Tuberculosis (TB)

Our Approach in Managing Tuberculosis

TB management in Mumbai in 2025 is not the TB management of a decade ago. Rapid molecular diagnostics have changed timelines. Newer anti-TB therapy options have changed what is possible in drug-resistant disease. And the integration of nutrition, HIV testing, and contact screening has changed what a complete TB care programme looks like. Our TB specialist pulmonologist team in Mumbai, India delivers all of it as a coordinated programme, not a prescription and a discharge.

1. Diagnosis - Microbiological Confirmation

TB is a clinical and microbiological diagnosis. Clinical suspicion must be confirmed before treatment is started.

• Sputum smear microscopy - rapid, widely available; sensitivity 40–60% in pulmonary TB; still the first-line test in resource-limited settings
• GeneXpert MTB/RIF (CBNAAT) - detects M. tuberculosis DNA and rifampicin resistance simultaneously within 2 hours; now standard of care at Shree Hospitals
• GeneXpert Ultra - increased sensitivity for smear-negative and paucibacillary TB
• Culture on MGIT liquid medium - gold standard; detects all drug sensitivities; results in 2–6 weeks
• First- and second-line DST (Drug Sensitivity Testing) - mandatory when GeneXpert detects rifampicin resistance
• HRCT chest - identifies cavities, nodular-bronchogenic spread, miliary pattern, mediastinal lymphadenopathy
• Mantoux test (TST) and IGRA (Interferon Gamma Release Assay) - for latent TB infection identification in contacts and immunocompromised patients

2. First-Line Anti-TB Therapy - Standard Regimen

• 2HRZE / 4HR (6-month regimen): Isoniazid, Rifampicin, Pyrazinamide, Ethambutol for 2 months, followed by Isoniazid and Rifampicin for 4 months
• Fixed-dose combination (FDC) tablets - preferred over individual drugs; improves adherence and reduces prescription error
• Directly Observed Treatment - Short Course (DOTS): a DOT supporter witnesses each dose in the initial intensive phase
• Pyridoxine (Vitamin B6) - mandatory with Isoniazid to prevent peripheral neuropathy
• Baseline liver function, uric acid, and visual acuity - before starting treatment; monthly monitoring

3. Drug-Resistant TB - MDR and XDR

Drug resistant TB diagnosis and management is one of the most complex challenges in modern infectious disease.

• MDR-TB: resistant to at least Isoniazid and Rifampicin; prevalence in new TB cases in India approximately 2–3%; rising in retreatment cases
• XDR-TB: MDR-TB plus resistance to fluoroquinolones and at least one injectable agent
• New BPaL regimen (Bedaquiline + Pretomanid + Linezolid) - 26-week all-oral regimen for XDR-TB and treatment-intolerant MDR-TB; significantly superior outcomes to previous injectable-based regimens
• BPaLM (BPaL + Moxifloxacin) - for MDR-TB without fluoroquinolone resistance; 6-month regimen under WHO operational research
• Bedaquiline - inhibits ATP synthase; bactericidal; QTc monitoring mandatory
• Linezolid - potent but associated with peripheral neuropathy, myelosuppression; dose and duration optimisation critical

4. Extrapulmonary TB

TB is not confined to the lungs - approximately 20% of Indian TB cases are extrapulmonary.

• TB meningitis - the most dangerous form; dexamethasone added to anti-TB therapy is mandatory; 12-month regimen
• TB pleural effusion - pleural fluid ADA, culture; treated with standard 6-month regimen ± corticosteroids
• Spinal TB (Pott's disease) - MRI spine for diagnosis; surgical decompression for neurological compromise; 9–12 month regimen
• Lymph node TB - FNAC or excision biopsy for diagnosis; standard 6-month regimen
• Abdominal TB - ileocaecal most common; colonoscopy and biopsy; 6-month regimen
• Genitourinary TB - urine culture for AFB; early diagnosis prevents irreversible renal damage

5. Latent TB Infection Management

Latent TB infection - IGRA or TST positive without active disease - is not harmless. 5–10% of latent infections reactivate over a lifetime.

• Indications for latent TB treatment: HIV-positive, immunosuppressed (biologics, transplant, steroids), close household contacts of active TB cases, healthcare workers
• 6H regimen: 6 months Isoniazid daily - standard
• 3HP regimen: 3 months weekly Isoniazid + Rifapentine - superior completion rates, equivalent efficacy
• 4R regimen: 4 months Rifampicin - for INH-intolerant patients
• Exclude active TB before starting latent treatment - mandatory

6. Nutrition, HIV & Contact Screening

• Nutritional support - TB is a catabolic disease; malnutrition worsens outcomes; Nikshay Poshan Yojana provides nutritional support in India's national programme
• HIV testing - mandatory for all TB patients; co-treatment of TB-HIV requires specific timing (TB treatment first, ART within 2 weeks for CD4 <50)
• Contact screening - household contacts evaluated for active and latent TB infection; children under 5 in contact with smear-positive TB receive prophylactic Isoniazid regardless of TST result
• Adverse drug reaction monitoring - hepatotoxicity (DILI) is the most common serious complication; suspend treatment and restart sequentially if LFTs exceed 3× ULN