pitfalls in tb
TRANSCRIPT
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Pitfallsin
TBmanagement
.
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TheGreatImitator
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DiagnosisOver:cavit miliar NTM etc.
Under,delayeddiagnosis
Treatment
inappropriateregimen
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DiagnosisOver:cavit miliar NTM etc.
Under,delayeddiagnosis
Treatment
inappropriateregimen
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.
2.Laboratorydiagnosis
Radiologicaldiagnosis
Bacteriologicaldiagnosis
Moleculardiagnosis
pitfall
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60
Currentsmoker
1
SputumAFB:neg x3
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Estimatedbacterialpopulationswithin
erentTB es ons.
SmearpositiveTB 107109 bacilli
Cavitation 107109 bacilli
Infiltrating 104107 bacilli
Nodules 104106 bacilli
4 6
RenalTB 107109 bacilli
xtrapu monary ac
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CT:cavitating mass
TBBx :adenocarcinoma
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DiagnosisofTBisunlikely
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Infection
Tuberculosis
Nontuberculous
Nocardiosis
Fungalinfections
Histoplasmosis
CryptococcosisViralinfections
Pneumoconiosis
Sarcoidosis
Metastases Histiocytosis X
Am loidosis
Alveolarmicrolithiasis
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Miliary lesions
PredictorsofTB
BMC
Infect
Dis 2008,8;160
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Clinicalsuspicion
ofdisseminated
TB
HighsuspicionofTB
Weightloss,feverandcough
AbnormalCXRmiliary patternLargespleen/liver
Anaemia
Rigors
Verybreathless(respiratoryrate>30/min)
Severediarrhoea
BloodinstoolPositivecryptococcal Ag
malariasmearorlikelypathogen
isolatedfrombloodC/S
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Case:RUL
opacity
60
Currentsmoker10py
.
SputumAFB:negative
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Impression
Rx:HRZE
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Otherinfection
Ma ignancy
LungcarcinomaMesothelioma
Autoimmunedisease
eumato art r t s
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na agnos s: ung
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CXR : usua y sma to mo erate uni atera
effusion
: rare y mass ve e us on
Associated parenchyma : 2080%
Rarely mesothelial cells > 5%
.
AFB stain : + < 510%
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DiseasewithhighADAinPF
Rheumatoidarthritis,Bronchoalveolar carcinoma,
Mesothelioma,
Mycoplasma andchlamydiapneumonia
Infectiousmononucleosis
Brucellosis
Histoplasmosis,Coccidioidomycosis
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Immunologicaldiagnosis
PCR:reliable?
PCR:reliabilit isvariableinsmearne ativeTB
:techniquesthatamplifyRNA:morereliable
:sensitivit 5080% false ositive15%
:falsenegativeresultsgeneratedby
nonrespiratorysamples
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HighsuspicionofTB
UnilateraleffusionPleuralfluidisclearandstrawcoloured
Clotsonstandinginatubewithoutanticoagulants
Weightloss,nightsweats,fever
EvidenceforTBelsewhere
FindingsthatsuggestanonTB
Bilateraleffusion
ClinicalmalignancyPleuralfluidiscloudy/pus(probableempyema)
Failstoclot doesnotexcludeTB
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Approachtothediagnosisof
presume p eura
Lymphocyticexudative pleuraleffusionin
:40 years
riskfactors forCAnegativepleuralfluidorbiopsy
a
pleuroscopy
before
starting
empirical
Rxisindicated
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AFB CXR
World Health Organization (WHO) smearnega ve
50
()
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70
10
1
CXR:TB
Rx:HRZE: SputumAFB2:1+,2+,1+
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mycobacterium S utumC S 51 :no rowth
Diagnosis
:Nontuberculous mycobacterium Rx:Clarithromycin +Imipenem
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ImpactofNTMinsputumorbronchialwashing
Crevel RV,
et
al.
Infection
2001;29
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Characteristicof86patientswithTBandNTM
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Clinical
1.+symptoms,nodularorcavitary opacitiesonCXR,oranHRCTscanthatshowsmultifocalbronchiectasis
withmultiplesmallnodules.
2.exclusionofotherdiagnoses
Microbiologic:oneofthefollowings
1.positiveC/Sof2samplesofseparatesputum
2. ositiveC/Sof1sam leofBALorwashin
3.lungbiopsywithmycobacterial histopathologic featuresandpositiveC/Sof1sampleofanysputumor
BAL washin
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.
NTM(preexistingstructurallungdisease)
NTMcolonization
Theriskofuntreatedactivetuberculosismustbe
weighedagainsttheconsequencesofanincorrectdiagnosis.
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40 mentalretardation
4 c, m n
Lungs:crepitation anddecreasedBSLtlung
gramstain: fewWBC,fewgrampositivecocciandgramnegativebacilli
: not oun pleuralfluidanalysis: neutrophilic exudate
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1
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: Nonres ondin neumonia
TBBX: granulomatous inflammation
nomali nantcells AFB : positive
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Neutrophilic exudate pleuraleffusion
:earl TB leuralfluid
neutrophillymphocyte
Nonresolvingpneumonia:
:TBpneumonia
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Case:Hilar enlar ement
CXR
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CTscan
Nextinvestigation?
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AFBnoninvasive
f
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DDx ofTB
OtherpulmonaryInfection Malignancy
:Cavitatorycausing bacteria
Staphylococcus
(bilateral
)Klebsiella (unilateral)
squamous cellCA
AlveolarcellCALymphoma
Melioidosis
:InHIVpositivepatients
Leukaemia (solitarylesion)
Vasculitides
Cytomegalovirus
Kaposissarcoma
Rheumatoidnodule
Organising pneumonia(usually
:NTM(inbronchiectasis orCOPD)
:Viralpneumonia
mu p e es ons
Pulmonaryinfarction
Fibroticdisease
Extrinsicallergicalveolitis
Sarcoidosis
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ConsidercommonmedicalriskfactorsforTB
Davies
PDO.
Int
J
Tuberc
Lung
Dis
2008;12
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Conclusions:Pitfalls&CluesinDia nosis
AFBTB
AFB Atypicalpresentation:
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Diagnosis
Over:cavit miliar NTM etc.
Under,delayeddiagnosis
Treatmentinappropriateregimen
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AFB:positive
2+
HRZE:
+
?
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Smearconversion :~6090%
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conversion2
poorcompliance
slowrateofconversion
:extensive
cavitation
:heavyinitialbacillaryload
initialdrugresistance(rare)
HRZE1
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+
AFB:positive2+
2HRZE/4HR:
+
?
WHO guideline for CAT II
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WHOguidelineforCATII
?
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?1.
HIV ositive
contactMDRTB
2. :CATICATII
stillsmear+at3rd
motreatmentfailure
TAD
3.
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CATIfail 3K5OPEZ/15OPEZ
CATIIfail 3K5OPEtZ/15OPEtZ
2
3K5OPEZ/3K3OPEZ/12OPEZ
3 3K5OPEtZ/3K3OPEtZ/12OPEtZ
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4
(FQ) 6 PZA,ethambutol,FQ 1
smearnegativeculturenegative
18cultureconversion
PZA(inflammed lungacidity)
treatment failure
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treatmentfailure
Pitfall:
treatmentfailure
Clue:
CATI
DOTCATII
treatmentfailureCATIV(WHO)
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Treatmentafterinterruption:CDC
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Intensivephase Continuousphase
80%
initial
+misseddose
smear++missed
ose6
ActionininterruptionofTBRx:WHO
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microbiology
Case1 :5152
Case2 :4952
:management2
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ro ease n ors
rifampicin +2NRTIs
nonhormonal Rxestrogen>50
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Noconversionat2nd month A itiono asing e rugtoa ai ingregimen
Failureto identifypreexistingoracquireddrugres stance
Initiationofan inadequateprimaryregimen
Failuretoidentifyandaddressnoncompliance
W r nin f l i n Para xical r acti n
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W r nin f l i n Para xical r acti n
Fever,enlargementofLN,worseningofchest
Prevalence :HIV+antiTB+HAART 36%
:HIV+antiTB 7%:nonHIV+antiTB 215%
Dueto:restoresaneffectiveTh1immuneres onse
totuberculous Ag selflimitedandgenerallylastfor1040days
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Overallprevalence:upto20%
EPTB:PTB=4:1
mediantimetoonsetofCNSmanifestation>othersites. .
VerycommoninTBlymphnode
:prevalence23%
:onset =me an4 aysa terRx 11
:persisting=medianof67.5days(34111d)
Developmentofnewlesionsinanatomicalsites
otherthan thoseobservedatinitialpresentationwasobservedin25%
Hawkey CR,etal.Clin InfectDis 2005;40
ChengVC,etal.Eur JClin Microbiol InfectDis 2002;21
1majoror2minorcriteria:paradoxicalreaction
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Major
1 New enlar in l m hnodes coldabscessesorotherfocal
tissueinvolvement
2)NeworworseningradiologicalfeaturesofTB
4)Neworworseningserositis (ascites,pleuralorpericardial
effusion)
Minor
1)Neworworseningconstitutionalsymptoms
3)Neworworseningabdominalpainwithhepatosplenomegaly,abdominalLN(onU/S)
changeinTBRx
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Exclusion of alternative ex lanation
FailureofTBRxorARTduetodru resistance PooradherencetoRx
Drugtoxicityorreaction
Treatment of aradoxical reaction
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Treatmentof aradoxicalreaction
Immunomo u at on
Corticosteroids(Useful?Duration?Dose?)
similarinthegroupsofpatientswhodidordidnot
receivesteroidRx(medianduration,64vs.68days;P=0.6)
s
Other
ARTinterru tionandreART reintroductionundersteroid
cover(especiallyneurologicalTB) Drainageprocedures
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Dia nosis
:nondiagnosticcytology???
Duringtreatment
:increaseinsizeofLN???
AttheendofRx
:
persistent
enlargement
of
LN
???
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HighsuspicionofTB
>2cm
asymmetrical/localized
pa n ess
cervical
wei htloss ni htsweat fever inHIV
FindingsthatsuggestnonTB
symmetrical(lymphomaorHIV)
tender,inflammed,purulent(bacteriaorfungus)
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Increaseinsize
=
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DuringRx
SizeofLN decreasesveryslowly(overweeks or
20%: insizewithinthefirst2months
10%:localcomplicationsincludingulceration,
fistula,orabscess
AttheendofRx
91.7%:normalsize8.3% :nofurtherenlargement
GeldmacherH,etal.Chest2002;121
Conclusion : Pitfallsin TB mana ement
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Diagnosis
Over:cavit miliar NTM etc.
Under,delayeddiagnosis
Treatmentinappropriateregimen
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