Respiratory Tuberculosis
For more information, consult the Canadian Tuberculosis Standards, 8th edition, Chapter 3: Diagnosis of tuberculosis disease and drug resistant tuberculosis.
Delays in diagnosis of respiratory TB are common. Respiratory TB is often treated as a more common lower respiratory tract infection multiple times before TB is ruled in. A high index of suspicion is important to diagnose TB disease among those who have an epidemiologic risk factor for TB that presents with symptoms consistent with TB disease. For such clients, always consider testing with sputum samples and chest radiology.
Clinical presentation
The classic symptom of pulmonary TB disease:
- New or worsening cough of at least 2 to 3 weeks’ duration (dry or productive)
- Fever and night sweats (may be absent in the very young and the elderly)
- Unexplained weight loss
- Unexplained fatigue
- Hemoptysis, loss of appetite, chest pain may be present.
Epidemiologic risk factor
Client is from or has spent time with populations with higher rates of TB:
- Individuals from countries with high rates of TB. WHO Incidence Maps 2021 and Global Tuberculosis Report 2022 (who.int)
- Indigenous Canadians from communities with high rates of TB
- Houseless persons
- History of incarceration
History and Physical
Chronic health conditions, such as the following, are additional risks for developing TB disease
- HIV
- Chronic disease, ex: Diabetes
- Immunosuppression
The most common physical finding in respiratory TB is a totally normal examination, even in relatively advanced cases.
- Bronchial breathing, crackles and rhonchi may be found in more advanced cases
- Examine for signs of extrapulmonary disease as these may be present concomitantly particularly in HIV-infected individuals, such as
- Lymphadenopathy
- Pleural effusion
- Abdominal involvement
- Bone and joint involvement
How to test for TB:
Tests:
- 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
Tuberculin skin test (TST) should not be used for diagnosing active TB disease in adults – it is used for TB infection screening
Sputum collection:
- Sputum microbiology is the gold standard for TB diagnosis:
- Sputum smears are important for Public Health to determine infectivity
- Work up of suspected non-respiratory TB disease should also assess for respiratory TB with sputa and chest x-ray along with the appropriate testing for the suspected site of non-respiratory symptoms
All sputum testing is performed by Shared Health Diagnostic Services. The link to the Shared Health Diagnostic Services requisition is below.
Shared Health Diagnostic Services 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 and Control:
- Infection 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)
Home Isolation for Tuberculosis (TB)
Home Isolation Fact Sheets:
Consultation and Referrals
If concernced that a client has respiratory TB, 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 the 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 to 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 infectious TB will be placed on isolation in the hospital or at home on what is called ‘Home Isolation' until they are deemed noninfectious
- Once clients are noninfectious, they can resume usual activities. Clients do need to continue taking their medications, making regular clinic visits and any needed testing
- TB treatment is usually given by directly observed therapy (DOT): a health-care worker observes the client taking their medication.
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
- Patients with infectious 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
Other relevant links
WRHA Infection Prevention & Control
- Infection Prevention & Control: Community Health Services Manual (see Additional Precautions – community setting)
Prescription forms (Prescriptions should be provided by specialist TB care providers)
Manitoba Tuberculosis Protocol
Tuberculosis Testing Laboratory Reporting
Admission and Discharge Process for hospitalized TB patients