Pitfalls in Tb

7/24/2019 Pitfalls in Tb

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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.


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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51


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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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40

: 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.


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.


Treatmentinappropriateregimen


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Pitfalls in Tb

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