My apologies to William Shakespeare for the paraphrase. But it’s a legitimate question. We know that tuberculosis is highly endemic in the Philippines, and almost everybody has had a brush with it either personally, a family member, relatives, friends or acquaintances.

People usually associate tuberculosis with “weak lungs,” but do you know tuberculosis can attack any and all organs in the body, and not just the lungs?

Children are especially susceptible to TB, and that is why vaccination for TB is done at birth. Nonetheless, when a child’s immunity weakens, the child can be infected through inhalation of the TB organisms from infected adults around him/her. The initial TB infection is known as primary complex. It’s seen when a chest x-ray is done, showing a lesion in the upper lobe/s of the lungs, along with enlarged lymph nodes in the perihilar area of the lungs.

Affected children are usually not symptomatic, though most will be underweight. Suspicion should be aroused when you can palpate/feel nodularities in the neck area behind the ears, which are enlarged lymph nodes (posterior cervical lymphadenopathy).

Whenever I am with friends, relatives or acquaintances who bring their children along, I ask permission to check for this abnormality in the child. Although, it is a highly predictive marker for primary complex, I still recommend seeing a pediatrician and having the child x-rayed. Treatment is usually just isoniazid for six months, after which the child should be re-evaluated for treatment success/failure.

When left untreated, primary complex can develop complications where the TB organism spreads through the bloodstream into the different organs. One serious complication is the development of TB meningitis, or inflammation of the lining (meninges) of the brain, which is serious and may cause the death of the patient if not treated adequately. Even when treated, it may leave the child with serious consequences, like mental retardation and all sorts of neurological issues.

Adults also develop TB of the lungs and other sites. I’ve seen cases of TB of the skin (lupus vulgaris), intestines, kidneys, bones, testis in males, genital tract (both sexes), brain meningitis or encephalitis, spine and practically all tissues in the body.

Diagnosing extrapulmonary TB can be difficult due to non-specific symptoms. Other than taking tissue biopsies (which is how we pathologists diagnose TB, both pulmonary and extra-pulmonary, there are other means of diagnosing TB.

A useful tool we use in the laboratory is to detect the immune response to tuberculosis in blood samples. Known as the Interferon Gamma Release Assay (IGRA), it detects the release of immune molecules (interferon gamma) by immune cells in response to specific TB antigens (substances that make up the TB bacillus). A positive result is reason to highly consider active TB in the absence of specific sites involved, especially when patients have non-specific symptoms like low grade fever, weight loss and others.

Treatment is usually highly effective but will involve taking multiple medications for months. Multi-drug-resistant (MDR) TB incidence is on the rise, due mainly to incomplete or irregular intake of medications, which will need to be given for four months or more. However, there are now highly effective medications for MDR TB.

What is more concerning now is the occurrence of TB in immunosuppressed patients, especially that HIV/AIDS is now a national epidemic. Most Filipinos have had contact with TB bacilli and still harbor the organisms in a seemingly dormant state only for the infection to flare up due to the loss of immunity, particularly in HIV/AIDS cases.

Due to the marked immunosuppression caused by the decimation of helper T-cells that guard against many opportunistic infections in HIV/AIDS patients, TB can become severe and deadly in these cases. It is concerning enough because some HIV/AIDS cases are undiagnosed due to denial caused by the stigma attached to the disease, which leads to rapid spread of the TB infection all over the body. Globally, TB is the leading cause of death in HIV/AIDS patients.

There is another entity that can mimic TB, a lung fluke infection caused by a parasite, Paragonimuswestermanii. Recently, Dr. Vicente Belizario Jr. (UP Manila) gave a talk on this TB mimic. He showed cases where the patient was treated for multi-drug-resistant TB but did not get well and the patients died. Only then was the parasitic infection diagnosed. Many more cases were identified subsequently.

Paragonimiasis is contracted by eating half-cooked or raw (kilawin) freshwater crabs and shrimps. It is present in several areas of the Philippines so we need to make sure the TB diagnosis is accurate and not based solely on X-ray since both have the same radiologic appearance. Diagnosis is through a sputum examination. We need to raise awareness of this TB mimic that can be fatal.

TB or not TB? It may be Paragonimiasis.