What are the symptoms of infected tuberculosis (TB) bronchiectasis in a patient with a history of respiratory issues and potential immunocompromised status?

Clinical Presentation of Infected TB Bronchiectasis

In a patient with respiratory history and potential immunocompromise, infected TB bronchiectasis presents with chronic productive cough with mucopurulent or purulent sputum, recurrent respiratory infections, hemoptysis, and constitutional symptoms including fever, night sweats, and weight loss. 1, 2

Cardinal Respiratory Symptoms

Chronic productive cough with daily sputum production is the hallmark symptom, with sputum typically mucopurulent or purulent in character. 2, 3 This represents the most consistent clinical feature across all patients with post-TB bronchiectasis. 2

• Hemoptysis occurs frequently due to bronchial arterial proliferation and arteriovenous malformations that develop in damaged airways. 2, 3 New or increased hemoptysis signals severe exacerbation requiring urgent intervention. 2

• Progressive dyspnea develops as airway damage advances and airflow obstruction worsens, with acute decline in exercise tolerance during exacerbations. 2, 3

• Recurrent respiratory infections manifest as repeated chest infections requiring antibiotic therapy, with frequent exacerbations (≥3 per year) indicating severe disease. 2, 3

Constitutional Symptoms (WHO-Endorsed TB Symptoms)

The combination of respiratory and systemic symptoms mandates immediate diagnostic evaluation. 1

• Fever is a common constitutional symptom in active pulmonary TB and during bronchiectasis exacerbations. 1, 4

• Night sweats represent one of the WHO-endorsed symptoms that increases likelihood of active TB disease. 5, 1

• Weight loss occurs as part of the constitutional symptom complex and is included in WHO screening criteria. 5, 1

• Fatigue and malaise develop, particularly during exacerbations, with significant energy depletion. 1, 2

Additional Clinical Features

• Chronic rhinosinusitis is frequently present in patients with post-TB bronchiectasis. 2

• Wheezing can occur due to bronchial hyperreactivity and airflow obstruction. 2, 6

• Thoracic pain and chest discomfort may develop with advanced disease. 2, 4, 6

Critical Considerations for Immunocompromised Patients

Immunocompromised patients may have active TB even with normal physical examination and chest radiograph findings. 5 This is particularly important in HIV-seropositive individuals, where diagnostic sensitivity is reduced. 5

• In people living with HIV (PLWHIV), the Xpert MTB/RIF test has an estimated pooled sensitivity of only 79% (95% credible interval, 70%-86%). 5

• The presence of any WHO-endorsed symptom (cough, fever, night sweats, weight loss) in PLWHIV increases the likelihood of pulmonary TB and warrants screening. 5

Disease Severity Indicators

Chronic Pseudomonas aeruginosa colonization, indicated by persistent isolation from sputum, is a sign of severe disease and carries disproportionate clinical importance. 2, 3 This is associated with three-fold increased mortality risk and seven-fold increased hospitalization risk. 3

• Frequent exacerbations requiring repeated antibiotic courses mark severe disease. 2, 3

• Worsening dyspnea with acute decline in exercise tolerance signals severe exacerbation. 2

Common Diagnostic Pitfall

The most critical pitfall is assuming normal chest radiographs exclude active TB in immunocompromised patients. 5 In geographic areas with high TB prevalence or in high-risk populations (HIV-seropositive persons, injection drug users), TB should be considered in all patients with chronic cough, sputum production, hemoptysis, fever, or weight loss, regardless of radiographic findings. 5