Non-Respiratory Tuberculosis

For more information consult the Canadian Tuberculosis Standards, 8th edition, Chapter 7: Extra – pulmonary tuberculosis.

In 2010, 25% of TB cases in Canada were non-respiratory.
Non-respiratory TB is more common among individuals who are foreign-born.

Delays in diagnosis of non-respiratory TB are common. This is due to non-respiratory TB’s ability to present in any site of the body and have varying signs and symptoms that can mimic other ailments. A high index of suspicion is important to diagnose TB disease among those who have an epidemiologic risk factor for TB that presents with otherwise unexplained site-specific symptoms, fever of unknown origin, unexplained weight loss and/or constitutional symptoms (nights sweats, fatigue).

Suspected or confirmed cases of non-respiratory TB should all be assessed for infectious respiratory TB. Sputum samples x 3 and chest x-ray (PA and lateral) are strongly recommended. The frequency of respiratory TB in clients with non-respiratory TB disease can range from 10 to 50%.

Clinical presentation

TB disease can occur anywhere in the body and symptoms can vary:

Clients may have non-specific constitutional symptoms: fever, night sweats, weight loss, anorexia or low energy
Clients may have site-specific signs and symptoms:
- Lymph node – peripheral lymphadenitis; single or multiple sites; isolated, unilateral, non-tender neck mass is the most common presentation
- Bones and joints – spinal disease can present with slowly progressive back pain; joint/arthritis TB can present as an arthritis affecting a single large, weight-bearing joint
- Gastrointestinal – unexplained abdominal pain, abdominal swelling or with associated diarrhea
- Renal – "sterile" pyuria, gross hematuria, frequency and dysuria; back pain or flank pain with or without symptoms of bladder involvement
- CNS – meningeal TB may present with typical meningitis symptoms of headache, malaise, fever, cognitive changes and physical signs of meningeal inflammation; brain TB can present with headaches, seizures or focal neurological signs; ocular TB can involve any part of the eye
- Disseminated – active TB disease that affects three or more sites or positive blood culture for M. tuberculosis
- Miliary – disseminated active TB with abnormal chest x-ray showing diffuse micro-nodules
Radiology investigations may indicate granulomatous formations.
Pathology specimens may indicate granulomatous inflammation.

Epidemiologic risk factor for TB

Client is from or has spent time with populations with higher rates of TB:

Individuals from countries with high rates of TB (new WHO incidence maps 2021)
Indigenous Canadians from communities with high rates of TB
Houseless persons
History of incarceration

How to test for TB

All clients suspected of having non-respiratory TB disease should also be assessed for infectious respiratory TB. The frequency of respiratory involvement in patients with non-respiratory TB disease can range from 10 to 50%:

Sputum sample x 3 at least 1 hour apart for AFB smear and culture – see additional information and links below
Chest radiology PA and lateral

Other testing:

Site-specific tests will depend on location of suspected TB disease; usually a diagnosis requires a biopsy of the affected organ; samples must be sent for acid-fast bacteria (AFB) smear and culture; if uncertain, consultation is recommended

Tuberculin skin test (TST) should not be used for diagnosing active TB disease in adults – it is used for latent TB infection (TBI) screening (see TBI section)
adults

Sputum collection:

All sputum testing is performed by Shared Health Diagnostic Services. The link to the Shared Health Diagnostic Services requisition is below.

Shared Health Diagnostic Service requisition:

Requisition

Shared Health Diagnostic Services Manual:

Clinical Specimen Collection Procedure Manual (see Sputum chapter)

Ideally, patients should have 3 consecutive sputum samples collected for AFB smears at least one hour apart each (but even one sputum sample is better than none).

An on-the-spot sample of sputum should be requested of symptomatic clients who are able to spontaneously expectorate, and should be collected using proper infection control precautions.

On-the-spot sputum collection can safely be done in the community setting using proper infection control airborne precautions. See Infection Prevention Control fact sheet: I.P. & C. Considerations for Tuberculosis in Clinic Settings on collecting sputum on the spot, on PAGE 2 of document below.

WRHA Infection Prevention & Control:

Infecti on Prevention and Control Considerations for On-the-spot Sputum Collection in Clinic Settings (go to PAGE 2 of linked document)

The client can be instructed on how to collect sputum at home and should be provided with collection containers, link to patient information on sputum collection. Clients should be made aware to keep all samples collected at home in the refrigerator until they bring them to the clinic or laboratory.

Instructions to clients:

How to Collect Sputum Sample (English)
How to Collect Sputum Sample (French)

Consultation and Referrals

If concerned that a client has TB disease, consult Adult Chest Medicine or Pediatric Infectious Diseases at HSC by calling HSC paging: 204-787-2071.

If concerned that a client has nonrespiratoryTB, consult Adult Chest Medicine or Pediatric Infectious Diseases at HSC by calling HSC paging: 204-787-2071.

Outside of Winnipeg Health Region, health care providers can consult HSC Paging as above or:

In or near Brandon:
Infectious Diseases on-call (Dr. Bookatz) 204-578-4000 (pgr) or 204-727-6451 ext.2202 (office)

What patients can expect

Tuberculosis treatment:

Clients diagnosed with TB will be referred to a specialist for their TB care
Clients should be aware that the treatment for TB requires multiple antibiotics taken over 6-9 months, sometimes longer
Clients do not need to pay for their TB medications, Manitoba Health covers the cost of TB treatment
Clients may be admitted to the hospital initially
Clients with suspected or confirmed infectious TB will be placed on isolation in the hospital or at home on what is called ‘Home Isolation' until they are deemed noninfectious
Clients with non-respiratory TB, who have been found to have no evidence of respiratory TB may not require isolation
Once clients are deemed noninfectious, they can resume usual activities. Clients do need to continue with taking their medications, making regular clinic visits and any needed testing
TB treatment is given by directly observed therapy (DOT): a health care worker observes the client taking their medication.
TB treatment and directly observed therapy is similar for all forms of TB disease

Public Health contact investigations

In Manitoba, Public Health is responsible for contact investigations
- If a person attends a primary care provider or clinic with concerns that they have been exposed to someone with TB, refer the person to PH: Winnipeg Regional Health Authority, Population and Public Health, Tuberculosis Services (WRHA PPH TB) 204-940-2274.
Clients determined by the TB clinician to have non-respiratory TB only, are not infectious
Contact investigations are not necessary for clients with non-infectious TB
Isolation is not necessary for clients with non-infectious TB
Clients with co-existing infectious respiratory TB will be contacted by a public health nurse who will ask them questions about their activities during their period of infectivity in order to identify potential contacts
Individuals identified as contacts will be contacted by Public Health for further follow up
Every effort is made to protect the identity of the case in contact investigation follow up.
Public Health does contact all clients with TB disease to offer education, treatment support and directly observed therapy.

Non-Respiratory Tuberculosis

Other relevant links