Abstract

Although the underlying general principles of management of tuberculosis are the same for all cases, there are certain special situations in which the treatment regimen must be modified.

Uremia and post-renal transplant are both risk factors for tuberculosis due to the underlying immunodeficiency. Patients undergoing dialysis have a 10-25-fold higher risk of developing the disease than the general population.

Many antituberculosis drugs are hepatotoxic. If aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are increased more than three times the upper limit of normal in the presence of symptoms of hepatitis or >5 times the upper limit of normal, even if the patient is asymptomatic, all hepatotoxic drugs should be discontinued.

First-line drugs (HREZ) are safe during pregnancy, and regimen doses and duration are the same as in non-pregnant individuals. Pyridoxine (50 mg, vitamin B6) should be added to the regimen to prevent neuropathy in the mother and seizures in the fetus.

There is an increased risk of progression to active TB in subjects with latent infection TB and diabetes in comparison with the infected nondiabetic population. Also, outcomes for patients with TB and diabetes are worse than for TB patients without diabetes, and diabetes also increases the risk of drug-resistant TB.

Risk factors for extrapulmonary TB (EPTB) include advanced age, female gender, immunosuppression (including HIV) and chronic comorbidities. Symptoms and signs are usually non-specific, and except for miliary forms, the chest radiograph might be normal; therefore, the diagnosis of EPTB is frequently delayed with the consequent increase in morbidity and mortality.