BGS Spring Conference 2015

Transcription

1 TB in the elderly Dr Anna Rich Respiratory Consultant, Nottingham University Hospitals

2 Outline Why relevant? Elderly vs young adults Diagnosis Treatment Side effects

3 TB in the 21 st century Stats 2013; 9 million infected, 1.5 million died 95% deaths in low/middle income countries WHO control disesae by 2000 UN; Millennium Development Goals Fall TB incidence, prev, mortality rates Increase detection, completion rates

4

5 Why is TB important? globally WHO

6 Eng & Wales

7 Elderly vs young adults Globally; highest burden in young adults HIV co-infection Elderly Developed countries Reduced immunity/co-morbidities Reactivation Treatment Mortality higher Schaaf HS et al. Tuberculosis at extremes of age. Respirology (2010) 15,

8 Diagnosis in the elderly Poor historians Typical symptoms Radiology Lower Lobe not Upper Few cavities Miliary disease TST less helpful Davies PDO. TB in the elderly in industrialised countries. Int J Tuberc Lung Disease (2007) 11:

9 MM 74 yr old lady Respiratory f up with SPNs Cough, green sputum No haemoptysis No fevers, night sweats PMH: COPD (50 pack yr Hx) TB osteomyelitis aged 7; father died of TB aged 11

10 MM

11 MM Sputum; smear neg, culture pos, fully sensitive Started Rx May 2012 Completed Rx Nov 2012 Min cough, no sputum Appetite better; 3kg wt gain Late reactivation

12 MM

13 BT 82 yr old lady GCA under Rheum; steroids?myositis (PET scan) Oct 13-Feb 14; 3 admn? Sepsis Chronic high inflam markers Cough, green sputum Anorexia, wt loss, lethargy ++

14 BT Brother TB joint 1960 Godmother TB too

15 BT Bronchoscopy; culture pos M.TB Started Rx March 2014 Pre-existing GI upset Struggled with nausea Chronic immunosuppression Admitted; HCOP with resp input Anorexia, dysphagia, poor mobility Tablet holiday

16 BT Low albumin Frailty OGD unsafe CCF RIP May 2014

17 JM 73 yr old lady 2WW cough, smoker CT LLL abnormality (end 2012) Ex/recurrent smoker; 40 pack yr Hx 4 G&T s a night IHD, lives with partner Bx unsafe, PET scan, increase size Clinical Dx of lung cancer (T1N0M0) SABR April 2013

18 JM

19 JM Completed SABR April 2013 Nov 2013 increasing SOB CT; new LLL changes, RUL lesion Small left effusion Effusion tapped Bronch Jan 14 Smear negative, culture positive, fully sens Started triple therapy Aunt died of TB; not a household contact

20 JM

21 JM Cancer mimic Started triple Rx March 2014 Caution re EtOH groggy so meds at night April; Breathing better than it has been for years Appetite back Completed Sept 2014 New Years Eve; made it to midnight!

22 JM

23 TB treatment in the elderly Standard Rx Adherence Memory, eye sight, confusion Adverse events due to altered physiology Polypharmacy Warfarin, theophylline, prednisolone B blockers, thyroxine,

24 MZ 77 yr old man from Pakistan UK since 2004 Co-morbidities HT, DM, CCF, CVA Back pain, confusion, urinary incontinence Sept 2010; Cough, purulent sputum, admission, rec Abx GP Anorexia, wt loss, fevers

25 MZ

26 MZ Admitted via A&E Feb 2011; SOB Bronchoscopy Feb 2011 M.TB, fully sensitive Started Rx New patient end March 2011 Fully compliant Scratching, confusion, double incontinence CXR/Bloods Visiting Pakistan for wedding 3 rd April for 2 months

27 MZ Renal failure

28 MZ Renal function deteriorated within first 2 weeks No other cause for AKI Urgent renal US Advised to stop all meds, and not to travel Pt travelled anyway Restarted whilst in Pakistan; without Z Returned in July, 8kg wt loss Gradually improved; completed 9/12 (Jan 12)

29 MZ RIP Feb 2013

30 VD 70 yr old lady Returned from cruise in Spring 2014 Left sided neck nodes ENT; biopsy Granulomas with caseous necrosis TB culture pending Cough, green sputum, drenching sweats 3 sputum sent Start Empirical TB Rx

31 VD Drug induced liver injury No family contact But close friend dx as teenager All 3 sputa grow MAI Neck aspiration; TB culture negative Meanwhile; within 4 weeks Deranged liver function, nausea, rash Stop all Rx, repeat neck node aspiration/sputa

32 VD

33 VD All subsequent sputa negative culture Repeat aspiration; smear and culture neg Gradual re-introduction regime Established on full dose quad therapy Nov 2014 Tablets at night Glands shrunk, systemic symptoms resolved Completed Rx April 2015

34 TB in the elderly-summary Consider TB Regardless of ethnicity Never too old to reactivate! Treatment Caution Side-effects Polypharmacy Kidney and liver dysfunction

35 Thank you