Pleural Effusion and +PPD
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Pleural Effusion Pleural Effusion and +PPD and +PPD Sandy Valmadrid, MD Sandy Valmadrid, MD 13 December 2006 13 December 2006
description
Pleural Effusion and +PPD. Sandy Valmadrid, MD 13 December 2006. Case. EH, 56 yo nonsmoker Shortness of breath, fever, night sweats Dc’d 3 days ago, St. Mary’s Hospital 102 fever, sob, cough WBC 19.3, neutrophilic predominance Cxray: RLL pneumonia Sputum: Streptococcus pneumoniae - PowerPoint PPT Presentation
Transcript of Pleural Effusion and +PPD
Pleural Effusion and +PPDPleural Effusion and +PPD
Sandy Valmadrid, MDSandy Valmadrid, MD13 December 200613 December 2006
CaseCase
EH, 56 yo nonsmokerEH, 56 yo nonsmokerShortness of breath, fever, night sweatsShortness of breath, fever, night sweatsDc’d 3 days ago, St. Mary’s HospitalDc’d 3 days ago, St. Mary’s Hospital
102 fever, sob, cough102 fever, sob, coughWBC 19.3, neutrophilic predominanceWBC 19.3, neutrophilic predominanceCxray: RLL pneumoniaCxray: RLL pneumoniaSputum: Streptococcus pneumoniaeSputum: Streptococcus pneumoniaeMoxifloxacin, O2, LOS 7 days Moxifloxacin, O2, LOS 7 days
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Comorbidities:Comorbidities:Chronic Venous Insufficiency, bipedal edemaChronic Venous Insufficiency, bipedal edemaMild MR, TR, EF 65%Mild MR, TR, EF 65%DVT, chronic anticoagulationDVT, chronic anticoagulationAnemia Hct 28%, recent dental bleedingAnemia Hct 28%, recent dental bleedingDM 2, diet controlledDM 2, diet controlledHypertensionHypertensionAbdominal HerniaAbdominal HerniaObese (BMI 37), Chronic OA painsObese (BMI 37), Chronic OA pains
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MedicationsMedicationsFurosemide 40 mg, KCl 20 meq QAMFurosemide 40 mg, KCl 20 meq QAMWarfarin 5 mg QPMWarfarin 5 mg QPM? Atenolol 50 mg QAM? Atenolol 50 mg QAMAmlodipine 10 mg QAMAmlodipine 10 mg QAMClonidine 200 mcg QAMClonidine 200 mcg QAMPRN Acetaminophen/Codeine QIDPRN Acetaminophen/Codeine QIDPRN Zolpidem, OTC’s PRN Zolpidem, OTC’s
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sob, sweatssob, sweats 148/70, 104 bpm, 26 bpm, 99.2 F148/70, 104 bpm, 26 bpm, 99.2 F O2 sats RA 87%, with 2Li 96%O2 sats RA 87%, with 2Li 96% Pale, coughing, short sentencesPale, coughing, short sentences decreased bibasilar breath sounds, depth decreased bibasilar breath sounds, depth
rhonchi clears with coughrhonchi clears with cough CXray: small bibasilar effusions, R>LCXray: small bibasilar effusions, R>L
Moxifloxacin, O2, incentive spiro, watch Moxifloxacin, O2, incentive spiro, watch
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+2 weeks+2 weeksFeels “worse,” some sob, sweats, Feels “worse,” some sob, sweats,
nonproductive coughnonproductive coughO2 sats RA 95%, 97.8 FO2 sats RA 95%, 97.8 FWBC 9.3WBC 9.3CXray: mod sized R pleural effusion, small LCXray: mod sized R pleural effusion, small LPneumonia with parapneumonic effusion or Pneumonia with parapneumonic effusion or
something elsesomething else
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PleurocentesisPleurocentesis WBC 2,175WBC 2,175
Neut 0%Neut 0% Lymph 80%Lymph 80% Mphag 9%Mphag 9% Eos 3%Eos 3% 0thers 0%0thers 0%
RBC 23,150RBC 23,150 Protein 5.2 (s8.0)Protein 5.2 (s8.0) LDH 198 (s240)LDH 198 (s240)
GS and CulturesGS and Cultures NegativeNegative AFB not doneAFB not done Cytology NegativeCytology Negative
?? Infection, TB, ?? Infection, TB, mesothelioma, mesothelioma, malignancy, PEmalignancy, PE
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+TST skin test 20 mm+TST skin test 20 mm
CT ThoraxCT ThoraxR pleural effusion, small R pleural effusion, small RUL nodular (up to 14 mm) airspace disease RUL nodular (up to 14 mm) airspace disease
w/ surrounding ground glass patternw/ surrounding ground glass pattern<1cm paratracheal and axillary lymphnodes<1cm paratracheal and axillary lymphnodesMinimal pericardial effusionMinimal pericardial effusion
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??Active TB??Active TB
3 sputum AFB samples Negative3 sputum AFB samples NegativePulmonary Clinic: Bronchoscopy if negativePulmonary Clinic: Bronchoscopy if negative
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While working on diagnostics,While working on diagnostics,Clinically improvedClinically improvedLess compliantLess compliantHIV test negative, Hep C positiveHIV test negative, Hep C positiveReview of historyReview of history
? Mother or relative with active TB, 70’s? Mother or relative with active TB, 70’s? Positive skin test or treatment in the past? Positive skin test or treatment in the past
Repeat CT - resolving nodules/effusion Repeat CT - resolving nodules/effusion
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NO active TBNO active TBResolving CT scan and respiratory symptoms, Resolving CT scan and respiratory symptoms,
HIV negativeHIV negative
YES Latent TB Infection (LTBI)YES Latent TB Infection (LTBI)
ObjectivesObjectives
Update on LTBIUpdate on LTBITB EpidemiologyTB EpidemiologyMaking the diagnosisMaking the diagnosisTreatmentTreatment
TB BurdenTB Burden
Airborne Mycobacterium tuberculosis has Airborne Mycobacterium tuberculosis has infected humans since ancient timesinfected humans since ancient times
WHO Worldwide Estimates:WHO Worldwide Estimates:~ 1.9 billion infected ~ 1.9 billion infected ~ 16 million active cases~ 16 million active cases~ 6 million new cases every year~ 6 million new cases every year~ 1.7 million deaths every year~ 1.7 million deaths every year
……TB Burden TB Burden continuedcontinued
US estimatesUS estimates~ 26,000 cases/year - late 80’s, early 90’s a ~ 26,000 cases/year - late 80’s, early 90’s a
resurgence attributed to HIV and multidrug resurgence attributed to HIV and multidrug resistant TBresistant TB
~ 15,000 cases/year – 2001~ 15,000 cases/year – 2001
Treatment of LTBI in moderate to high risk Treatment of LTBI in moderate to high risk patients reduces risk of developing active TB patients reduces risk of developing active TB by up to ~70% by up to ~70%
LTBILTBI(Latent TB Infection)(Latent TB Infection)
After the primary TB infectionAfter the primary TB infectionUp to 85% - Infection eradicatedUp to 85% - Infection eradicated
Up to 5% - Progress to active TB; Up to 5% - Progress to active TB; much higher % in HIV and other risk groups much higher % in HIV and other risk groups
Up to 5% - LTBI or those who temporarily Up to 5% - LTBI or those who temporarily control infection only to fail at a later time control infection only to fail at a later time (“endogenous reactivation”)(“endogenous reactivation”)
LTBI diagnosisLTBI diagnosis
Identify moderate to high risk groupsIdentify moderate to high risk groupsTest (TST, Quantiferon G)Test (TST, Quantiferon G)R/O Active TBR/O Active TB
……LTBI DiagnosisLTBI Diagnosis
Tuberculin Skin TestTuberculin Skin Test
Issues administering, Issues administering, interpretinginterpreting
Difficult with BCG orDifficult with BCG or
other mycobacterium sp.other mycobacterium sp.
Cheaper?Cheaper? $40-70 facility charge$40-70 facility charge
+ $13.70 test+ $13.70 test
ELISA or ELISPOTELISA or ELISPOT(Quantiferon, T Spot-TB)(Quantiferon, T Spot-TB) EasierEasier No booster No booster
phenomenonphenomenon Better Specificity, PPVBetter Specificity, PPV
Comparable?Comparable? $15-18 venipunture$15-18 venipunture $87-123 test$87-123 test
……LTBI DiagnosisLTBI Diagnosis
R/O Active TBR/O Active TB Hx, PEHx, PE PA Chest XrayPA Chest Xray
(-) = LTBI - Treat LTBI(-) = LTBI - Treat LTBI
(+) (+) OROR (-) and HIV/chr respiratory ssx (-) and HIV/chr respiratory ssx Obtain 3 Sputum samples (AFB, NAA, cultures):Obtain 3 Sputum samples (AFB, NAA, cultures):
Sputum (-), Low suspicion – Treat LTBISputum (-), Low suspicion – Treat LTBI Sputum (-), High suspicion - Treat Active TB until cultures outSputum (-), High suspicion - Treat Active TB until cultures out
Culture (+) – continue treat Active TBCulture (+) – continue treat Active TB Culture (-) , cxray improving – continue treat Active TB Culture (-) , cxray improving – continue treat Active TB
Sputum (+) - Treat Active TBSputum (+) - Treat Active TB
Case revisitedCase revisited
EH qualifies as having LTBI EH qualifies as having LTBI
Two hurdles to successful treatmentTwo hurdles to successful treatment ComplianceCompliance High risk for adverse reactionsHigh risk for adverse reactions
Ask help from IDAsk help from ID Would Quantiferon help?Would Quantiferon help? Suspect 4 mo. RIF or 6 mo INH with Directly Suspect 4 mo. RIF or 6 mo INH with Directly
Observed Therapy and close LFT monitoringObserved Therapy and close LFT monitoring
ReferencesReferences
http://www.thoracic.orghttp://www.thoracic.org http://findtbresources.orghttp://findtbresources.org CDC. Guidelines for using the QuantiFERON-TB Gold CDC. Guidelines for using the QuantiFERON-TB Gold
Test for detecting Mycobacterium tuberculosis infection, Test for detecting Mycobacterium tuberculosis infection, United States. MMWR 2005;54(No.RR-15):49-55United States. MMWR 2005;54(No.RR-15):49-55
American Thoracic Society, CDC. Targeted tuberculin American Thoracic Society, CDC. Targeted tuberculin testing and treatment of latent tuberculous infection. Am testing and treatment of latent tuberculous infection. Am J Respir Crit Care Med 2000:161:S221-47. J Respir Crit Care Med 2000:161:S221-47.
