Tuberculosis1

MEDICAL PATHOLOGICAL PHARMACOLOGICA L AND November 29, 2007 RADIOLOGICAL Rm. 204 CONFERENCE

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Approach to Patient with

Pulmonary Tuberculosis Subsection A4

Aquino, Elenor Arguelles, Aldrich Arias, Mark Anthony Arriola, Anna Carlisa Asuncion, Lyndon Paolo Atanacio, Shari Ann Atanga, Pascal Atazan, Judy Carissa Atienza, Bryan Jason Atutubo, Cosette Esmeralda 3

Complete History and Physical Examination 4

General Data Name: Age: Religion: Occupation: Address:

A.S. 55 years old Catholic Caretaker Cavite

Chief Complaint:

Melena, Chronic Cough

History of present illness

1 Day PTA

6 Months PTA • Episodes of non-productive cough with no accompanying symptoms. • No consultation • No medication

4 Months PTA • Productive cough with yellowishgreenish phlegm. • Medication – Carbocisteine syrup tid for weeks, no relief – Guiafenessin syrup tid, partial relief

1 Month PTA • Intermittent epigastric pain – aggravated by hunger – relieved by food.

• accompanied by • headache, nausea and vomiting. • Medication – Famotidine 20 mg/tab, 1 tab tid – provided partial relief.

1 Month PTA • Intermittent productive cough • Physician diagnosis : Pulmonary Tuberculosis – Positive AFB smear – Sputum sensitivity – Chest x-ray – Lymph node biopsy Main menu

1 Month PTA • Medication for PTB – Ethambutol – Rifampicin

• Compliance was unrecalled

2 Weeks PTA • persistence of symptoms • tested for blood chemistry and urinalysis at a local clinic – Elevated creatinine level

• impression was Urinary tract infection.

2 Day PTA • Bloody-streaked phlegm • Chronic cough

1 Day PTA • persistence of the symptoms • accompanying 10 episodes of dark tarry stools tinged with blood. • This prompted patient to seek consult, hence admission. • Hence chief complain – CHRONIC COUGH – MELENA

Past Medical History • 2000: Diagnosed with Hypertension – highest BP was unrecalled. – maintained on • Metoprolol 50 mg/tab, 1 tab bid • amlodipine 10 mg/tab, 1 tab o.d.

• 2006: Diagnosed with BPH – was prescribed • Terazosin HCL.

Family History/Personal History • (+) asthma, brother • No family history of HPN, DM, stroke, cancer, tuberculosis

• Previous smoker - 35 pack years – (20 sticks/day for 35 years)

• Previous alcoholic beverage drinker – (80 g/day for 20 years)

Subjective and Objective Data on Admission Subjective • (+) weight loss, unquantified, (+) anorexia, (+) weakness • (+) insomnia, no fever • (+) dyspnea, (+) shortness of breath, (+) cough, (+) sputum production, no hemoptysis • (+) 2 pillow orthopnea occasional chest pains • urine stream flow abnormally, no dysuria • (+) polyuria, (+) polydipsia,

Objective • Respiratory Distress, conscious, ambulatory • BP supine: 140/90, • BP sitting: 120/70, • PR: 80, RR: 32 T: 36.5° • Pale palpebral conjunctiva, dirty sclerae • (+) cervical lymph nodes • Symmetrical chest expansions, (+) supraclavicular retractions, (+) crackles, both lung fields • No cyanosis, no edema, pulses full and equal

Subjective and Objective Data on Nov. 22 Objective Subjective • (+) weight loss, unquantified, (+) anorexia, (+) weakness • (+) insomnia, no fever • (+) dyspnea, (+) shortness of breath, (+) cough, (+) sputum production, (+) hemoptysis • (+) 2 pillow orthopnea occasional chest pains • urine stream flow abnormally, no dysuria • (+) polyuria, (+) polydipsia,

• • • • • • •

• •

No respiratory Distress, conscious, cachectic BP supine: 110/80 BP sitting: 100/70 PR: 64, RR: 24, T: 36.5° Pale palpebral conjunctiva, dirty sclerae (+) cervical lymph nodes Asymmetrical chest expansions, (+) supraclavicular and intercostal retractions, (+) crackles, (+) wheezes, dullness at lower lung fields on percussion (+) chest tenderness, left subcostal area No cyanosis, bipedal edema, pulses full and equal

Risk Factors for Active Tuberculosis • Recent Infection • Fibrotic Lesions (spontaneously healed) • Comorbidity – – – – – – – – –

HIV Infection Silicosis Chronic Renal Failure/ Hemodialysis Diabetes Intravenous Drug Use Immunosupressive treatment Gastrectomy Jejunoileal Bypass Posttransplantation period (renal, cardiac)

• Malnutrition and Severe Underweight Source: Harrison’s Principles of Internal Medicine 16th Edition

Additonal Slides

AFP RESULTS

Back

Actual patient x-ray back

Actual Patient x-ray

back

Chief Complaints • Melena • Chronic Cough

Chief Complaints • Cough - is an explosive expiration that provides a normal protective mechanism for clearing the tracheobronchial tree of secretions and foreign material. • Acute: <3 weeks duration • Chronic: >3 weeks duration

Harrison’s Internal Medicine 16th ed.

Organ Systems Involved • Pulmonary System – Airways • Inflammation • Neoplasm

– Lung Parenchyma

• Cardiovascular System – Pulmonary edema due to LVF

Symptomatology and Physical Examination Findings Atienza, Bryan Jason B.

Review of Systems • Yellow sputum, Cough, Dyspnea, Orthopnea – Bacterial infection – Cough reflex – Dyspnea in PTB – 2-pillow orthopnea

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ATIENZA, Bryan Jason B., II-A3

Review of Systems • Anorexia, Weight change, Weakness – Anorexia in PTB: Inflammatory cytokines – Anorexia  Weight loss • Clinically significant: >5% usual body weight over 6-12 mos. (progressive) >10% protein-energy malnutrition >20% severe

– Anorexia  Neoplasm? – Weakness 2

ATIENZA, Bryan Jason B., II-A3

Review of Systems • Insomnia – Due to cough, dyspnea, depression

• Adenopathy – Chronic infection

• Edema (Right leg, Abdomen) – Right-sided heart failure

• Chest pain – Angina pectoris, HPN, LVH?

• Polyuria, polydypsia, dysuria – BPH, DBM.

• Depression, mood changes 3

ATIENZA, Bryan Jason B., II-A3

Physical Examination Findings • Hypertension – Hx

• Displaced apex beat – Cardiomegaly

• Tachypnea – Compensatory response

• Respiratory distress – Supraclavicular, subcostal retractions – Crackles 4

ATIENZA, Bryan Jason B., II-A3

Physical Examination Findings • Abdominal tenderness • Pale palpebral conjunctivae, dirty sclerae

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ATIENZA, Bryan Jason B., II-A3

Differential Diagnosis

PROBLEM

COUGH AND SPUTUM

ASSOCIATED SYMPTOMS AND SETTING

ACUTE INFLAMMATION Bacterial Pneumonias

Pneumoccocal: sputum mucoid or purulent; maybe blood-streaked, diffusely pinkish or rusty

An acute illness with chills, high fever, dyspnea and chest pain. Often preceded by upper respiratory infection

Klebsiella: similar; or sticky, red, jellylike

Typically occurs in older alcoholic men

CHRONIC INFLAMMATION Postnasal Drip

Chronic cough; sputum mucoid to mucopurulent

Repeated attempts to clear the throat. Postnasal discharge maybe sensed by patient or seen in posterior pharynx. Associated with chronic rhinitis, with or without sinusitis.

Chronic Bronchitis

Chronic cough; sputum Often long-standing cigarette mucoid to purulent, maybe smoking. Recurrent superimposed blood-streaked or even bloody infections. Wheezing and dyspnea may develop. Bates' Guide to Physical Examination and History Taking, 9th ed.

Bronchiectasis

Chronic cough; sputum purulent, often copious and foul-smelling; maybe blood streaked or bloody

Recurrent bronchopulmonary infections common; sinusitis may coexist.

Lung Abscess

Sputum purulent and foulsmelling; maybe bloody

A febrile illness. Often poor dental hygiene and a prior episode of impaired consciousness.

Pulmonary Tuberculosis

Cough dry or sputum that is mucoid or purulent; maybe blood streaked or bloody

Early, no symptoms. Later anorexia, weight loss, fatigue, fever, night sweats

Cough dry to productive; sputum may be blood-streaked or bloody

Usually long history of cigarette smoking. Associated manifestations are numerous.

NEOPLASM Lung CA

CARDIOVASCULAR DISORDERS Left Ventricular Failure or Mitral Stenosis

Often dry, especially on exertion or at night; may progress to pink frothy sputum of pulmonary edema or to frank hemoptysis

Dyspnea, orthopnea, paroxysmal nocturnal dyspnea

Pulmonary Emboli

Dry to productive; maybe dark, bright red, or mixed with blood

Dyspnea, anxiety, chest pain, fever; factors that predispose to deep vein thrombosis

Bates' Guide to Physical Examination and History Taking, 9th ed.

RADIOLOGY

Normal Lungs (PA view)

www.umm.edu/pulmonary/cases.htm

CXR Findings that Suggest Active TB: • • • • •

Infiltrate or consolidation Any cavitary lesion Nodule with poorly defined margins Pleural effusion Hilar or mediastinal lymphadenopathy

Center for Disease Control & Prevention

Consolidation

www.umm.edu/pulmonary/cases.htm

Infiltrates

www.umm.edu/pulmonary/cases.htm

Cavitation

www.umm.edu/pulmonary/cases.htm

Nodules

www.umm.edu/pulmonary/cases.htm

Pleural Effusion

www.rad.msu.edu/.../pages/steps/step8.htm

NORMAL

PATIENT’S

Ancillary Procedures

Acid Fast Bacilli (AFB) stain for light microscopy • 1-hour-to-1-day • Three sputum specimens in am • MTB retains certain stains after being treated with acidic solution, it is classified as an AFB • Ziehl-Neelsen, dyes AFBs a bright red www.labtestsonline.org

Acid Fast Bacilli (AFB) stain for light microscopy • Other ways to visualize AFBs include an auramine-rhodamine stain and fluorescent microscopy • can be used to monitor the effectiveness of treatment and can help determine when a patient is no longer infectious • negative culture may mean that you do not have an AFB infection or that the mycobacteria were not present in that particular specimen www.labtestsonline.org

PPD test (Purified Protein Derivative) • Give 0.1 ml of 5 Tuberculin Units PPD intradermally • 48 and 72 hours • Measure the induration(mm) not erythema

http://www.cdc.gov/

PPD test (Purified Protein Derivative) 15 or more millimeters induration is always considered positive. with no risk factors for tuberculosis. 10 or more millimeters induration is considered positive for high risk groups, such as: • Foreign-born persons from high prevalence areas , • Intravenous drug users known to be HIV seronegative • Medically-underserved low income populations • Residents of long-term care facilities (such as correctional institutions, nursing homes, mental institutions) • increase the risk of tuberculosis such as silicosis, being 10% or more below ideal body weight, chronic renal failure, diabetes mellitus, high dose corticosteroid and other immunospressive therapy, leukemias and lymphomas other malignancies • Children who are in one of the high risk groups listed above • Health care workers who provide services to any of the high risk groups http://www.cdc.gov/

PPD test (Purified Protein Derivative) 5 or more millimeters induration is considered positive for the highest risk groups, such as: • Persons with HIV infection • Persons who have had close contact with an infectious tuberculosis case • Persons who have chest radiographs consistent with old, healed tuberculosis • Intravenous drug users whose HIV status is unknown

http://www.cdc.gov/

PPD test (Purified Protein Derivative) False positive result • Infection with nontuberculosis mycobacteria • Previous BCG vaccination • Incorrect method of TST administration • Incorrect interpretation of reaction • Incorrect bottle of antigen used

False negative result • Cutaneous anergy (anergy is the inability to react to skin tests because of a weakened immune system) • Recent TB infection (within 8-10 weeks of exposure) • Very old TB infection (many years) • Very young age (less than 6 months old) • Recent live-virus vaccination (e.g., measles and smallpox) • Overwhelming TB disease • Some viral illnesses (e.g., measles and chicken pox) • Incorrect method of TST administration • Incorrect interpretation of reaction

http://www.cdc.gov/

Mycobacterial Culture • solid media (eggbased, such as Lowenstein-Jensen or agar such as Middlebrook 7H11) • incubation for 3 to 6 weeks • Optimal Temperature: 37C • Optimal pH: 6.8

http://www.cdc.gov/

Mycobacterial Culture • A positive culture for M. tuberculosis confirms the diagnosis of TB disease. • Culture examinations should be completed on all specimens, regardless of AFB smear results.

http://www.cdc.gov/

QuantiFERON®-TB Gold Test • incubation of the blood with antigens • 16 to 24 hours • amount of interferon-gamma (IFNgamma) is measured • additional tests needed to confirm the diagnosis of LTBI or TB disease http://www.cdc.gov/

QuantiFERON®-TB Gold Test • Results can be available within 24 hours. • Is not subject to reader bias that can occur with TST • Is not affected by prior BCG (bacille Calmette-Guérin) vaccination. http://www.cdc.gov/

Additional Diagnostic Procedures • Urine cultures:    Urine cultures can be used to diagnose cases of genitourinary Tuberculosis.        • Gastric aspirate test: A gastric aspirate test involves placing a tiny nasogastric tube in the stomach early in the morning.  Gastric contents are then suctioned and processed for smears and Harrison’s 16th Edition culture.    

Additional Diagnostic Procedures • Lymph node biopsy: involves removing an enlarged lymph node and culturing a small portion.  The remaining portion is stained and observed under a microscope for presence of a caseating granuloma with AFB • Culture body fluids: Fluid drained from the pleural space, the pericardial space, or the peritoneal space Harrison’s 16th Edition may be positive for AFB and culture.

Additional Diagnostic Procedures • Bronchoalveolar lavage: performed in patients with suspected pulmonary Tuberculosis when sputum smears are negative. • Fiberoptic bronchoscope with bronchial brushings or transbronchial biopsy Harrison’s 16th Edition

Pathophysiology of Pulmonary Tuberculosis

Atutubo, Cosette

Etiology of PTB • Mycobacterium tuberculosis complex • Non-motile, nonspore-forming Aerobic bacterium • Weakly gram (+) Atutubo, Cosette

Pathogenesis • Breathe in the droplets • Bacteria into their lungs • Response: engulfed by alveolar macrophages • Hilar lymph nodes • Beginning of primary tuberculosis • Middle or lower lobes of the Atutubo, lungs Cosette