Rehuka Khurana, MD, MPH has the following disclosures to make:

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1 Case Presentation Steps to a Systematic Approach to Diagnosis of TB Case Presentation Steps to a Systematic Approach to Diagnosis of TB Renuka Khurana, MD, MPH March 13, 2015 TB for Pulmonologist March 13, 2015 Phoenix, AZ EXCELLENCE EXPERTISE INNOVATION Rehuka Khurana, MD, MPH has the following disclosures to make: No conflict of interests No relevant financial relationships with any commercial companies pertaining to this educational activity 1

2 Objectives Recognize multiple clinical manifestations of TB disease Maximize yield of mycobacteria from clinical specimens Review risk factors for infection and progression to TB Case History 55 year old Asian Male Born Hong Kong, immigrated to US 1973 Medical History DM Type 2 for 20 + years HTN Pancytopenia (Bone Marrow Biopsy 2011) Deletion of the long arm of chromosome 20 [del(20)q11] Can cause myeloid dysplasia leukodystrophy Cirrhosis new diagnosis Hypothyroidism (Thyroidectomy during Childhood) TB Exposure to brother in law 2

3 Risk Factors for Progression to TB Which of the following medical conditions are more likely for progression from TB infection to disease? Hypertension Diabetes Pancytopenia Foreign Birth Contact to TB Hypothyroidism Risk Factors for TB Risk of TB Infection Contacts/Converters Recent Immigrant Residents/Employees of high risk congregate settings (corrections, nursing homes, dialysis unit) Foreign born from high risk countries Health Care workers Medically underserved (homeless, migrant workers, street drug users, children with parents who have risk factors) Risk of TB Progression HIV Abnormal CXR consistent with old TB < 5 years of age Diabetes Immunosuppression (prednisone, chemo, TNF alpha inhibitors) Other medical conditions: Gastrectomy, silicosis, low body weight, malnutrition, malabsorption, head/neck cancers, organ transplant, jejunoilealbypass Smoking, IVDU, alcoholism 3

4 Case History Admitted on 8/24/14 for Cough Shortness of breath Increasing dyspnea on exertion Orthopnea Bilateral lower extremity edema Past History Right anterior cervical abscess /drained, No AFB cultures or smears done Treated with antibacterials Social History No ETOH, illicit drug use Non smoker Travel to Mexico March 2014 Bus Driver Case History Vital Signs: Temp 38.7, BP 127/58, RR 23/min, HR 105/min Pulse Ox 99% on 2 L of oxygen Labs and CXR TST Positive 20 mm QFT G Negative (TB Antigen Nil=0.00) HIV Negative Cocci Negative Hep B and C Negative Sed Rate 97 CRP 64.7 CBC WBC 2600, 122k platelets, Hgb/Hct 7.7/24.9 Creatinine 1.83 and GFR 39 HgA1C 6.7 (Previously >10) 4

5 Pericardial Effusion Moderately large Pleural effusion 5

6 Lymph Nodes Right Hilar Node 6

7 Subcarinal Node Chest CT Scan Radiology Patchy nodular infiltrates in the left upper lobe Several small scattered nodular opacities in the right upper lobe Mildly enlarged gastro hepatic lymph nodes. Cirrhotic configuration of the liver. 7

8 Microbiological Investigation ECHO with Pericardial Effusion, Cardiac Tamponade S/P Pericardial window Pericardial tissue chronic inflammation Chest tube placement for large pleural effusions Specimen Collection and Results Date Source AFB Smear AFB Culture Rx Week Initial Phase 8/25/14 Pericardial Tissue Negative Negative 8/25/14 Pericardial Fluid Negative Light Growth MTB 8/25/14 Pleural Fluid (L) Negative Negative 8/25/14 Pleural Fluid (R) Negative Negative 8/29/14 BAL Negative Slight Growth MTB 8/30/14 Sputum (Induced) Negative MTB (RIE) 9/2/14 Sputum (Induced) 0:10 AM 9/2/14 Sub carinal Node Tissue 9/2/14 Sputum (Induced) 06:28 AM Rare MTB 1 st week INH, RIF, EMB and Moxi Negative MTB Rare MTB Prednisone 9/8/14 Sputum (Induced) Negative MTB (RIE) 2 nd Week 9/11/14 Sputum Negative MTB 9/15/14 Sputum Negative Negative 3 rd Week 11/20/14 Sputum Negative Negative 8 weeks completed 10/28/14 12/3/14 Sputum Negative Negative 8

9 Pleural Tissue biopsy and culture yield higher than pleural fluid Pleural fluid microscopy rarely positive (<5%) Pleural fluid culture low sensitivity (24 58%) Pleural Tissue culture Incremental Yield of Sputum examination Either the first or the second Sputum smear was diagnostic in 94.9% of cases Third smear added 4.2% 84% cases 1 st sputum was culture positive Second and third sputum culture additional yield 11% and 4.5% Method of Specimen Collection Yield for Smear Positive (% of smear positive) Yield for Culture (% of culture positive) Spontaneous Sputa Spontaneous Morning Sputa Induced Sputum Induced Morning Sptuta Morning Sputum combined Spontaneous and Induced Combined Bronchoscopy 63 9

10 Diagnostic Value of ADA Jimenez, CD et al Eur Respir J 2003; 21: Distribution of Clinical Manifestation Pulmonary Parenchymal Disease Pleural Effusion Hilar/ Mediastinal Adenopathy Pericardial Effusions 10

11 Differential Diagnosis What is the differential diagnosis in a patient with Bilateral Nodular parenchymal disease Bilateral Pleural effusion Pericardial Effusion Mediastinal Node Hilar Node Subcarinal Node AND Contact to TB Foreign Born TST Positive Diabetic Uncontrolled 11

12 Questions? Acknowledgements and Thanks Dr Carlos Perez MD Dr Felipe Gutierrez MD, MPH Case Manager Brenda Cabrales LPN Radiologist Dr David August MD Victoria Santiago Treatment RIE initiated with Moxifloxacin 9/2/14 Monitoring of LFT every week till stable Prednisone 60 mg started with slow taper over 8 10 weeks Diabetes management with Endocrinologist Complaints of nausea and vomiting treated with Zofran Mild elevation of ALT (100) but medication continued Switched to twice a week continuation phase 12

13 12/31/14 developed leukopenia (WBC 2000) and thrombocytopenia (79K) Neutropenia ANC RIF stopped added EMB and FQ with INH 7 days a week No change in leukopenia and thrombocytopenia with medication change Restarted INH with FQ WBC decreased to 1700 with ANC 500 Meds on hold Started on Neupogen 3/16/15 by hematologist Resumed TB medication Does a negative QFT G rule out TB? Yes No TST and QFT G complimentary 13

14 Specimen Collection Maximize the yield of MTB 14

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