Pulmonary Tuberculosis

PULMONARY TUBERCULOSIS • •

Is a preventable disease that is curable if detected early, before the bacilli disseminate and complications occur. Is an infectious disease that primarily affects the lung parenchyma.

A.CAUSATIVE AGENT: •

Mycobacterium Tuberculosis (tubercle bacillus).  

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Is a slow-growing aerobic bacterium that divides every 16 to 20 hours; This is extremely slow compared to other bacteria that have division times measured in minutes. In contrast, one of the fastest growing bacteria is a strain of E. coli that can divide roughly every 20 minutes. As MTB only has one phospholipid outer membrane, it is classified as Gram-positive bacteria. However, if a Gram stain is performed, MTB either stains very weakly Gram-positive, or does not retain dye, due to the high lipid content of its cell wall. withstand weak disinfectants and can survive in a dry state for weeks. Normally, the bacteria can only grow within a host organism, so in vitro culture of M. tuberculosis took a long time to develop, but is now a routine laboratory procedure

B. MODE OF TRANSMISSION: • • •

Droplet nuclei (1 to 5 microns in size) are produced when people cough, laugh, sneeze, or sing. Infected droplet nuclei may then be inhaled by a susceptible person (host). Direct invasion through mucous membranes or breaks in the skin may occur, but extremely rare.

B. INCUBATION PERIOD:

4-6 weeks to develop after the initial contact

C. INITIAL SYMPTOM: Typically asymptoinatic, early infection is of no significance, clinically, at the time, but is of importance in that it sensitizes the body tissues to the tuberculo-protein as evidenced by a positive tuberculin reaction.

D. ETIOLOGY AND PATHOPHYSIOLOGY • • • •

• • •

Infection of lungs caused by Mycobacterium tuberculosis, an acidfast bacterium. Causes tubercles, fibrosis, and calcification within the lungs. Tubercle bacillus may be communicated to others by means of drop formation (inhalation), ingestion, or inoculation. Predisposing factors include debilitating diseases such as alcoholism, cardiovascular disease, HIV infection, diabetes mellitus, and cirrhosis, as well as poor nutrition and crowded living conditions. The emergence of multi-drug-resistant tuberculosis has complicated management of the disease. Chronic, progressive, and reinfection phase is most frequently encountered in adults and involves progression or reactivation of primary lesions after months or years of latency. Swallowing infected sputum may lead to laryngeal, oropharyngeal, and intestinal tuberculosis.

Mycobacterium Tubercle Bacilli

Dried Droplet Nuclei

Inflammation in Alveoli

Lymph Nodes Filter Drainage Primary Tubercle Necrosis Caseation

Calcified

“GHON TUBERCLE” Primary

Liquefaction

Coughed up

Cavity

E. PATTERNS OF INFECTION •

There are two major patterns of disease with TB:

1.Primary tuberculosis o o o o

Seen as an initial infection, usually in children. The initial focus of infection is a small subpleural granuloma accompanied by granulomatous hilar lymph node infection. Together, these make up the Ghon complex. In nearly all cases, these granulomas resolve and there is no further spread of the infection.

3.Secondary tuberculosis o Seen mostly in adults as a reactivation of previous infection (or o o

reinfection), particularly when health status declines. The granulomatous inflammation is much more florid and widespread. Typically, the upper lung lobes are most affected, and cavitation can occur.

F. CLINICAL FINDINGS •

Subjective o Malaise o Pleuritic pain o Easily fatigued

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Objective

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o o o o o o

Fever Night sweats Cough that progressively becomes worse. Hemoptysis Weight loss Chest x-ray examination to determine presence of active or calcified lesions.

o

Analysis of sputum and gastric contents for the presence of acid-fast bacilli.

OTHER SYMPTOMS o

Chronic dry cough or non- productive or productive cough.

o o o o

o o

o o o o o o

o o o o o o o

Difficulty of breathing/dyspnea. Digestive disturbances. Pulse is frequently rapid. Chest tightness. Examination of the sputum will frequently reveal the presence of tubercle bacilli. If the disease remains unchecked, erosion of a blood vessel by the pathogenic process may occur. Hemoptysis results with the expectoration of small or, at times, large amounts of blood that occasionally a massive hemorrhage. Crackles Malaise Increasing amounts of sputum (first mucoid and later purulent, appear). Cavities Pleuritic pain may result from extension of the infection to the pleural surfaces. Fever lasting two or three weeks / a low-grade fever. Persistent night sweat and chills. Drowsiness. Easy fatigability. Chest pain that maybe pleuritic or dull. Loss of weight. Loss of appetite or anorexia.

G. CLASSIFICATION OF TUBERCULOSIS •

CLASS 0 o

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CLASS 1 o

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Disease; clinically active

CLASS 4 o

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Latent infection; no disease

CLASS 3 o

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Exposure; no evidence of infection

CLASS 2 o

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No exposure; no infection

Disease; not clinically active

CLASS 5 o

Suspected disease; diagnosis pending

H. DIAGNOSIS

I. The Mantoux test •

The Mantoux test (or Mantoux screening test, Tuberculin Sensitivity Test, Pirquet test, or PPD test for Purified Protein Derivative) is a diagnostic tool for tuberculosis.

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Is used to detect latent Tuberculosis infection, to detect recent infection (as shown by conversion of the Mantoux from negative to positive) and as part of the diagnosis of Tuberculosis disease.

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Mantoux testing is not recommended for people who have had a past Mantoux reaction of 15 mm or greater or in people who have had previous Tuberculosis disease.

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PROCEDURE: 1. Provide patient education and locate the injection site o

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Collect necessary supplies and explain why the Mantoux test is given and what is involved in the procedure. Explain that 48 to 72 hours after the test is administered, the patient must return to have the in duration measured and interpreted. Place the forearm palm side up on a firm, well-lit surface and select an area of healthy skin 5 to 10 centimeter below the elbow joint which is free of muscle margins, heavy hair, veins, sores, or scars . Only visibly dirty skin needs to be washed with soap and water.

2.Prepare the syringe o o o o o o o

Check expiry date and ensure that the vial contains SSI tuberculin 2TU in 0.1ml Securely fasten an appropriately sized (21G green) needle to a 1ml graduated syringe and draw up just over 0.1ml of tuberculin Safely dispose of the needle used to draw up the tuberculin and securely fasten a 26G short bevel needle Expel air and excess tuberculin to leave exactly 0.1ml of tuberculin

3.Inject 0.1ml of tuberculin

a)Stretch taut the selected area of skin between the thumb and forefinger. b)Insert the needle slowly, bevel upwards, at an angle of 5 to 15 degrees

c)Advance the needle through the epidermis approximately 3mm so that the entire bevel is covered and visible just under the skin.

d)Release the stretched skin and, holding the syringe in place on the forearm, slowly inject the tuberculin solution. e)If the needle is inserted correctly you should feel quite firm resistance as the tuberculin enters the skin to form a tense, pale wheal 6 to 10 mm in diameter.

4. Check the skin test, record information and confirm return appointment.

o o o o

If the wheal is less than 6mm in diameter the test should be repeated at a site at least 5cm (50mm) from the original site Explain that mild itching, swelling, or irritation may occur and that these are normal reactions that do not require any treatment Tell the patient to avoid scratching the site, keep the site clean and avoid putting creams, lotions, or adhesive dressings on it Record all required information and provide an appointment card for the patient to return and have the test read

5. Reading •

Inspect the site o o

Visually inspect the site on a firm, well-lit surface Only the induration, which is a hard, dense, raised formation, is measured,

even if there is soft swelling or redness (erythema)

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Palpate induration o

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Mark induration o

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The diameter of the induration is measured across the forearm, from the thumb side of the arm to the little finger side. Use fingertip as a guide to mark lightly with a fine dot at the widest edges of induration across the forearm. If the margins of induration are irregular, mark and measure the longest diameter across the forearm.

Measure induration o

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Induration is not always visible or present and can only be determined by palpation with the fingertips. Using a light, gentle motion, sweep the fingertips over the surface of the forearm in all four directions to locate the margins or edges of induration.

Measure the diameter of the induration using a plastic flexible millimeters (mm) ruler Place the zero ruler line inside the left dot edge and read the ruler line inside the right dot edge If the measurement falls between two divisions on the millimeters scale, record the lower mark

Record measurement of induration in mm

o o o o

Record the exact measurement in millimetres (mm) of induration If there is no induration, record as 0mm Do not record results as ‘positive’ or ‘negative’ Record the date and time the test was read, the name and signature of the person who read the skin test, and the presence or absence of adverse effects

6. Interpretation The Mantoux test does not measure immunity to Tuberculosis but the degree of hypersensitivity to tuberculin. There is no correlation between the size of induration and likelihood of current active Tuberculosis disease but the reaction size is correlated with the future risk of developing Tuberculosis disease. The interpretation of the test result will depend on all relevant clinical circumstances. In the absence of specific risk factors for Tuberculosis, an induration of between 6 and 15mm is more likely to be due to previous BCG vaccination or infection with environmental mycobacteria than to TB infection. Where there is a higher probability of TB infection, such as recent contact with an infectious case, a high occupational risk or residence in a high prevalence country, then an induration of 6mm or greater is more likely to be due to Tuberculosis. A reaction of 6mm or greater, indicates a response of the immune system due to either Tuberculosis infection, infection with environmental mycobacteria or previous BCG vaccination (BCG vaccinated persons normally become tuberculin positive after 4-8 weeks). There is no correlation between the size of positive vaccination Mantoux reactions and protection against Tuberculosis disease and routine post-BCG Mantoux testing serves no purpose. Reactions larger than 15mm are unlikely to be due to previous BCG vaccination or exposure to environmental mycobacteria. Viral infections, especially HIV, can cause false negative reactions. Other factors that can weaken the Mantoux reaction include severe Tuberculosis disease, renal failure and diabetes, treatment with immunosuppressive drugs, old age or newborn infants and improper storage, insufficient dose and inadvertent subcutaneous injection.

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The booster effect

‘Boosting’ is mainly seen in adults and elderly persons who have been sensitised to mycobacteria many years earlier and now have too few sensitised lymphocytes in circulation to produce a significant local response to the Mantoux test. A repeat test can result in a larger response due to boosting of the immune response by the first test. The second boosted reaction is correct. Boosting can occur up to two years after the first Mantoux test and can therefore be confused with Mantoux conversion.

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Mantoux conversion

This is defined as when the second of two Mantoux tests increases by 10mm or greater over the first test. This is most useful in providing evidence of infection in exposed contacts but does not apply if vaccination takes place in the meantime. If a person is exposed to infectious TB who has a documented Mantoux test result within the past 12 months, then only one test is necessary to detect conversion. People who demonstrate Mantoux conversion should be investigated for latent TB infection or active disease.

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Two-step-testing

In persons who may be liable to boosting in whom it is important to establish a true baseline Mantoux response a second Mantoux test can be administered one week after the first. Two-step-testing is not necessary for contacts of infectious cases who will have already been re-sensitised if transmission has occurred, or for anyone who has been Mantoux tested in the previous two years.

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Mantoux reversion

This is defined as a reduction in Mantoux response following a previous test and, while rare, is most common in elderly people and in those who had an induration of 15mm or greater following a previous test.

II. Heaf Test • • • • • • •

The Heaf test for Tuberculosis was first described in the Lancet on 28 July 1951. It consists of firing a circular pattern of six needles into the skin through a film of prepared protein derivative (ppd). The site is inspected for reaction, usually seven days after the test. If the six puncture points have united to form a circle, or a more severe reaction is noted, the test is considered to give a positive indication of exposure to Tuberculosis. Patients who exhibit a negative reaction may be offered BCG vaccination. Only available in United Kingdom. PROCEDURE:

1) Disposable Heads for the Heaf Test The single use heads are to be used only with the Model 2000 handle and are not suitable for use with the much older Mark 7 apparatus. Two types of head are available which can be identified by both the description on the unit pack and by the colour of the outer plastic moulding. a) The Standard Heaf Test Head (White) This head has six needles, which protrude 2mm when actuated. It is for routine use in the Heaf method of multiple puncture tuberculin testing, for all patients aged 2 years or over. b) The Paediatric Heaf Test Head (Blue) This head has six needles, which protrude 1 mm when actuated. It should be used only for testing neonates and children of less than 2 years of age when using the Heaf method of tuberculin testing. 2) Assembly for each test One end of the pouch has been prepared to make opening easier. This is identified on the printed side and has a chevron shaped seal visible from the transparent side. With the printed side on a firm surface, the transparent side of the pouch is peeled back from this end. This will leave the head exposed, with the metal plate uppermost. The re-useable handle may now be used to pick up the head by means of the circular magnet at the open end. The handle should be held upright and the magnet brought into contact with the metal plate on the head. The head will then attach itself to the magnet and the apparatus is ready for use. 3) Preparation of the skin test site The front (volar aspect) of the forearm is the preferred area of skin for testing. A site midway between wrist and elbow, or just above, should be chosen to avoid visible veins or skin abnormalities.

If the skin requires cleansing, the area should be lightly prepared with alcohol and allowed to dry completely by evaporation before applying the test. 4) Applying the test Purified protein derivative (PPD) specifically prepared for the Heaf method of tuberculin testing (100,000 units/ml) is the only solution used. This should be transferred from a newly opened ampoule to the skin by means of a syringe (with the needle removed), bulb pipette, glass rod or loop. Enough must be put on the skin site so that the whole end plate of the head will be coated when applied to the skin. This may require up to 0. 1 ml of PPD and can be confirmed by observing a complete rim of fluid around the end face, when in contact with the skin.

The complete apparatus is placed on the PPD liquid, so that the plastic end face is completely touching the skin and so that the apparatus is at right angles to the skin. The head may be gently moved a small amount to ensure an even coating. To actuate the apparatus, the tester supports the forearm with one hand and, with the other hand, presses down firmly, but steadily, on the handle, keeping the whole apparatus at right angles to the skin. A click is heard as the needles are released to penetrate the skin. The PPD has now been introduced into the skin and six sites of needle entry should be visible in the coated area.

5) Aftercare of the skin Excess liquid can be wiped from the skin. No dressing is needed. The subject should be instructed not to rub or scratch the area and to return in seven days for reading the result. 6) Disposal of the Head The head should be separated carefully from the handle and immediately put into a sharps disposal container. The heads are for single use only and, after use, the needles remain protruding from the end face. The tester should hold only the wide edge of the head, to avoid self injury. Any head with protruding needles should be discarded as it may have been used and it will not fire again.

7) Next test The handle is now ready for a new head and the next test, following instructions 2 to 6 again 8) Reading the test The skin tones in the photographs have been selected to give the best visual images. On darker skin tones, the reactions may be less visible and palpation may be necessary to detect them. Grade 0 Reaction An absence of any reaction is a grade 0 reaction, which is classed as a negative reaction.

Grade 1 Reaction Discrete palpable induration at three or more puncture points is a grade 1 reaction. Today, a grade 1 reaction is classed as a negative reaction

. Grade 2 Reaction Coalescence of the indurate points to form an edematous ring is a grade 2 reaction, which is classed as a positive reaction

Grade 3 Reaction More intensive induration forming a coin pattern approximately 1cm in diameter is a grade 3 reaction, which is also classed as a positive reaction

Grade 4 Reaction More intensive induration and possible necrosis of the centre is a grade 4 reaction, which is strongly positive.

9) Care of the handle The handle should not require servicing in normal use and does not require sterilisation. After use, the handle should be wiped with a soft clean cloth or tissue, before being replaced in the container provided. If there is any debris attached to the magnet, pull the shield around the magnet back and remove the debris. Note: the screw at the centre of the magnet should be clearly visible. If it is not, one of the disks from the back of a disposable head may have detached and become attached to the magnet. This disk must be removed, as it will reduce the effectiveness of the magnet. To remove stubborn stains, the handle may be wiped with a solvent cleaner or washed with detergent. If using a water based cleaner, dry the magnet immediately to avoid corrosion. Ensure that the handle is completely dry before replacing it in the container.

III. Tine test

Is a multiple puncture tuberculin skin test used to aid in the medical diagnosis of tuberculosis (TB). This test uses a small "button" that has four to six short needles (tines) coated with Tuberculosis antigens (tuberculin). The tines are pressed into the skin (usually on the inner side of the forearm), forcing the antigens into skin. The test is read by measuring the size of the largest papule. A negative result is the presence of no papules.

IV. SPUTUM MICROSCOPY

Tuberculosis Symptomatic (Cough for 2 weeks or more)

3 sputum collection

2/3 smears positive

Classify as smear positive tuberculosis

Only 1 smear positive

Collect another 3 sputum specimen immediately

If at least 1 smear positive

If all smear negative

Classify smear – positive Tuberculosis

Request for Chest xray

If consistent with active Tuberculosis

If not consistent with active Tuberculosis

Classify as smear positive Tuberculosis

Observation or further exam if necessary

All smear negative

Refer to medical officer (Observe patient with symptomatic treatment for 2 or 3 weeks)

If symptoms persist, collect another 3 sputum specimens and refer to medical officer

V. CHEST X-RAY

Chest X-ray of a patient with advanced pulmonary tuberculosis

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X-rays are valuable to detect old lessions or new ones they are large enough to be seen. Cavities maybe present with far advanced disease. Inflammation that accompanies a new infection may also be apparent.

TUBERCULOUS INFECTION: Suspected because of: Unresolved Pneumonia Persistent Cough Unexplained Fever Contact

Epidemiologic History

Diagnosi s less

negativ

e

Positive

Tuberculin Skin Test

not significant

Diagnosis unlikely

Significan t Risk Factor

negativ e

Chest x-ray

Positive

Positive

Sputum Smears & cultures

negativ

Positive

Asymptomat ic infection

Prophylaxis

Absence of other diseases

Positive

Diagnosis Confirme d

Diagnosis Probable

Treatment

negativ

e

Diagnosis Unlikely

NURSING CONCERNING PROGNOSIS. I.

DIAGNOSIS: KNOWLEDGE DEFICIT THE DISEASE, TREATMENT AND

As-recently as the 1960s, people with TB were often confined for treatment for months or years in sanatoriums. o

TB is infectious but may be cured -or arrested if medication is taken as prescribed.

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TB s transmitted by droplet infection (e.g., when coughing, sneezing, laughing, singing), and is not carried on fomites such as clothing books eating utensils.

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Cover nose and mouth when coughing, laughing, or sneezing.

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Wash hands very carefully after any contact with body substances, masks, or soiled tissues. Sputum is highly contaminated. Wear masks in appropriate situations when advised. People with TB are usually not restricted in their activities for more than 2 to 4 weeks after chemotherapy is begun and they are not isolated from others. Treatment maybe necessary for a long time. Keep an adequate supply of medication available in all times.

J. MEDICAL INTEVENTIONS • •

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Treatment for TB uses antibiotics to kill the bacteria. Treatments are more difficult than the short courses of antibiotics used to cure most bacterial infections as long periods of treatment (around 6 to 12 months) are needed to entirely eliminate mycobacteria from the body. Latent TB treatment usually uses a single antibiotic, while active TB disease is best treated with combinations of several antibiotics, to reduce the risk of the bacteria developing antibiotic resistance. People with these latent infections are treated to prevent them from progressing to active TB disease later in life.

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Drug resistant tuberculosis is transmitted in the same way as regular TB.

K. NURSING CARE OF CLIENTS WITH PULMONARY TUBERCULOSIS •

Assessment

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Analysis/Implementation

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Planning/Implementation

1. Detailed history related to exposure, travel, or BCG inoculation. 2. Fatigue, anorexia, low-grade fever, and night sweats. 3. Sputum for color, amount, and consistency.

•Ineffective Airway Clearance •Ineffective Breathing Pattern •Impaired Gas Exchange •Pain •Ineffective Individual Coping •Ineffective Family Coping •Altered Health Maintenance •Noncompliance •Sleep Pattern Disturbances •Deficient Knowledge •Ineffective Therapeutic Regimen Management •Activity Intolerance •Imbalanced Nutrition Less Than Body Requirements •Risk for Infection •Fatigue

1.Teach client to provide for scheduled rest periods. 2.Teach which foods to include in the diet and which are nutritious between meal supplements. 3.Teach the importance of adhering, without variation, to the drug program that has been established.

4.Teach the proper techniques to prevent spread of infection. a. b. c. d. e.

Frequent hand washing. Cover the mouth when coughing. Proper use and disposal of tissues. Proper cleansing of eating utensils and disposal of food wastes. In addition to standard precautions, use airborne precautions with high filtration masks when sputum is positive for the organism.

5.Encourage client to participate in developing a schedule of activities and therapy and follow the schedule once established. 6.Instruct client to be alert to the early symptoms of hemorrhage, such as hemoptysis, and to contact the physician immediately if any occur. 7.Instruct client to be alert to the early symptoms of adverse drug reactions (e.g. neuritis, ringing in the ears, ataxia, dermatitis) and to contact the physician immediately if any occur. 8.Encourage client to follow prescribed program for productive coughing and deep breathing. 9.Instruct client to avoid any medications such as cough syrups without physician’s approval. 10.Explain the need and instruct client to continue follow-up care and supervision. 11.Encourage client to express feelings about disease and the many ramifications (stigma isolation, fear) it creates. 12.Expect and accept client’s expression of feelings related to the disease. 13.Encourage client to limit activities until the physician gives approval for gradual increase. 14.Help client plan a realistic schedule for taking the large number of necessary medications. 15.Monitor client’s compliance with therapeutic regimen.

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Complications:

1. Tuberculosis empyema 2. Brorichopleural fistula 3. Potts Disease 4. Meningitis 5. Homaturia 6. Tuberculous osteomyelitis 7. Pericarditis 8. Bronchiectasis 9. Pneumonia 10. Headache 11. Diarrhea

L. EXTRAPULMONARY TUBERCULOSIS (XPTB) •

Is Tuberculosis anywhere outside the lungs; can spread throughout the body via the blood and lymph, following the initial invasion or primary pulmonary infection.

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most commonly grows in the: a)Renal cortex b)Bone growth plates c)Meninges which are highly aerobic sites d)Genitourinary tract e)Pleura f)Pericardium g)Abdomen h)Endocrine glands

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MYCOBACTERIUM TUBERCULOSIS • •

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MILIARY TUBERCULOSIS • •

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Difficult to detect High among Caucasians ASSESSMENT: a)Weight loss b)Fatigue c)Malaise d)Fever e)Sweats

Disseminated in a widespread pattern throughout the body may affect any age group. Common in people aged 50 and older and in very young children with unstable or undeveloped immune systems. ASSESSMENT: a)Anorexia b)Weakness c) Fatigue d)Weight loss e)Fever f) Chills g)Sweats h)Headache i) Abdominal pain

ASSESSMENT FOR EXTRAPULMONARY TUBERCULOSIS a)Administering a Mantoux test using intermediate strength PPD. b)Examination of sputum and other body fluid. c) History

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d)Physical Examination

INTERVENTION FOR EXTRAPULMONARY TUBERCULOSIS a)The treatment for extra pulmonary Tuberculosis is similar to that for pulmonary tuberculosis except the treatment period may be longer. b)Chemotherapeutic Agents c) Corticosteroids

M. OTHER TYPES OF TUBERCULOSIS OUTSIDE THE LUNGS: •

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Skeletal Tuberculosis: Tuberculous osteomyelitis involves mainly the thoracic and lumbar vertebrae (known as Pott's disease) followed by knee and hip. There is extensive necrosis and bony destruction with compressed fractures (with kyphosis) and extension to soft tissues, including psoas "cold" abscess. Genital Tract Tuberculosis: Tuberculous salpingitis and endometritis result from dissemination of tuberculosis to the fallopian tube that leads to granulomatous salpingitis, which can drain into the endometrial cavity and cause a granulomatous endometritis with irregular menstrual bleeding and infertility. In the male, tuberculosis involves prostate and epididymis most often with non-tender induration and infertility. Urinary Tract Tuberculosis: A "sterile pyuria" with WBC's present in urine but a negative routine bacterial culture may suggest the diagnosis of renal tuberculosis. Progressive destruction of renal parenchyma occurs if not treated. Drainage to the ureters can lead to inflammation with ureteral stricture. CNS Tuberculosis: A meningeal pattern of spread can occur, and the cerebrospinal fluid typically shows a high protein, low glucose, and lymphocytosis. The base of the brain is often involved, so that various cranial nerve signs may be present. Rarely, a solitary granuloma, or "tuberculoma", may form and manifest with seizures. Gastrointestinal Tuberculosis: This is uncommon today because routine pasteurization of milk has eliminated Mycobacterium bovis infections. However, M. tuberculosis organisms coughed up in sputum may be swallowed into the GI tract. The classic lesions are circumferential ulcerations with stricture of the small intestine. There is a predilection for ileocecal involvement because of the abundant lymphoid tissue and slower rate of passage of lumenal contents. Adrenal Tuberculosis: Spread of tuberculosis to adrenals is usually bilateral, so that both adrenals are markedly enlarged. Destruction of cortex leads to Addison's disease. Scrofula: Tuberculous lymphadenitis of the cervical nodes may produce a mass of firm, matted nodes just under the mandible. There can be chronic draining fistulous tracts to overlying skin. This complication may appear in children, and Mycobacterium scrofulaceum may be cultured.

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Cardiac Tuberculosis: The pericardium is the usual site for tuberculous infection of heart. The result is a granulomatous pericarditis that can be hemorrhagic. If extensive and chronic, there can be fibrosis with calcification, leading to a constrictive pericarditis.