tuberculosis and cocci...tuberculosis and cocci webinar december 5, 2019 presented live, via the...

Tuberculosis and Cocci Webinar

December 5, 2019

Presented live, via the Internet from Curry International Tuberculosis Center

Berkeley, California 1

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Tuberculosis and CocciA National Webinar

Identifying Coinfectiona Public Health Approach

Tuberculosis

+

CocciEvan Timme –AZ TB Control


December 5, 2019



No known disclosures or

conflicts of interest

Surveillance Epi

Objectives

describe a public health approach to identifyingpersons with tuberculosis cocci comorbidity

identify TB-only & TB-Cocci differences


December 5, 2019



Public HealthTB Data

200+

2009-2016TBCocci

http://theoldmotor.com/?p=162836

TBCocci

~73,000

Camden, NJ

~1,750

2009-2016


December 5, 2019



TBCocci

Total TB

1,743

TB-Cocci TB-only

1,586157

9%


December 5, 2019



What about Cx positivity?

TB-Cocci is less likely to be Cx(+), right?


December 5, 2019



What about country of birth?

How does Completion of Tx look?


December 5, 2019



Cavitary Chest Imaging

Miliary Chest Imaging


December 5, 2019



Lastly, time between TB & Cocci work-up

TB-Cocci TB-Only

MTB Cx(+)

US-born

Tx Completed

Cavitary

Miliary

50% of TB-Cocci worked-up ≤30-days


December 5, 2019



ExamplesHighlights

Clinical Points of Interest

Cherie Stafford, RN, MSN/MPH

TB Nurse Coordinator

Arizona Department of Health Services

3

Disclosure

• Nothing to disclose

• These are best described as case examples. ADHS does not provide direct patient care. In Arizona,

direct patient care is provided by local health departments, as well as hospitals and correctional

facilities.

• In this presentation, Cocci = Coccidioidomycosis aka Valley Fever


December 5, 2019



There is value for TB programs in “thinking cocci” when “thinking

TB”

• 38 year old, US born white male, hospitalized in another state with possible TB. LUL cavity on x-ray. Public health concern as he is an airline pilot who travels internationally.

• Plan: 3 sputums for AFB smear and culture, including NAA.

• Statistically, most likely to be cocci. Online clinical resources on Cocci available.

1

Clinical Snapshot• Chief complaint: worsening cough and chest tightness x 5

days. Non-productive cough associated with left sided chest pain. Patient self reported crackles on breathing. Denies fever, hemoptysis, change in weight, nausea, vomiting, or wheezes.

• X-ray: LUL cavitary lesion. • CT: 3.3 x 3.7 x3.9 cm LUL cavitary mass with a RUL 6 mm

nodule.

• QFT: negative

• AFB smear neg x 3 on sputums (collected >8 hr apart). • AFB smear neg on BAL.

• Cocci IgG: positive (0.557)

• Cocci CF Antibody: 1:8

Ruled out as “not TB”All 3 sputums & BAL sent for AFB culture. Did not

grow out MTB.


December 5, 2019



7,636 reported cocci

2018AZ

44x’s

178reporte

d TB

Cocci diagnosis does not exclude TB

disease2

62x’s


December 5, 2019



Clinical Snapshot

50 yr old, white, US born male. Retired from US military >10 years ago,

including overseas deployments to Asia. Former smoker with 25 year pack

history. Quit 9 years ago.

Month 0: onset of symptoms: cough, night

sweats, unintentional weight loss, fatigue

Month 3: Xraydetected cavitary

lesion LUL. Started

fluconazole

Month 5: Biopsy showed non-necrotizing

granulomatous inflammation with necrosis. AFB stain neg. Referred for

sleep apnea.Month 7: new diagnosis DM

Month 9: LUL lobectomy. Cavity had increased despite 5 months

of Fluconazole. Had lost 60+ pounds over 8 months. BMI 27.8

Lung Fluid 4+ AFB. Necrotizing

granulomatous inflammation with

numerous mycobacteria.

Day after surgery: QFT done. Positive.

5 days after surgery: 1st

sputum collected. NAA detected MTB. Smear negative. RIPE

started.

1st month of TB treatment: readmitted to hospital for reasons not related to TB

By 4th month of TB treatment: Symptoms resolved. Back at

work. Switched from 7 days/wktreatment to 3 days/wk DOT with 900 mg INH and 600 mg RIF. Susceptible to all first line

medications. Genotype associated with the Philippines.

No epi link within Arizona.

6 months: Treatment completed.


December 5, 2019



TB (even with concurrent cocci) is

curable3

Clinical Snapshot

• 60 yr old, white US born male. Smokes 1 ppd. DM. Hospitalized for 6 weeks for:

• Disseminated TB involving bone marrow, adrenal and pulmonary tuberculosis (started tx 3 1/2 wks after admission)

• Coccidiodomycosis• Acute respiratory failure &

pneumonia (resolved)• Sepsis with associated

hypotension (resolved)• Hemorrhagic shock (resolved)• Acute renal failure (resolved)

• Chief complaint: Abdominal pain, headache, SOB. Subjective fevers, no weight loss. Denied cough. 6 months history of mediastinal lymphadenopathy, lost to follow up due to insurance issues.

• TB suspected when granulomatous disease found on bone marrow biopsy as well as adrenal and lung biopsy.

• QFT done and came back positive.

• Smear neg BAL grew out MTB.

• Xray abnormal: interstitial markings throughout both lungs.


December 5, 2019



Successful outcome with outpatient TB management

• Case management challenges included insurance issues. Local TB program worked to get him on insurance. Also ensured that he was able to get access to Fluconazole.

• After release from hospital, successfully treated for 39 weeks for Pansusceptible TB.


December 5, 2019



Coccidioidomycosis (Valley Fever)What Is It and How Is it Different

FromTuberculosis


December 5, 2019

John N Galgiani MD

Banner-University Health Valley Fever Program

Disclosures

Drs. Galgiani

Has no conflicts of interest to disclose


December 5, 2019



What Is Valley Fever?

• Caused by soil fungiCoccidioides immitis

Coccidioides posadasii

• Other names:

– Coccidioidomycosis

– “COCCI”

• Inhalation of one spore

causes infection

• Spectrum of disease

– Sub-Clinical: 60%

– Self-Limited: 30%

– Complicated: 10%

• After infection, most

persons develop life-

long immunity to a

second infection

Valley Fever Endemic Regions


December 5, 2019



The Valley Fever Corridor:

2/3 of all U.S. disease occurs here

Valley Fever in Non-endemic States

Benedict et al.

EID, 2018


December 5, 2019



Valley

Fever

Center for

Excellence

Valley Fever in the U.S.150,000-

15,000-

1,500-

150-

15-

Total Infections

Seek Medical Attention

Diagnosed/Reported

Disseminated Infection

Deaths

75% Stopped working,

50% lost > 2 weeks

50% Illness >4 months

40% Hospitalized (Az)

Cost=$700M (CA, 2017)

Total US Impact: >$1 B/year

Common “Mild” Self-Limited Valley Fever

Signs and Symptoms, < 1 months from exposure:

– Cough, chest pain, fever, weight loss

– Fatigue

– Bone and joint pains (a.k.a. Desert Rheumatism)

– Skin rashes (painful or intense itching)

Course of illness:

– Weeks to months

– 25% of college students are sick for > 4 months

– 50% of workers lose > 2 weeks


December 5, 2019



Arizona CAP– ~ 25% - 30% due to Coccidioides

BUT

– < 15% are tested for Coccidioides

~ 1,000 new AZ medical licenses/year– 12% received MD in AZ

– 40% no AZ GME

80% didn’t know: – VF is reportable

– Vaccine does not exist

40% of clinicians are not confident to treat VF

Current Clinical Practice for

Valley Fever in Arizona

All Cocci Diagnoses in Az Banner Health, 2017-19

Only 247 out of 1,812

unique patients (13.6%)

who were newly

diagnosed as Cocci in

primary care clinics

(orange bar)

Dots indicate percent of

patients receiving anti-

bacterial drugs.


December 5, 2019



Delay of Valley Fever Diagnosis

BUMC-P45% of Diagnoses

Delayed > 1 month

Ginn et al. EID, 2019

0 30 60

0

50

100

120 360 600 840

Figure 1.

Days of Delay until Diagnosis

Perc

en

tag

e D

iag

no

sed

Asymptomatic

Acute Pulm

Chron Pulm

Dissemin

Delay of Valley Fever Diagnosis

BUMC-T43% of Diagnoses

Delayed > 1 month

Donovan et al. EID, 2019


December 5, 2019



What Do Weeks of Delayed Diagnosis Mean?

• Unnecessary anti-bacterial drug use

• Protracted patient anxiety and fear

• Over-utilization CT scans and

bronchoscopies, even thoracotomies

Hypothesis: Earlier diagnosis would

improve outcomes and reduce cost

Available online:

VFCE.ARIZONA.EDU


December 5, 2019



Primary Care of Coccidioidomycosis

C onsider the diagnosis

O rder the right tests

C heck for risk factors

C heck for complications

I nitiate management

Consider the diagnosisRespiratory: Previous visit, needs X-ray or antibacterial Rx?

Musc/Skel: More than one week, associated with fever or

fatigue.

Rashes: E. nodosum or E. multiforme

CConsider the diagnosis

Respiratory: Previous visit, needs X-ray or antibacterial Rx?

Musc/Skel: More than one week, associated with fever or

fatigue.

Rashes: E. nodosum or E. multiforme

Clinician reviews chief

complaint(s) and medical

history, examines patient,

and documents findings

( HPI, ROS, PE)

Syndrome:

respiratory?

musculoskel?

rashes?

Valley Fever

Process Completed

Go to:

Order

the

right

tests

Yes

Add

Valley Fever

to the

Differential

Endemic

Exposure?

residence

or recent

travel

No

No

Yes


December 5, 2019



Have you diagnosed a patient with Valley

Fever in the last 12 months?

A. Yes

B. No

Have you tested for Valley Fever in the

last 12 months?

A. Yes

B. No


December 5, 2019



Number of Clinicians for Each Test

Count

BMG and BUMG, total, 2018

Total Clinicians: 223

# ≤ 2 tests ordered: 119

% ≤ 2 tests ordered: 53%

Table 5. Consider testing for coccidioidomycosis

if endemic history and any of the following:

• Respiratory symptoms plus one of:

– More than 1 office visit

– Chest X-ray ordered

– Antibiotic prescribed

• Two of the following for a week or more:

– Fever, Fatigue, Arthralgia

• Unexplained peripheral blood eosinophilia

• Skin lesions of:

– Erythema nodosum or Erythema multiforme


December 5, 2019



Order the right testsEIA screen for coccidioidal antibodies with reflex to �

immunodiffusion and quantitative CF.O Order the right tests

EIA screen for coccidioidal antibodies with reflex to

immunodiffusion and quantitative CF.

Order EIA

screen for

coccidioidal

antibodies

Illness resolved in

3 weeks

Valley Fever

Process Completed

Go to: &

Check for risks and

complications

Yes

No

Test

Positive

Test

Negative

Order the Right Tests:

EIA screen for Coccidioidal Antibodies

Enzyme Immunoassay (EIA) test

–A positive test is very specific and

usually is diagnostic.

–A negative test never rules out

Valley Fever. Repeated testing

improves diagnostic sensitivity.


December 5, 2019



Check for Risk FactorsImmunosuppression (HIV, organ recipient, Rheum/GI/Derm

response modifier Rx, renal failure

Diabetes, major cardiac or pulmonary comorbidities, pregnancyC

Check for Risk FactorsImmunosuppression (HIV, organ recipient, Rheum/GI/Derm

response modifier Rx, renal failure)

Diabetes, major cardiac or pulmonary comorbidities, pregnancy

Risk factors

present?

No

Complicated VF:

Refer to Specialist

(ID or Pulmonary)Yes

Go to: Management,

Uncomplicated infect.

Risk Factors

Pulmonary Complications

–Diabetes mellitus

–Cardio-pulmonary or other co-morbidities (Evidence: “common sense”).

Disseminated Infection

– Major and critical

• Cell immunodificiency

• Pregnancy

– Minor and small effect

• Males > Females

• Racial background

• Adults > Children


December 5, 2019



CCheck for complications evident by physical

exam or imagingFocal ulceration or skin/soft tissue inflammation.

Asymmetric skeletal pain, joint effusions.

Progressive or unusual headache.

Risk factors

present?

Complications

present?

No No

Complicated VF:

Refer to Specialist

(ID or Pulmonary)Yes

Yes

Go to: Management,

Uncomplicated infect.

Check for Complications

Detecting Focal Lesions

in Coccidioidomycosis

• Review of Systems: Pain or discomfort

– Headache

– Back pain

– Joint pain or loss of function

• Physical Examination:

– Skin lesions

– Subcutaneous fluctuation

– Joint effusions


December 5, 2019



Disseminated

Coccidioidomycosis

Disseminated

Coccidioidomycosis


December 5, 2019



Check for Complications

• Most complications are focal

• A review of systems and physical

examination will usually detect or

exclude the possibility of

complications.

• New focal findings warrant either

evaluation or referral for Infectious

Diseases or Pulmonary consultation.

Primary Care of Coccidioidomycosis

C onsider the diagnosis

O rder Cocci Serologies

C heck for complications

C heck for Risk Factors

+

N

Specialty

Referral

Retest-

I nitiate management

N

Repeate

d e

valu

ations


December 5, 2019



Management

Low Risk, Simple Early Infection

• Follow-up office visits

• Serial body weights

• Check for new symptoms or signs

• Repeat coccidioidal antibody testing

• Repeat Chest PA and Lateral X-rays

• Most patients do not need therapy

Clin Infect Dis, 2016


December 5, 2019



2016 IDSA Guidelines

Treatment of Coccidioidomycosis

“It should be emphasized that no

randomized trials exist to assess

whether antifungal treatment either

shortens the illness of early

uncomplicated coccidioidal infections

or prevents later complications.”

Median days to ≥50% decline

in total clinical score

P = 0.899

Ampel et al. CID 2009


December 5, 2019



Outcome of Subjects(> 1 month follow-up)

• 50 not treated– Median follow-up: 3.1 years

– All without complications

• 51 treated– Median follow-up: 2.9 years

– 38 off-therapy and without complications

– 5 remained on treatment

– 8 had relapses• 5 with pulmonary disease

• 3 with extrapulmonary dissemination

• Relapses occurred up to 2 years after stopping treatment

Ampel et al. CID 2009

Valley Fever Can Look Like TB

• Illness is often subacute or chronic

pulmonary syndrome.

– Nights sweats, weight loss, hemoptysis

and fatigue are common symptoms.

– Treatment for bacterial pneumonia has

failed is a common history.

– Chest X-rays may show fibrocavitary

lung lesions.


December 5, 2019



TB or Cocci?

TB or Cocci?


December 5, 2019



TB or Cocci?

The Binational Project improving the Diagnosis and Surveillance of Coccidioidomycosis in the

Border Region of “Four Corners” Arizona-Sonora and New Mexico-Chihuahua

Dra Nubia Hernandez , Orion McCotter, Katherine Perez-Locket, Mariana Casal, Cristhian Tapia, Robert Guerrero, Dr. Gumaro Barrios, Dr Francisco Navarro Galvez, Olvera Alba Sergio, QC Rosario Aguayo, Frida Adams, Marta Alicia Bueno, Cesar Vera, Gloria Carrete, Ken Komatsu

Secretaría de Salud Pública de SonoraSecretaría de Salud Pública de Chihuahua

Arizona Department of Health Services New Mexico Department of Health Services


December 5, 2019



Algorithm for detection, notification and sample for Coccidioidomycosis cases.

Possible Tuberculosis caseNotification due to epidemiological study and

identification of case in TB platform

Serum sample100% cases,100% deaths

Sample send to PH laboratory with copy of TB epidemiology study

PH laboratory: testing IgG/IgM for Coccidioidomycosis

Reactive (+)

For one or both Ig’s

Undetermined result

Process againNon reactive (-)

For one or both Ig’s

Report positive (+) result with the specific reactivity

InDRE/PH lab: immunodiffusion confirmatory test and report InDRE

results

Report negative (-) result to both Ig’s

FINAL classification of the case by the Notification Unit. Consider clinical, epidemiological and laboratory criterias.

Sonora Preliminary Results

Positive samples 2012-2013

IgM IgG 9

IgG 13

IgM 5

Total samples 2012-2013

samples tested 159 17%

Negatives 132


December 5, 2019



New Banner Clinical Practice for

Ambulatory Management of Valley Fever

Thank-You

Valley

FeverCenter for

Excellence

For more information:

http://vfce.arizona.edu/toolkit


December 5, 2019



TB and Cocci – what else?

Marcos Burgos, MD

Professor of MedicineUNM School of Medicine

Medical Director TB ProgramNM Department of Health

Section Chief, Infectious DiseasesNew Mexico VA Health Care System

Valley Fever in Non-endemic States


December 5, 2019



Presenters

Evan Timme, MPH

TB Control Program

Office of Disease

Integration and Services

Arizona Department of

Health Services

Cherie Stafford, RN, MSN/MPH

TB Control Program

Office of Disease Integration and

Services

Arizona Department of Health

Services

Diana Fortune, RN, BSN

Former New Mexico Department

of Health TB Program Manager

Transitioning to NTCA

National TB Nurse Consultant

(moderator)

Marcos Burgos, MD

Professor of Medicine

University of New Mexico School of Medicine

Medical Director Tuberculosis Program

New Mexico Department of Health

Section Chief, Infectious Diseases

New Mexico VA Health Care System

John Galgiani, MD

Director, Valley Fever Center

for Excellence

Professor, Medicine

University of Arizona College

of Medicine

tuberculosis and cocci...tuberculosis and cocci webinar december 5, 2019 presented live, via the...

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