Signs And Symptoms

Signs and Symptoms
Active TB

For PLWHIV the clinical presentation of active TB varies with CD4 count. In patients with high CD4 counts, pulmonary TB is the most common manifestation. The proportion of patients presenting with extrapulmonary TB increases with decreasing CD4 count.1,2   

Pulmonary TB
  • Active pulmonary TB may cause symptoms such as: 3,4

    • a cough lasting 3 weeks or longer
    • chest pain
    • coughing up blood or sputum
    • weakness or fatigue
    • weight loss
    • loss of appetite
    • fever
    • night sweats
  • Early symptoms may be vague and could be unnoticed by the affected person4
Extrapulmonary TB

Extrapulmonary TB is more common in PLWHIV, particularly as CD4 count decreases, compared with non HIV-infected individuals.1,2,5 Symptoms include constitutional symptoms such as fever, anorexia, weight loss, malaise and fatigue alongside the following:5,6

  • Lymph node TB:

    • persistently swollen lymph nodes (usually nodes in the neck)
    • discharge of fluid from swollen nodes through the skin
  • Skeletal TB:

    • arthralgia of the affected bone or joint
    • curving of the affected bone or joint
    • loss of articulation or sensation in the affected bone or joint
    • weakened bone that may be prone to fracture
  • Gastrointestinal TB:

    • abdominal pain
    • diarrhea
    • anal bleeding
  • Genitourinary TB:

    • hematuria
    • aseptic pyuria
    • nocturia
    • painful urination (dysuria)
    • groin pain
  • Central nervous system TB:

    • headaches
    • vomiting
    • stiff neck
    • changes in mental state, e.g. confusion
    • blurred vision
    • seizures
  • Miliary/disseminated TB:7

    • fever (for several weeks)
    • anorexia
    • weight loss
    • lassitude
    • cough
    • organ specific symptoms, although organ involvement is usually asymptomatic
Common extrapulmonary manifestations in PLWHIV
  • Presentations among PLWHIV co-infected with TB include:8

    • ​lymphadenopathy
    • pleural effusion
    • pericardial disease
    • miliary TB
    • meningitis
  • Many patients with extrapulmonary TB have coexistent pulmonary TB8
  • In PLWHIV infected with TB, lymphadenopathy with multifocal involvement, intrathoracic and intraabdominal lymphadenopathy are more common than in TB patients not infected with HIV6
  • Hepatobiliary and pancreatic TB are rare and occur more often in immunocompromised patients than in immunocompetent patients6
  • Isolated splenic tuberculosis is very rare in immunocompetent persons

    • splenic tuberculosis can present as hypersplenism, splenic abscess, or as a solitary splenic lesion
    • multiple splenic tuberculosis abscesses have been described in patients with HIV infection6

For further information on extrapulmonary TB, refer to this review from Sharma SK, Mohan A. (2004) Extrapulmonary tuberculosis.6

Latent TB
  • Latent TB is asymptomatic, but PLWHIV who have latent TB are more likely to develop active TB than the general population.9,10
  • Screening for TB in PLWHIV is critically important as latent TB infection can be managed with isoniazid preventive therapy.11

Find out more about diagnostic tools

  1. Jones BE, Young SM, Antoniskis D, et al. Relationship of the manifestations of tuberculosis to CD4 cell counts in patients with human immunodeficiency virus infection. Am Rev Respir Dis 1993;148:1292–1297. 
  2. Jaryal A, Raina R, Sarkar M, et al. Manifestations of tuberculosis in HIV/AIDS patients and its relationship with CD4 count. Lung India. 2011;28:263–266. 
  3. Centers for Disease Control and Prevention. Features – Tuberculosis: Learn the Signs and Symptoms of TB. Accessed 27 November 2011.
  4. National Institute of Allergy and Infectious Diseases. Tuberculosis – Symptoms. Accessed 27 November 2011.
  5. National Health Service. Symptoms of Tuberculosis. Accessed 27 November 2011.
  6. Sharma SK, Mohan A. Extrapulmonary tuberculosis. Indian J Med Res 2004;120:316–353. 
  7. Sharma SK, Mohan A, Sharma A, Mitra DK. Miliary tuberculosis: new insights into an old disease. Lancet Infect Dis 2005;5:415–430.
  8. Harries A, Maher D, Graham S. Stop TB Department; Department of HIV/AIDS; Department of Child and Adolescent Health and Development. World Health Organization. TB/HIV: A clinical manual. Second edition, 2004.  Accessed 16 April 2012.
  9. World Health Organization. Guidelines for Intensified Tuberculosis Case-Finding and Isoniazid Preventive Therapy for People Living with HIV in Resource-Constrained Settings. Accessed 25 November 2011.
  10. Getahun H, Gunneberg C, Granich R, Nunn P. HIV Infection-Associated Tuberculosis: The Epidemiology and the Response. Clin Infec Dis 2010;50:S201–207. 
  11. World Health Organization. Three I’s Meeting (2008). Accessed 25 November 2011.
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