Extrapulmonary tuberculosis

Red Flags

Tubercular meningitis with raised intracranial pressure or hydrocephalus — neurosurgical evaluation; corticosteroids alongside ATT^[1]
Spinal TB (Pott's spine) with neurological deficit — emergency surgical decompression plus ATT^[1]
Miliary TB with respiratory failure or CNS involvement — admit; ICU; ATT plus high-dose corticosteroids; rule out HIV^[1]
TB pericarditis with cardiac tamponade — emergency pericardiocentesis; ATT plus corticosteroids^[1]

First-line treatment

Interventions

Directly observed treatment (DOT)^[1]
All ATT under DOT (in-person or video) per NTEP; family or treatment supporter validated
Surgical involvement for selected sites^[1]
Pott's spine with deficit — decompression; lymph node abscess — drainage; pericardial effusion with tamponade — pericardiocentesis

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
HRZE (isoniazid + rifampicin + pyrazinamide + ethambutol)^[1]	First-line antitubercular fixed-dose combination	Weight-band: 30–37 kg: 2 FDC tabs; 38–54: 3 tabs; 55–69: 4 tabs; ≥70: 5 tabs daily for intensive phase	Weight-band per NTEP paediatric tables	Standard 6-month regimen for most extrapulmonary TB (2HRZE / 4HR). Extended to 9–12 months for CNS, bone, joint, disseminated TB
Pyridoxine (vitamin B6)^[1]	Adjunctive co-prescription	10 mg PO daily during ATT	5–10 mg daily	Prevents isoniazid-induced peripheral neuropathy
Dexamethasone (TBM and TB pericarditis)^[1]	Glucocorticoid adjunct	TBM: dexamethasone 0.4 mg/kg/day IV tapering over 6–8 weeks. TB pericarditis: prednisolone 60 mg/day for 4 weeks then taper	0.3 mg/kg/day (TBM)	Reduces mortality in TBM and prevents constriction in pericarditis
MDR/XDR-TB regimen (BPaL/BPaLM)^[2]	All-oral shorter regimen for MDR-TB	Bedaquiline + pretomanid + linezolid (± moxifloxacin) for 6 months per WHO 2024 update	—	Specialist (programmatic management of drug-resistant TB) only. DST-driven; shorter than 18-month regimens

HRZE (isoniazid + rifampicin + pyrazinamide + ethambutol)^[1]

First-line antitubercular fixed-dose combination

Adult: Weight-band: 30–37 kg: 2 FDC tabs; 38–54: 3 tabs; 55–69: 4 tabs; ≥70: 5 tabs daily for intensive phase
Paediatric: Weight-band per NTEP paediatric tables

Standard 6-month regimen for most extrapulmonary TB (2HRZE / 4HR). Extended to 9–12 months for CNS, bone, joint, disseminated TB

Pyridoxine (vitamin B6)^[1]

Adjunctive co-prescription

Adult: 10 mg PO daily during ATT
Paediatric: 5–10 mg daily

Prevents isoniazid-induced peripheral neuropathy

Dexamethasone (TBM and TB pericarditis)^[1]

Glucocorticoid adjunct

Adult: TBM: dexamethasone 0.4 mg/kg/day IV tapering over 6–8 weeks. TB pericarditis: prednisolone 60 mg/day for 4 weeks then taper
Paediatric: 0.3 mg/kg/day (TBM)

Reduces mortality in TBM and prevents constriction in pericarditis

MDR/XDR-TB regimen (BPaL/BPaLM)^[2]

All-oral shorter regimen for MDR-TB

Adult: Bedaquiline + pretomanid + linezolid (± moxifloxacin) for 6 months per WHO 2024 update
Paediatric: —

Specialist (programmatic management of drug-resistant TB) only. DST-driven; shorter than 18-month regimens

Safety-net

Take ATT every day even when feeling well — interruption causes resistance and relapse; full course is essential^[1]
Watch for jaundice, severe vomiting, vision changes, or numb hands/feet during ATT — same-day medical review (drug toxicity)^[1]
Tell your dentist, surgeon, or any other doctor that you are on ATT — drug interactions are common (especially with rifampicin)^[1]

Referral criteria

TB meningitis or spinal TB with neurological deficitNeurology / neurosurgery and ID urgently^[1]
Drug-resistant TB (rifampicin-resistant on Xpert, MDR/XDR)Programmatic Management of Drug-Resistant TB (PMDT) centre^[2]
Treatment failure or relapseTB specialist for re-evaluation and DST^[1]
Severe ATT-related hepatitis (ALT >3× ULN with symptoms or >5× without)Hospital admission; pause ATT; sequential reintroduction under supervision^[1]

Clinical summary

Diagnosis and treatment of extrapulmonary TB (lymph node, pleural, abdominal, CNS, bone, miliary); longer durations for CNS, bone, and disseminated disease.

References

1.Index-TB Guidelines for Extrapulmonary TB; NTEP Technical Operational Guidelines (2022); WHO Consolidated Guidelines on TB Treatment 2022 (2022)
2.WHO Consolidated Guidelines on Tuberculosis: Drug-Resistant TB Treatment, 2024 Update. WHO, Geneva (2024)