case presentations
DESCRIPTION
Case Presentations. Adrian Gardner MD, MPH Clinical Research Fellow Miriam Hospital/Alpert School of Medicine at Brown University May 1, 2010. 24 yo F from Liberia US in 1999 PMH: HIV (dx 2004), CD4 350-400, VL ND on ARVs LTBI (TST 24 mm) s/p INH (2002)- ? Poor adherence - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/1.jpg)
Case Presentations
Adrian Gardner MD, MPH
Clinical Research Fellow
Miriam Hospital/Alpert School of Medicine at Brown University
May 1, 2010
![Page 2: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/2.jpg)
Case 1
24 yo F from Liberia US in 1999 PMH:
– HIV (dx 2004), CD4 350-400, VL ND on ARVs– LTBI (TST 24 mm) s/p INH (2002)- ? Poor adherence
• Annual trips to Liberia
– Asthma– h/o RUL PNA (2/08) clinically improved w/ moxifloxacin x 7d
8/08: Developed cough, fever x 5 days– Called PCP, started on moxifloxacin– Few days later, pursued “follow-up” CXR
![Page 3: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/3.jpg)
Case 1
![Page 4: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/4.jpg)
Case 1 Admitted to hospital for further work-up
– Exam: T 102 HR 80-120 wt 126 lbs O2 sat: 99% RA• Bronchial BS anteriorly on right side
5.336
N:61 L:25 M:13 E:0.5 Bas:0.2 AST: 18
ALT: 11
12189
6
1.0
![Page 5: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/5.jpg)
Case 1
Hospital course:– CT scan: dense consolidation RUL with septated cavity, no
LAD– Antibiotics changed to CTX/Clindamycin– Unable to produce sputum– Bronchoscopy performed
• BAL: AFB smear +
– Started on Rifabutin/I/Z/E
![Page 6: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/6.jpg)
• 33 patients in Baltimore, MD with culture-confirmed TB
•16 (48%) had received FQ for CAP before TB diagnosis
•Of these 16, 83% improved clinically within ~ 3 days. 10 were discharged from hospital prior to TB diagnosis being made.
•Median time until re-presentation and initiation of TB treatment was 5 days in those who did not receive a FQ vs. 21 days in those who did (p=0.04)
•Initial empiric treatment with FQ is associated with delay in initiation of appropriate anti-TB treatment.
![Page 7: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/7.jpg)
• 640 pts in TN with culture-confirmed TB (2002-2006)
•116 (18%) had FQ exposure in 12 months prior to TB diagnosis
•16 (2.5%) isolates were FQ resistant
•FQ exposure >10 days was associated with FQ resistance (OR= 7.0, p= 0.001) and highest risk if exposed >60 days prior to TB diagnosis (OR= 17, p < 0.001)
![Page 8: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/8.jpg)
Case 1
Seen in TB clinic– BAL (8/7/08) and sputum cx grew MTB– Placed under quarantine
9/08: Lab reports difficulty with DST– Prelim results:
• Resistance to I/Z• Low level resistance to E
– Specimen sent to CDC for 2nd line DST
![Page 9: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/9.jpg)
Case 1
What would you do?
a) Re-assess clinically
b) Continue current meds until DST results final
c) d/c I/Z, add FQ, injectable (Rifabutin/E/FQ/AG)
d) d/c all, change to Ethio/AG/FQ/Cycloserine/PAS
e) Worry about Rifabutin, FQ resistance
f) Seek help!
Cough improved
Sputum smears neg
CXR unchanged
![Page 10: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/10.jpg)
Case 1
9/12/08…..d/c I/Z, E dose increased, add FQ, injectable – (Rifabutin/E ( )/FQ/AG)
Four days later, lab reports…– Resistance to I, Z, low dose E– Sensitive to R/SM (initial isolate)
11/08: sparse growth on cx specimens from 8/24/08, 9/21/08– Identification not possible
12/08: CDC reports specimen “contaminated”– request new isolate
![Page 11: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/11.jpg)
Case 1
1/09– CXR improved– Specimen from 8/24 reported as
pan-S MTB– CDC reports 2 mycobacteria
• Confirms pan-S MTB• Unable to grow #2
2/09– 6 months tx complete– Rifabutin/I/FQ x 3 mo
5/09– Completed therapy– Q 6 mo surveillance
8/09– Pregnant!
![Page 12: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/12.jpg)
Case 1: Take Home Points
• Use of FQ to treat respiratory or other infections in patients with undiagnosed TB leads to delays in starting TB treatment and FQ resistant TB.
• When TB is on the differential, consider another drug for treatment of community acquired pneumonia
• Always talk directly with the lab—the lab is your friend!
• Consider the possibility of a mixed/complex mycobacterial infection
![Page 13: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/13.jpg)
Case 2 20 year old Caucasian, female University Student
• PMH significant for anorexia nervosa 4 yrs ago, recent wisdom teeth extraction
• Has lived in New Zealand in the past• Two years ago, spent 3 months living with host families in
Yunan Province, China as part of a student exchange program• Last year, traveled to Thailand, Japan for 2 weeks• No known TB contacts, never had a PPD in past.
• June, 2009: PPD placed prior to starting volunteer, research position at VA hospital. PPD 30 mm. She reported no symptoms.
![Page 14: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/14.jpg)
Case 2: CXR
![Page 15: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/15.jpg)
Case 2
Sputum smears negative
Started on R/I/Z/E
Sputum cx grew TB
![Page 16: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/16.jpg)
Case 2: Take Home Point
Students/volunteers/health care workers spending time in TB endemic areas of the world should receive counseling about:
1) the risks of TB exposure
2) strategies for minimizing exposure
3) signs and symptoms of active TB
4) the importance of pre and post-travel testing for LTBI
![Page 17: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/17.jpg)
• 41,168 people who sought medical advice after recent travel
•Risk of latent TB infection
•Short-term: 4/1000
•Long-term: 11/1000
Travel time %
< 1 month 60%
1-6 months 30%
> 6 months 10%
![Page 18: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/18.jpg)
• Peace Corp Epidemiologic Surveillance System 1996-2005
•44,070 volunteers
•801,780 volunteer-months
•1028 PPD conversions
•46 cases active TB
•Overall rate: 68.9 per 100,000
•Conversion rates (conv/ vol-mo):
•Africa region 1.467
•Central America 1.272
•Caribbean 0.994
![Page 19: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/19.jpg)
Rates of TB infection in students, trainees in an academic, international
medical exchange program (Adrian Gardner, E. Jane Carter)
Survey of 400+ travelers to Western Kenya (2004 – 2009)
![Page 20: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/20.jpg)
Methods and Preliminary Results
Survey program participants who traveled to Eldoret, Kenya in association with the AMPATH program between July, 2004 – June, 2009
Administered questionnaire via an online survey tool and by hard copy upon request
69% responded (N=418)
Analysis in progress
![Page 21: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/21.jpg)
Results: DemographicsAge (years)
18-21
22-30
31-40
41-50
51-60
>60
N (%)
6 (1.4)
167 (40.3)
110 (26.6)
57 (13.8)
53 (12.8)
37 (8.9)
Gender
Female 227 (54.8)
Medical History
No chronic medical illness 340 (93.4)
TB History
Negative test for LTBI
History of LTBI
Never tested for LTBI/Unknown
326 (80.5)
36 (8.9)
43 (10.6)
![Page 22: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/22.jpg)
*Other- PCP, Health center, previous travelers, self
![Page 23: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/23.jpg)
![Page 24: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/24.jpg)
Other includes safari trips, downtown restaurants/dance clubs, classrooms, weddings, operating room, pharmacy,TB clinic
![Page 25: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/25.jpg)
![Page 26: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/26.jpg)
47%
41%
9%
![Page 27: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/27.jpg)
Revealing Comments….
“I visited AMPATH, but was not involved in any of the TB work. Just wanted you to know that I will not be completing the survey.”
“I don't think I should be on this list. I took a short mission trip to Kenya but I know nothing about the TB testing. I do not remember any council specific to TB before we left, just general information about immunizations but the discussions focused more on malaria.”
“I work with SMILE providing laboratory support. The survey does not really apply to my experience in Eldoret. Therefore, I did not fill in the survey.”
![Page 28: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/28.jpg)
Results: “Ideal care”
Definition of “Ideal Care”– Pre-travel counseling on TB– Pre-travel TST within one year of departure– Post-travel TST related to travel
Only 28% of adult participants received “ideal care” (i.e. met all three criteria)
![Page 29: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/29.jpg)
Results: TST conversions
10 participants reported a negative pre-travel TST and + TST post-travel for a conversion rate of 2.7 - 3.8%. – Of those who reported TST conversion or active TB, 8 (3.2%)
reported participation in direct medical care vs. 3 (1.6%) reported no participation in direct medical care.
One participant reported active TB
66 children under the age of 21 years accompanied survey respondents to Kenya. – Of these, 26 (39%) had a TST upon return and 3 had a
conversion for a conversion rate of 4.5% - 11.5%.
![Page 30: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/30.jpg)
Rates of TB infection in students, trainees in an academic, international medical exchange program
• HCW and students are not receiving the pre-travel counseling they need
• Participants, especially non-HCW do not perceive their risk
• Program participants are not getting adequate pre-travel/post-travel screening
![Page 31: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/31.jpg)
Case 2: Clinical Course
She reports that the risk of TB was not discussed prior to her trip to China
Hepatotoxicity requiring discontinuation of PZA
Currently on R/I and tolerating well
![Page 32: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/32.jpg)
Case 2: Take Home Point
Students/volunteers/health care workers spending time in TB endemic areas of the world should receive counseling about:
1) the risks of TB exposure
2) strategies for minimizing exposure
3) signs and symptoms of active TB
4) the importance of pre and post-travel testing for LTBI
“Targeted testing” should include these individuals
![Page 33: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/33.jpg)
Case 3
36 yo F from Rhode Island– Referred to TB clinic in 2006 with +TST (22 x 22mm) done
with pre-natal screening– Father was from Cape Verde and had a history of TB in
1992 in RI. She was contact and had negative TST at that time. She also reported neg TST in 1997 when she worked at a homeless shelter
– Works in RI, no travel outside US
CXR: normal
![Page 34: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/34.jpg)
Case 3
Per protocol, LTBI therapy was deferred until post-partum
Scheduled for visit 3 mo post-partum
DNKA appt on 1/5/07, 2/1/07, 4/13/07. Per clinic protocol, memo sent back to her referral site and DOH.
![Page 35: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/35.jpg)
Case 3
2009- She is referred to TB clinic after a LN biopsy reveals……– NECROTIZING GRANULOMATOUS
LYMPHADENITIS – Special stains are NEGATIVE for mycobacteria
(AFB, Fite) and fungal organisms (GMS, PAS) – Cx of LN grew MTB (pan-susceptible)
What happened between 2006-2009?
![Page 36: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/36.jpg)
Case 3
July, 2006: She developed proteinuria during her pregnancy and HIV test performed during that work-up revealed that she was HIV+ (30 wks pregnant)– CD4 201, VL 101,372– Started on ARVs, followed closely in HIV clinic
viral load undetectable
Sept, 2006: Delivered healthy baby boy
![Page 37: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/37.jpg)
Case 3
Continued ARVs until August, 2007 then stopped and lost to follow up
March, 2008: Returned to HIV clinic but never re-started her ARVs
April, 2009: Returned to HIV clinic with 1 month history of fever, cough which resolved with azithromycin and prednisone.– Re-started on ARVs
![Page 38: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/38.jpg)
Case 3
April, 2009: – Admitted with watery diarrhea, nausea– no vomiting but unable to take meds, ARF– CT Abd/pelvis:
• Extensive RP lymphadenopathy• Lymph node biopsy was performed• Started on moxifloxacin with improvement in
fever, diarrhea
![Page 39: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/39.jpg)
Case 3
![Page 40: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/40.jpg)
Case 3
Pathology– NECROTIZING GRANULOMATOUS
LYMPHADENITIS – Special stains are NEGATIVE for
mycobacteria (AFB, Fite) and fungal organisms (GMS, PAS)
![Page 41: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/41.jpg)
Case 3
June, 2009– Cx of LN grew MTB (pan-susceptible)– Started on TB therapy
![Page 42: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/42.jpg)
Case 3
What went wrong between 2006-2009?
Missed opportunity• Better communication between providers/clinics• Patient kept her appointments• Someone in HIV clinic- thought about TB• Someone in TB clinic- thought about HIV
![Page 43: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/43.jpg)
HIV testing in TB clinic
HIV testing of active TB patients
What about patients with LTBI?– CDC guidelines (2006) recommend opt-out
HIV testing in all health care settings
![Page 44: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/44.jpg)
Extended back-calculation model to estimate the prevalence of undiagnosed HIV in US– Demographic and
behavioral groups
![Page 45: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/45.jpg)
![Page 46: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/46.jpg)
Rapid HIV testing in TB clinic
Pilot of opt-out HIV testing for all LTBI patients
![Page 47: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/47.jpg)
![Page 48: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/48.jpg)
Case 4
21 year old M presented to the emergency room with a six month history of neck pain and headaches.
– Over the last two weeks prior to admission he had worsening neck pain now with limited mobility. No trauma. He notes history of both fevers and chills but has not taken his temperature.
– 40 pound weight loss over 6 months.– No cough, sputum production, chest pain, nausea, vomiting,
anorexia.
![Page 49: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/49.jpg)
Case 4
Denies stumbling, weakness or loss of bowel or bladder control
He has no past medical problems and is on no medications
– He was born in Guatemala and has been in the US for two years. He works as a landscaper (heavy lifting and physical activity)
– No known history of exposure to TB. He has no animal exposure including domestic cats. He neither smokes nor drinks alcohol
– Lives with his brother. Denies any sexual partners
![Page 50: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/50.jpg)
Case 4
Physical Examination:
T 99 HR 109 BP 136/82 Gen: Uncomfortable due to neck pain HEENT: Unremarkable except limited range of motion of his
neck. Moderate tenderness diffusely over the posterior neck, no discernable mass or adenopathy
Chest: clear to auscultation bilaterally Neurologic: alert and oriented. Cranial nerves II-XII were intact.
Sensation intact to light touch and pinprick throughout. Reflexes 2 + (biceps, triceps, patellar and Achilles). Normal rectal tone.
![Page 51: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/51.jpg)
10.236.2
N:85 L:8 M:6.0 E:0 Bas:0 AST: 18
ALT: 14
AP: 66
T. bili: 0.7
12.6383
13
0.7
Case 4
![Page 52: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/52.jpg)
Case 4
CXR: Clear lung parenchyma, suggestion of a paratracheal soft tissue density on the right and left hilar fullness
Cervical spine x-ray: unremarkable
![Page 53: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/53.jpg)
Case 4
![Page 54: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/54.jpg)
Case 4
Admitted to the hospital for pain control and diagnostic work-up. – ENT consulted and an US-guided biopsy of pharyngeal mass was performed from a posterior
approach. Specimens were collected for cytology and revealed necrotizing granulomatous inflammation with no sign of malignancy, gram stain/AFB stain negative.
– TST positive, HIV negative
– Sputum smear neg x 3, BAL smear neg. Given the patient’s background, the diagnosis of tuberculous osteomyelitis with mediastinal adenitis and retropharyngeal abscess was considered to be most likely. The patient was started on four drug anti-tuberculous therapy with Isoniazid, Rifampin, Pyrazinamide and Ethambutol.
Two and a half weeks later, the biopsy specimen, BAL fluid, and all three sputa grew Mycobacterium tuberculosis.
Diagnosis: TB osteomyelitis of C1-2 with retropharyngeal abscess and intrathoracic nodal involvement.
![Page 55: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/55.jpg)
TB Vertebral Osteomyelitis
Pott’s disease– 1-2% of TB cases
Many case series re: role of surgery– Debridement vs. debridement + stabilization
Cochrane Review– Routine surgery in addition to chemotherapy for treating
spinal tuberculosis (2010)
Outcomes– Mortality, TB cure– Kyphosis angle, neurologic deficits, pain, bone loss, activity level
![Page 56: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/56.jpg)
TB Vertebral Osteomyelitis
Debate goes back to 1960s
Possible indications for surgery– Non-diagnostic biopsy – Neuro deficit caused by cord compression– Spinal instability caused by destruction of
vertebrae or kyphosis > 30°– No response to chemotx– Large para-spinal abscess
![Page 57: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/57.jpg)
TB Vertebral Osteomyelitis 2 randomized controlled trials (N=331)
– 1964-69 (BMRC), 1975-78 (BMRC-ICMR)
– Pts with thoracic/lumbar disease (T1-S1)– All able to walk at entry– Pts with total bone loss > 3 Units excluded
– chemotx alone (I/PAS18 +/- strep3) vs. chemotx (I/R6) + surgery
• One debridement, one debridement and reconstruction– Follow-up at 1.5, 3, 5, 10 yrs
![Page 58: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/58.jpg)
TB Vertebral Osteomyelitis
Conclusion:– Data insufficient– No statistically significant benefit of routine
surgery
Limitations– Now using better medical and surgical tx
![Page 59: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/59.jpg)
TB Vertebral Osteomyelitis
Outcome ConclusionKyphosis Probably no difference (? Age <15)
Neuro deficit No difference*
Pain Neither trial evaluated pain
Bone fusion No difference
Death, Absence of TB
No difference
Regained activity
No difference
Bone loss No difference
Adverse events 4 deaths due to surgery, 7 bone graft failures
![Page 60: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/60.jpg)
Case 4
Our patient did not have any neurological deficits and did not require surgery
He recovered completely with medical therapy
![Page 61: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/61.jpg)
Thanks!
Jane Carter and Phyllis Losikoff
![Page 62: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/62.jpg)
![Page 63: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/63.jpg)
![Page 64: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/64.jpg)
Case 5
87 yo F from Peru US (1969)
PMH:– HTN– Hyperlipidemia– GERD– H/o BRCA s/p L
mastectomy– R TKR (2006); L TKR
(2007)– h/o LTBI s/p 12 mo INH
Family History: Mother died from TB in 1932 when patient was 10 years old
SH: Travel to Venezuela, Peru. No TB contacts
![Page 65: Case Presentations](https://reader036.vdocuments.us/reader036/viewer/2022062500/568152b7550346895dc0daa3/html5/thumbnails/65.jpg)
Case 5
CC: R knee pain worsening over 5 months refractory to medical mgmt and s/p fall
ROS: 30 lb weight loss, fatigue R knee arthrocentesis
• WBC 3780 (92P…), RBC 1260• WBC 6000 RBC 4680
L knee arthrocentesis• WBC 4500 (94P ) RBC 600