Advanced Management of Patients with Tuberculosis Little Rock, Arkansas August 13 14, 2014 TB Case Presentation Andrea Cruz, MD, MPH August 14, 2014 Andrea Cruz, 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
Case Study: TB Cervical Adenitis Andrea T. Cruz, MD, MPH Disclosures I have no disclosures or conflicts of interest to report Page 3 xxx00.#####.ppt 2:55:08 PM 2
Objectives Discuss the case of an adolescent with massive cervical adenitis Review the role of steroids in the management of TB adenitis Discuss options regarding fine needle aspiration as part of the therapeutic management Page 4 xxx00.#####.ppt 2:55:08 PM History of Present Illness 15-yo African-American male, previously healthy, with 3 months of progressively enlarging left neck swelling No fever, weight loss, cough, or other symptoms Nodes are not red or tender Page 5 xxx00.#####.ppt 2:55:08 PM 3
Medical History Never been hospitalized or had surgery prior to this illness 1 month prior to presentation in TB clinic, had been seen by an ENT who told family it was a lipoma and he would outgrow it when he turned 21. A 2 nd ENT biopsied it; culture results unknown by family No medications or allergies Page 6 xxx00.#####.ppt 2:55:08 PM Social History Born and raised in Houston No international travel, no relatives visiting from abroad Lived with multiple (non-parental) relatives since birth Social chaos Father died in jail 4 years ago of multiorgan system failure and had been coughing Child had never been screened for TB Page 7 xxx00.#####.ppt 2:55:08 PM 4
Examination Well-appearing male with obvious L facial and neck swelling Neck: 3 large nodes, the latter 2 very fluctuant; not adherent to overlying skin, not tender, no skin color changes No supraclavicular or other adenopathy Remainder of examination was normal, except for TST site Page 8 xxx00.#####.ppt 2:55:08 PM Initial Presentation Page 9 xxx00.#####.ppt 2:55:08 PM 5
Page 10 xxx00.#####.ppt 2:55:08 PM Page 11 xxx00.#####.ppt 2:55:09 PM 6
Laboratory Evaluation HIV seronegative CBC: WBC: 8.7k (32 neutrophils/14 bands/44 lymphs) Hgb 9.9 g/dl (MCV 70) Platelets 189k Inflammatory markers: ESR: 123 mm/hr CRP: 4 mg/dl AST/ALT: 34/19 Page 12 xxx00.#####.ppt 2:55:09 PM Initial Regimen? TB or nontuberculous? Do you need to make changes in initial regimen given the extent of disease? To what degree do drugs penetrate such a necrotic area? Page 13 xxx00.#####.ppt 2:55:09 PM 7
Clin Infect Dis 2011;53:555 Page 14 xxx00.#####.ppt 2:55:09 PM TB or not TB (AKA, NTM) We sometimes cover for both the most common NTM species we see in children in this region (MAC) and TB with the following regimen: INH RIF EMB Azithro *Downside: longer treatment duration because PZA not included in initial regimen Page 15 xxx00.#####.ppt 2:55:09 PM 8
Do antibiotics need to be modified for lymph node TB? IDSA recommendations do not differ between pulmonary and lymph node TB if the isolate is drug-susceptible 4-drug therapy recommended for 6 months No benefit in terms of increase cure rate or decreasing relapse rate between 6 and 9 months Respir Med 1993;87:621; Otolaryngol Head Neck Surg Page 16 1997;116:189; Eur Respir J 2000;15:192 xxx00.#####.ppt 2:55:09 PM Initial Regimen Initial weight: 53kg Daily INH 300mg RIF 600mg PZA 1g EMB 800mg Twice weekly INH 900mg RIF 600mg PZA 2g EMB 2g Page 17 xxx00.#####.ppt 2:55:09 PM 9
Further Data Called microbiology laboratory: culture was growing M. tuberculosis This had not been reported to the family or the health department Page 18 xxx00.#####.ppt 2:55:09 PM Use of steroids? Concern for paradoxical worsening after starting therapy with formation of draining sinus tract Page 19 xxx00.#####.ppt 2:55:09 PM 10
Data on steroids for TB adenitis Only 1 pediatric RCT (1967) on lymphatic and endobronchial TB showing decreased symptoms and node size with steroids Remainder of studies have been cohort studies where steroids were not administered systematically and have shown conflicting results Am Rev Respir Dis 1967;95:402 Page 20 J Infect Dis 2009;59:56; Clin Infect Dis 2005;40:1368 xxx00.#####.ppt 2:55:09 PM 23% of HIV-negative patients Median of 46 days Persisted ~2 months No association between steroids and duration of paradoxical reaction Clin Infect Dis 2005;40:1368 1371 Page 21 xxx00.#####.ppt 2:55:09 PM 11
23% of adults had paradoxical reactions More common in younger patients, in males, and if tenderness was present on exam Steroids appeared beneficial J Infect Dis 2009;59:56 Page 22 xxx00.#####.ppt 2:55:09 PM Steroids We started prednisone 50mg (~1mg/kg) daily for 2 weeks with a 2 week taper Child noted increased urination His caregiver noted he was grumpy and eating incessantly Page 23 xxx00.#####.ppt 2:55:10 PM 12
Page 24 xxx00.#####.ppt 2:55:10 PM Role for drainage? Not for diagnostic, but for therapeutic purposes Again, concern for spontaneous rupture through skin, leading to infection control concerns that he did not currently have Page 25 xxx00.#####.ppt 2:55:10 PM 13
Clin Infect Dis 2011;53:555 Page 26 xxx00.#####.ppt 2:55:10 PM Drainage Given concern for fluctuance of nodes, interventional radiology drained the 2 most posterior nodes, removing 45cc of purulent material Last case of the day in the IR suite Child tolerated with only local anesthetic Page 27 xxx00.#####.ppt 2:55:10 PM 14
Immediate Post Drainage Page 28 xxx00.#####.ppt 2:55:10 PM Pre/Immediately post drainage Page 29 xxx00.#####.ppt 2:55:10 PM 15
Pre/Post 1 month of therapy pictures Page 30 xxx00.#####.ppt 2:55:10 PM Plan Ethambutol stopped after 4 weeks when drug susceptibilities available PZA stopped at 2 months Steroids successfully tapered off 6 month course of therapy is planned Page 31 xxx00.#####.ppt 2:55:10 PM 16