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Pneumologie 2008; 62(5): 284-294
DOI: 10.1055/s-2008-1038131
Serie: Tuberkulose
© Georg Thieme Verlag Stuttgart · New York

Klinik und Diagnose der Tuberkulose

Clinical Features and Diagnosis of TuberculosisB.  Kalsdorf1, 2 , A.  Strassburg1 , U.  Greinert1 , J.  Lotz3 , C.  Lange1
  • 1Klinische Infektiologie, Medizinische Klinik, Forschungszentrum Borstel,
  • 2Institute for Infectious Diseases and Molecular Medicine, University of Cape Town, Republik Südafrika
  • 3Institut für Radiologie, Medizinische Hochschule Hannover
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Publication History

Publication Date:
09 April 2008 (online)

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Zusammenfassung

In den vergangenen Jahren hat es bedeutende Fortschritte auf dem Gebiet der Diagnostik der akuten Tuberkulose gegeben. Eine umfassende Tuberkulose-Diagnostik beruht heute auf der Anamneseerhebung und körperlichen Untersuchung und auf den Ergebnissen radiologischer, mikrobiologischer, immunologischer, molekularbiologischer und histologischer Verfahren. Durch Zusammenführung dieser Ergebnisse kann rasch eine aktive Tuberkulose mit hoher Wahrscheinlichkeit klinisch diagnostiziert bzw. ausgeschlossen werden. Dadurch können Therapieentscheidungen frühzeitig fallen. Abhängig von den Ergebnissen der Mycobacterium tuberculosis-Kulturen und Sensitivitätstestungen, müssen diese Entscheidungen u. U. später angepasst werden.

Abstract

Recently, major advances have been accomplished in the diagnosis of active tuberculosis. A comprehensive diagnostic approach for a patient with possible tuberculosis includes a detailed medical history and clinical examination as well as the results of radiological, microbiological, immunological, molecular-biological and histological methods. In concert, these results enable the clinician to rapidly develop a decision with a high probability for the diagnosis or exclusion of active tuberculosis. Therapeutic intervention can thus be made early, even though corrections in these decisions need to be considered depending on the results of Mycobacterium tuberculosis culture and sensitivity testing.

Literatur

  • 1 WHO .Revised Global burden of Disease: Incidence, prevalence, mortality, YLL, YLD and DALYs by sex, cause and region, estimates for 2002 as reported in the World Health Report 2004. Geneva: WHO 2007; Available from: http://www.who.int/healthinfo/bodgbd2002revised/en/index.html
    Google Scholar
  • 2 WHO .Global tuberculosis control: surveillance, planning, financing. In: report WHO, editor. Geneva 2007
    Google Scholar
  • 3 Sonnenberg P, Glynn J R, Fielding K. et al . How soon after infection with HIV does the risk of tuberculosis start to increase? A retrospective cohort study in South African gold miners.  J Infect Dis. 2005 Jan 15;  191 (2) 150-158
    Google Scholar
  • 4 Corbett E L, Marston B, Churchyard G J. et al . Tuberculosis in sub-Saharan Africa: opportunities, challenges, and change in the era of antiretroviral treatment.  Lancet. 2006 Mar 18;  367 (9514) 926-937
    Google Scholar
  • 5 Wood R, Maartens G, Lombard C J. Risk factors for developing tuberculosis in HIV-1-infected adults from communities with a low or very high incidence of tuberculosis.  J Acquir Immune Defic Syndr. 2000 Jan 1;  23 (1) 75-80
    Google Scholar
  • 6 Robert Koch-Institut .Bericht zur Epidemiologie der Tuberkulose in Deutschland für 2005. Berlin 2007
    Google Scholar
  • 7 Aziz M A, Wright A, Laszlo A. et al . Epidemiology of antituberculosis drug resistance (the Global Project on Anti-tuberculosis Drug Resistance Surveillance): an updated analysis.  Lancet. 2006 Dec 16;  368 (9553) 2142-2154
    Google Scholar
  • 8 Zignol M, Hosseini M S, Wright A. et al . Global incidence of multidrug-resistant tuberculosis.  J Infect Dis. 2006 Aug 15;  194 (4) 479-485
    Google Scholar
  • 9 Migliori G B, Ortmann J EG, Besozzi G. et al . Extensively drug-resistant tuberculosis, Italy and Germany.  Emerg Infect Dis. 2007;  13 (5) 780-782
    Google Scholar
  • 10 WHO . Extensively drug-resistant tuberculosis (XDR-TB): recommendations for prevention and control.  Wkly Epidemiol Rec. 2006 Nov 10;  81 (45) 430-432
    Google Scholar
  • 11 Diagnostic Standards and Classification of Tuberculosis in Adults and Children . This official statement of the American Thoracic Society and the Centers for Disease Control and Prevention was adopted by the ATS Board of Directors, July 1999. This statement was endorsed by the Council of the Infectious Disease Society of America, September 1999.  Am J Respir Crit Care Med. 2000Apr ;  161 (4 Pt 1) 1376-1395
    Google Scholar
  • 12 Fanning A. Tuberculosis: 6. Extrapulmonary disease.  CMAJ. 1999 Jun 1;  160 (11) 1597-1603
    Google Scholar
  • 13 Sharma S K, Mohan A. Extrapulmonary tuberculosis.  Indian J Med Res. 2004 Oct ;  120 (4) 316-353
    Google Scholar
  • 14 Weir M R, Thornton G F. Extrapulmonary tuberculosis. Experience of a community hospital and review of the literature.  Am J Med. 1985 Oct ;  79 (4) 467-478
    Google Scholar
  • 15 Forssbohm M, Zwahlen M, Loddenkemper R. et al . Demographic characteristics of patients with extrapulmonary tuberculosis in Germany.  Eur Respir J. 2008 Jan;  31 (1) 99-105
    Google Scholar
  • 16 Burrill J, Williams C J, Bain G. et al . Tuberculosis: a radiologic review.  Radiographics. 2007 Sep - Oct;  27 (5) 1255-1273
    Google Scholar
  • 17 Abrams W B, Small M J. Current concepts of tuberculous pleurisy with effusion as derived from pleural biopsy studies.  Dis Chest. 1960 Jul;  38 60-65
    Google Scholar
  • 18 Arnold C, Moradpour D, Blum H E. Tuberculous colitis mimicking Crohn's disease.  Am J Gastroenterol. 1998 Nov;  93 (11) 2294-2296
    Google Scholar
  • 19 Marshall J B. Tuberculosis of the gastrointestinal tract and peritoneum.  Am J Gastroenterol. 1993 Jul;  88 (7) 989-999
    Google Scholar
  • 20 Geldmacher H, Taube C, Kroeger C. et al . Assessment of lymph node tuberculosis in northern Germany: a clinical review.  Chest. 2002 Apr;  121 (4) 1177-1182
    Google Scholar
  • 21 Kosters K, Nau R, Bossink A. et al .Rapid Diagnosis of CNS Tuberculosis by a T-Cell Interferon-gamma Release Assay on Cerebrospinal Fluid Mononuclear Cells. Infection 2008. epup ahead of print Jan 12
    Google Scholar
  • 22 Dinnes J, Deeks J, Kunst H. et al . A systematic review of rapid diagnostic tests for the detection of tuberculosis infection.  Health Technol Assess. 2007 Jan;  11 (3) 1-196
    Google Scholar
  • 23 Trautner B W, Darouiche R O. Tuberculous pericarditis: optimal diagnosis and management.  Clin Infect Dis. 2001 Oct 1;  33 (7) 954-961
    Google Scholar
  • 24 Hemal A K, Gupta N P, Rajeev T P. et al . Polymerase chain reaction in clinically suspected genitourinary tuberculosis: comparison with intravenous urography, bladder biopsy, and urine acid fast bacilli culture.  Urology. 2000 Oct 1;  56 (4) 570-574
    Google Scholar
  • 25 Muttarak M, ChiangMai W N, Lojanapiwat B. Tuberculosis of the genitourinary tract: imaging features with pathological correlation.  Singapore Med J. 2005 Oct;  46 (10) 568-574; quiz 75
    Google Scholar
  • 26 Watts H G, Lifeso R M. Tuberculosis of bones and joints.  J Bone Joint Surg Am. 1996 Feb;  78 (2) 288-298
    Google Scholar
  • 27 Lee K S, Im J G. CT in adults with tuberculosis of the chest: characteristic findings and role in management.  AJR Am J Roentgenol. 1995 Jun;  164 (6) 1361-1367
    Google Scholar
  • 28 Andreu J, Caceres J, Pallisa E. et al . Radiological manifestations of pulmonary tuberculosis.  European journal of radiology. 2004 Aug;  51 (2) 139-149
    Google Scholar
  • 29 Woodring J H, Vandiviere H M, Fried A M. et al . Update: the radiographic features of pulmonary tuberculosis.  AJR Am J Roentgenol. 1986 Mar;  146 (3) 497-506
    Google Scholar
  • 30 Moon W K, Im J G, Yeon K M. et al . Mediastinal tuberculous lymphadenitis: CT findings of active and inactive disease.  AJR Am J Roentgenol. 1998 Mar;  170 (3) 715-718
    Google Scholar
  • 31 Thompson B H, Stanford W, Galvin J R. et al . Varied radiologic appearances of pulmonary aspergillosis.  Radiographics. 1995 Nov;  15 (6) 1273-1284
    Google Scholar
  • 32 Leung A N. Pulmonary tuberculosis: the essentials.  Radiology. 1999 Feb;  210 (2) 307-322
    Google Scholar
  • 33 Curvo-Semedo L, Teixeira L, Caseiro-Alves F. Tuberculosis of the chest.  European journal of radiology. 2005 Aug;  55 (2) 158-172
    Google Scholar
  • 34 Eisenhuber E, Mostbeck G, Bankier A. et al . Radiologische Diagnose der Lungentuberkulose.  Der Radiologe. 2007 May;  47 (5) 393-400
    Google Scholar
  • 35 Gotway M B, Berger W G, Leung J WT. Pulmonary infections. Thoracic Imaging Pulmonary and Cardiovasculary Radiology. Lippincott: William & Wilkins 2004: 356-405
    Google Scholar
  • 36 Winer-Muram H T, Rubin S A. Thoracic complications of tuberculosis.  Journal of thoracic imaging. 1990 Apr;  5 (2) 46-63
    Google Scholar
  • 37 Choi D, Lee K S, Suh G Y. et al . Pulmonary tuberculosis presenting as acute respiratory failure: radiologic findings.  J Comput Assist Tomogr. 1999 Jan - Feb;  23 (1) 107-113
    Google Scholar
  • 38 Harries A D, Mphasa N B, Mundy C. et al . Screening tuberculosis suspects using two sputum smears.  Int J Tuberc Lung Dis. 2000 Jan;  4 (1) 36-40
    Google Scholar
  • 39 Mase S R, Ramsay A, Ng V. et al . Yield of serial sputum specimen examinations in the diagnosis of pulmonary tuberculosis: a systematic review.  Int J Tuberc Lung Dis. 2007 May;  11 (5) 485-495
    Google Scholar
  • 40 Daniel T M. The rapid diagnosis of tuberculosis: a selective review.  J Lab Clin Med. 1990 Sep;  116 (3) 277-282
    Google Scholar
  • 41 Hernandez-Garduno E, Cook V, Kunimoto D. et al . Transmission of tuberculosis from smear negative patients: a molecular epidemiology study.  Thorax. 2004 Apr;  59 (4) 286-290
    Google Scholar
  • 42 Brown M, Varia H, Bassett P. et al . Prospective study of sputum induction, gastric washing, and bronchoalveolar lavage for the diagnosis of pulmonary tuberculosis in patients who are unable to expectorate.  Clin Infect Dis. 2007 Jun 1;  44 (11) 1415-1420
    Google Scholar
  • 43 Willcox P A, Potgieter P D, Bateman E D. et al . Rapid diagnosis of sputum negative miliary tuberculosis using the flexible fibreoptic bronchoscope.  Thorax. 1986 Sep;  41 (9) 681-684
    Google Scholar
  • 44 Moore D A, Evans C A, Gilman R H. et al . Microscopic-observation drug-susceptibility assay for the diagnosis of TB.  N Engl J Med. 2006 Oct 12;  355 (15) 1539-1550
    Google Scholar
  • 45 Robledo J A, Mejia G I, Morcillo N. et al . Evaluation of a rapid culture method for tuberculosis diagnosis: a Latin American multi-center study.  Int J Tuberc Lung Dis. 2006 Jun;  10 (6) 613-619
    Google Scholar
  • 46 Piersimoni C, Scarparo C. Relevance of commercial amplification methods for direct detection of Mycobacterium tuberculosis complex in clinical samples.  J Clin Microbiol. 2003 Dec;  41 (12) 5355-5365
    Google Scholar
  • 47 Noordhoek G T, Mulder S, Wallace P. et al . Multicentre quality control study for detection of Mycobacterium tuberculosis in clinical samples by nucleic amplification methods.  Clin Microbiol Infect. 2004 Apr;  10 (4) 295-301
    Google Scholar
  • 48 Roth A, Schaberg T, Mauch H. Molecular diagnosis of tuberculosis: current clinical validity and future perspectives.  Eur Respir J. 1997 Aug;  10 (8) 1877-1891
    Google Scholar
  • 49 Abebe F, Holm-Hansen C, Wiker H G. et al . Progress in serodiagnosis of Mycobacterium tuberculosis infection.  Scand J Immunol. 2007 Aug-Sep;  66 (2 - 3) 176-191
    Google Scholar
  • 50 Steingart K R, Henry M, Laal S. et al . A systematic review of commercial serological antibody detection tests for the diagnosis of extrapulmonary tuberculosis.  Postgrad Med J. 2007 Nov;  83 (985) 705-712
    Google Scholar
  • 51 Steingart K R, Henry M, Laal S. et al . Commercial serological antibody detection tests for the diagnosis of pulmonary tuberculosis: a systematic review.  PLoS Med. 2007 Jun;  4 (6) e202
    Google Scholar
  • 52 Boehme C, Molokova E, Minja F. et al . Detection of mycobacterial lipoarabinomannan with an antigen-capture ELISA in unprocessed urine of Tanzanian patients with suspected tuberculosis.  Trans R Soc Trop Med Hyg. 2005 Dec;  99 (12) 893-900
    Google Scholar
  • 53 Sokal J E. Editorial: Measurement of delayed skin-test responses.  N Engl J Med. 1975 Sep 4;  293 (10) 501-502
    Google Scholar
  • 54 Lee J Y, Choi H J, Park I N. et al . Comparison of two commercial interferon-gamma assays for diagnosing Mycobacterium tuberculosis infection.  Eur Respir J. 2006 Jul;  28 (1) 24-30
    Google Scholar
  • 55 American Thoracic Society . Targeted tuberculin testing and treatment of latent tuberculosis infection.  MMWR Recomm Rep. 2000 Jun 9;  49 1-51
    Google Scholar
  • 56 Schaberg T, Hauer B, Haas W H. et al . Latente tuberkulöse Infektion: Empfehlungen zur präventiven Therapie bei Erwachsenen in Deutschland.  Pneumologie. 2004 Apr;  58 (4) 255-270
    Google Scholar
  • 57 Lalvani A. Diagnosing tuberculosis infection in the 21st century: new tools to tackle an old enemy.  Chest. 2007 Jun;  131 (6) 1898-1906
    Google Scholar
  • 58 Menzies D, Pai M, Comstock G. Meta-analysis: new tests for the diagnosis of latent tuberculosis infection: areas of uncertainty and recommendations for research.  Ann Intern Med. 2007 Mar 6;  146 (5) 340-354
    Google Scholar
  • 59 Richeldi L. An update on the diagnosis of tuberculosis infection.  Am J Respir Crit Care Med. 2006 Oct 1;  174 (7) 736-742
    Google Scholar
  • 60 Brock I, Weldingh K, Lillebaek T. et al . Comparison of tuberculin skin test and new specific blood test in tuberculosis contacts.  Am J Respir Crit Care Med. 2004 Jul 1;  170 (1) 65-69
    Google Scholar
  • 61 Diel R, Ernst M, Doscher G. et al . Avoiding the effect of BCG-vaccination in detecting MTB infection with a blood test.  Eur Respir J. 2006;  28 16-23
    Google Scholar
  • 62 Diel R, Nienhaus A, Lange C. et al . Tuberculosis contact investigation with a new, specific blood test in a low-incidence population containing a high proportion of BCG-vaccinated persons.  Respir Res. 2006 May 17;  7 (1) 77
    Google Scholar
  • 63 Ewer K, Deeks J, Alvarez L. et al . Comparison of T-cell-based assay with tuberculin skin test for diagnosis of Mycobacterium tuberculosis infection in a school tuberculosis outbreak.  Lancet.. 2003 Apr 5;  361 (9364) 1168-1173
    Google Scholar
  • 64 Shams H, Weis S E, Klucar P. et al . Enzyme-linked immunospot and tuberculin skin testing to detect latent tuberculosis infection.  Am J Respir Crit Care Med. 2005 Nov 1;  172 (9) 1161-1168
    Google Scholar
  • 65 Lange C, Schaberg T, Diel R. et al . Aktueller Stand der Tuberkulosediagnostik.  Dtsch Med Wochenschr. 2006 Feb 17;  131 (7) 341-347
    Google Scholar
  • 66 Jafari C, Ernst M, Kalsdorf B. et al . Rapid diagnosis of smear-negative tuberculosis by bronchoalveolar lavage enzyme-linked immunospot.  Am J Respir Crit Care Med. 2006 Nov 1;  174 (9) 1048-1054
    Google Scholar
  • 67 Jafari C, Ernst M, Strassburg A. et al .Local immunodiagnosis of pulmonary tuberculosis by enzyme-linked immunospot. Eur Respir J 2007. epub ahead of print Nov 7
    Google Scholar
  • 68 Wilkinson K A, Wilkinson R J, Pathan A. et al . Ex vivo characterization of early secretory antigenic target 6-specific T cells at sites of active disease in pleural tuberculosis.  Clin Infect Dis. 2005 Jan 1;  40 (1) 184-187
    Google Scholar
  • 69 Lange C, Hellmich B, Ernst M. et al . Rapid immunodiagnosis of tuberculosis in a woman receiving anti-TNF therapy.  Nat Clin Pract Rheumatol. 2007;  3 (9) 528-534
    Google Scholar
  • 70 Strassburg A, Jafari C, Ernst M. et al .Rapid diagnosis of pulmonary tuberculosis by BAL-ELISPOT in an immunocomromise host. Eur Respir J (in press)
    Google Scholar
  • 71 Golden M P, Vikram H R. Extrapulmonary tuberculosis: an overview.  Am Fam Physician. 2005 Nov 1;  72 (9) 1761-1768
    Google Scholar
  • 72 Streitz M, Tesfa L, Yildirim V. et al . Loss of receptor on tuberculin-reactive T-cells marks active pulmonary tuberculosis.  PLoS ONE. 2007;  2 (1) e735
    Google Scholar
  • 73 Breen R A, Hardy G A, Perrin F M. et al . Rapid Diagnosis of Smear-Negative Tuberculosis Using Immunology and Microbiology with Induced Sputum in HIV-Infected and Uninfected Individuals.  PLoS ONE. 2007;  2 (12) e1335
    Google Scholar
  • 74 Millington K A, Innes J A, Hackforth S. et al . Dynamic Relationship between IFN-gamma and IL-2 Profile of Mycobacterium tuberculosis-Specific T Cells and Antigen Load.  J Immunol. 2007 Apr 15;  178 (8) 5217-5226
    Google Scholar
  • 75 Ruhwald M, Bjerregaard-Andersen M, Rabna P. et al . CXCL10/IP-10 release is induced by incubation of whole blood from tuberculosis patients with ESAT-6, CFP10 and TB7.7.  Microbes Infect. 2007 Jun;  9 (7) 806-812
    Google Scholar
  • 76 Hougardy J M, Schepers K, Place S. et al . Heparin-Binding-Hemagglutinin-Induced IFN-γ Release as a Diagnostic Tool for Latent Tuberculosis.  PLoS ONE. 2007;  2 (10) e926
    Google Scholar
  • 77 Goletti D, Carrara S, Vincenti D. et al . Accuracy of an immune diagnostic assay based on RD1 selected epitopes for active tuberculosis in a clinical setting: a pilot study.  Clin Microbiol Infect. 2006 Jun;  12 (6) 544-550
    Google Scholar
  • 78 Vincenti D, Carrara S, Butera O. et al . Response to region of difference 1 (RD1) epitopes in human immunodeficiency virus (HIV)-infected individuals enrolled with suspected active tuberculosis: a pilot study.  Clin Exp Immunol. 2007 Oct ;  150 (1) 91-98
    Google Scholar
  • 79 Agranoff D, Fernandez-Reyes D, Papadopoulos M C. et al . Identification of diagnostic markers for tuberculosis by proteomic fingerprinting of serum.  Lancet. 2006 Sep 16;  368 (9540) 1012-1021
    Google Scholar

Priv. Doz. Dr. med. Dipl.-Biol. Christoph Lange

Klinische Infektiologie, Medizinische Klinik, Forschungszentrum Borstel

Parkallee 35

23845 Borstel

Email: clange@fz-borstel.de

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