3. Clinical presentations by organ-specific site

Clinical presentation, investigations and management by organ specific site are reviewed in the following sections. Evidence for treatment duration and other adjunct measures for each organ site is summarized in Table 3. Examples of published corticosteroid regimens for relevant organ sites are described in Table 2.

Table 2. Examples of published corticosteroid regimens for extra-pulmonary TB.^a

TBM Children^(329,330)(≤14 years) Adults/Adolescents⁽¹⁹⁶⁾ (>14 years)				Pericardial TB Adults⁽³⁰¹⁾ (≥18 years)
Clinical Status	All	Alert (GCS 15)	Altered LOC (GCS <15) +/- focal neurologic deficits (8 wk course)	Alert (GCS 15), no focal neurologic deficits (6 wk course)	HIV-negative
Week 1	DEXA 0.6 mg/kg/d IV	Prednisolone^a 4 mg/kg/d PO (max 60 mg/d)	DEXA 0.4 mg/kg/d IV	DEXA 0.3 mg/kg/d IV	Prednisolone PO 120 mg PO
Week 2	“	“	0.3 mg/kg/d IV	0.2 mg/kg/d IV	90 mg PO
Week 3	“	“	0.2 mg/kg/d IV	0.1 mg/d PO ^b	60 mg PO
Week 4	“	“	0.1 mg/kg/d IV	3 mg/d PO ^b	30 mg PO
Week 5+	Tapered through Week 8	Tapered through Week 8	4 mg/d PO ^b decrease by 1 mg/wk	2 mg/d PO ^b decrease by 1 mg/wk	Week 5 = 15 mg PO Week 6 = 5 mg PO

^{Abbreviations: TB, tuberculosis; TBM, tuberculosis meningitis; LOC, level of consciousness; GCS, Glascow Coma Scale; DEXA, dexamethasone; IV, intravenous; PO, by mouth; BMRC, modified British Medical Research Council TBM severity grading; GI, gastrointestinal.199}

^{aAll corticosteroid doses assume concurrent use of rifampin. If rifampin is not part of TB regimen, then dose adjustment advised.}

^{bcontinue as IV if significant GI intolerance or compromise, early switch to PO may be considered in those with prompt improvement and GI tolerance.}

Table 3. Summary of evidence for duration of treatment in extra-pulmonary TB with adjunct measures.

Site	Duration TB treatment	Level of guidance	Evidencea				Adjunct measures
			Type of Studies	Number		Consistency	Corticosteroids (ref)	Other Measures (ref)
			Type of Studies	Studies (refs)	Participants	Consistency	Corticosteroids (ref)	Other Measures (ref)
Pleural	6 months	Conditional	OBS	4^(122–125)	454	Good	Do not use⁽ ¹²⁶ ⁾	Drainage not necessary⁽ ¹²³ ^, ¹²⁷ ⁾
Lymph Node	6 months	Conditional	RCT	2⁽ ¹⁰⁵ ^, ¹⁰⁶ ⁾	290	Good	–^b	Surgery not necessary⁽ ⁹⁸ ⁾
Abdominal (all forms)	6 months	Conditional	SRMA	3⁽ ¹⁵¹ ⁾	328	Good
Bone and Joint	6 months, consider 9-12 months with markers of severe disease	Conditional	RCT/OBS/Review RCT thoracic/ lumbar	Review 77 studies⁽ ¹⁸³ ⁾ 2 RCTs⁽ ¹⁸⁴ ^, ¹⁸⁶ ⁾	2,889 293	Good, two studies with higher relapse rates Dutt et al. ³³¹ twice weekly self-administered therapy for 9 months and Ramachandran et al. ³³² primarily based on lack of radiograph response		Surgical intervention is not routinely recommended as part of treatment in spinal tuberculosis. Surgical treatment of spinal TB should be considered in those with neurologic deterioration and in those less than 15 years of age with significant kyphosis⁽ ¹⁶¹ ^, ¹⁸⁵ ^, ¹⁸⁹ ⁾
Central Nervous System	TBM 9-12 months	Conditional	OBS/SR	18 ^c ⁽ ²³⁶ ⁾	2,098	Good	Use for all individuals, dosing guided by age group and disease severity.⁽ ²³⁹ ⁾ See Table 2 for dosing guidance	Higher dose rifampin (IV or oral up to maximum dose 35 mg/kg/day) advised during intensive phase of therapy⁽ ^223–225 ^, ²²⁹ ^, ³³³ ^, ³³⁴ ⁾ Routine use fluoroquinolone not advised unless concern about drug resistant TBM⁽ ²²⁸ ^, ²³¹ ⁾
Central Nervous System	Tuberculoma/archnoiditis 9-12 months	Conditional	OBS	20⁽ ²⁴⁶ ⁾	742	Poor	Do not use unless clinical significant mass effect⁽ ²⁸ ^, ²⁴⁶ ⁾
Disseminated	6 months	Conditional	Expert opinion
Genitourinary	6 months	urinary female genital	OBS RCT	2⁽ ²⁸⁹ ^, ³³⁵ ⁾ 1⁽ ²⁹¹ ⁾	200 175	Good N/A – one study
Pericardial	6 months		OBS	4⁽ ⁸² ^,299–301)	660	Good	Use for HIV negative populations. People with HIV not on ARV-do not use.⁽ ²⁹⁶ ⁾ Limited data for People with HIV on ARV
Ocular	6 months	Conditional	OBS	4⁽ ³⁰³ ^, ³¹⁴ ^, ³¹⁶ ^, ³¹⁷ ⁾	426	Poor
Cutaneous	6 months	Conditional	OBS	Case reports and reviews

^{Abbreviations: ARV, anti-retrovirals; TB, tuberculosis; OBS, observational study; RCT, randomized clinical trial; SR, systematic review; SRMA, systematic review meta-analysis.}

^{a(-) Insufficient data.}

^{bOne cohort in SR was unpublished.}

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TB Manual

Table 2. Examples of published corticosteroid regimens for extra-pulmonary TB.^a

Table 3. Summary of evidence for duration of treatment in extra-pulmonary TB with adjunct measures.

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