reduction of swelling

B. Site-specific clinical markers

• Lymph node TB → reduction in tenderness, eventual shrinkage (size may persist)
• CNS TB → improvement in consciousness, cranial nerve deficits, seizures
• Bone/spine TB → pain reduction, neurological stabilization
• Pleural TB → breathlessness improves before radiology clears

11.3 Role of investigations in follow-up

Imaging

• Used to:
• Assess complications
• Guide surgical decisions
• Not routinely required if patient is clinically improving.
• Residual lesions ≠ active disease.

Microbiology

• Usually not available for follow-up.
• Repeat testing only if:
• Clinical deterioration
• Suspicion of drug resistance
• Non-adherence suspected

11.4 How to interpret “non-response”

Before labeling failure, systematically exclude:

1. Poor adherence
2. Wrong diagnosis (malignancy, autoimmune disease)
3. Drug resistance
4. Paradoxical reaction
5. Drug malabsorption / interactions

Guideline warning:

Lack of rapid improvement ≠ treatment failure in EPTB.

11.5 Treatment outcomes (programmatic definitions)

For EPTB, outcomes are largely clinical:

• Treatment completed
• Completed prescribed regimen
• Clinical improvement documented
• Died
• Death during treatment (any cause)
• Lost to follow-up
• Interrupted treatment for a defined period
• Treatment failure
• Very rare in EPTB
• Only after expert review and exclusion of PR/non-adherence

11.6 When to refer or re-evaluate

• Worsening neurological signs
• Persistent or progressive disease after adequate duration
• Suspicion of MDR-TB
• Need for surgery (compression, obstruction, empyema)

11.7 Documentation & reporting

• Maintain:
• Site of EPTB
• Basis of diagnosis (microbiological / clinical)
• Treatment start & end dates
• Outcome
• Ensure notification and outcome reporting through NPTCCD channels.

11.8 High-yield exam traps

• ❌ Declaring failure based on persistent lymph node enlargement
• ❌ Extending treatment solely due to slow radiological resolution
• ❌ Stopping ATT during paradoxical reaction
• ❌ Expecting sputum conversion in EPTB

11.9 Final one-page recall (entire EPTB guideline logic)

• Suspect early → site-specific symptoms
• Get tissue/fluid → micro + histology
• Always check lungs
• Treat most EPTB for 6 months
• Bone/joint → 9–12 months
• TB meningitis → 12 months + steroids
• Paradoxical reaction ≠ failure
• Contacts traced, but no TPT for EPTB contacts
• Clinical response decides success

Pregnancy-specific content in the EPTB Guideline (EXPLICIT + IMPLICIT)

National Programme for Tuberculosis Control and Chest Diseases

1️⃣ EPTB in Pregnancy — Guideline Position (Explicit)

The guideline does not dedicate a full chapter to pregnancy, but it clearly states key diagnostic and management principles under Special Diagnostic Situations.

Key rules

• Pregnancy does NOT reduce the risk of EPTB
• Diagnosis must NOT be delayed because of pregnancy
• Maternal TB is more dangerous than diagnostic procedures when indicated

👉 Exam reflex: Delay harms mother and fetus more than timely diagnosis.

2️⃣ Diagnosis of EPTB in Pregnancy (Very Important for OBGYN)

Imaging

• Avoid ionising radiation in the 1st trimester where possible
• Preferred:
• Ultrasound
• MRI (no contrast unless essential)
• CXR can be done if clinically essential, with abdominal shielding

👉 Exam trap: Pregnancy ≠ “no investigations”.

Specimen-based diagnosis

• Same site-specific sampling rules apply
• Lymph node biopsy
• Pleural fluid
• Ascitic fluid
• Tissue biopsy
• Pregnancy is not a contraindication to biopsy when needed

3️⃣ Treatment of EPTB in Pregnancy (CRITICAL)

Although drug safety tables are not repeated in this guideline, it follows national TB treatment policy:

Drug-susceptible EPTB

• Standard first-line drugs are SAFE in pregnancy:
• Isoniazid
• Rifampicin
• Ethambutol
• Pyrazinamide

👉 This is EXAM GOLD:

Sri Lanka DOES use Pyrazinamide in pregnancy.

What is avoided

• Streptomycin (ototoxic to fetus)
• Other injectables (general TB policy)

4️⃣ Duration of Treatment in Pregnancy

• Same as non-pregnant patients
• Most EPTB → 6 months
• Bone/joint → 9–12 months
• TB meningitis → 12 months + steroids

👉 Pregnancy does not shorten or lengthen duration by itself.

5️⃣ Paradoxical Reaction in Pregnancy

• Guideline notes paradoxical reactions can occur in:
• Lymph node TB
• Pleural TB
• CNS TB
• Pregnancy does not protect against PR
• Worsening ≠ failure

Steroids:

• Can be used if indicated (e.g. CNS involvement)
• Use lowest effective dose

6️⃣ Gynecology-Relevant EPTB Sites (IMPLICIT but IMPORTANT)

A. Genital TB (Female Genital TB – FGTB)

While not a standalone chapter, genital TB is included under genitourinary TB.

Clinical relevance for OBGYN:

• Chronic pelvic pain
• Menstrual irregularities
• Infertility
• Tubal damage
• Endometrial involvement

👉 Exam reflex: Infertility + TB endemic area → think genital TB.

B. Abdominal / Peritoneal TB

Highly relevant to gynecology:

• Mimics:
• Ovarian malignancy
• Endometriosis
• PID
• Presents with:
• Ascites
• Pelvic mass
• Weight loss

👉 Exam trap: Young woman + ascites ≠ ovarian cancer by default.

C. Lymph Node TB (Inguinal / Pelvic nodes)

• May present as:
• Pelvic mass
• Inguinal swelling
• Often misdiagnosed as malignancy

7️⃣ Pregnancy + Contact Tracing

• Same rule applies:
• EPTB is usually non-infectious
• Contacts are traced to find the source pulmonary case
• No LTBI prophylaxis for contacts of EPTB cases

8️⃣ What the guideline does NOT include (important to know)

• ❌ No trimester-wise drug dosing
• ❌ No obstetric outcome tables
• ❌ No fertility-specific management algorithms
• ❌ No ART–pregnancy–TB combined protocols

These are handled in separate national TB / OBGYN / HIV guidelines, not the EPTB document.

9️⃣ OBGYN EXAM SUMMARY (One-Box Recall)

• Pregnancy ≠ delay TB diagnosis
• US/MRI preferred; CXR allowed if needed
• HRZE is safe in pregnancy (Sri Lanka)
• Streptomycin contraindicated
• Genital & peritoneal TB → infertility & malignancy mimics
• Treatment duration same as non-pregnant
• Paradoxical reaction ≠ failure