Impostors and Preconceived Notions: Lessons Learned in TB Diagnosis & Treatment Tuberculosis Nursing Workshop June 1, 2015 Christopher Spitters, MD, MPH Tuberculosis Clinic Public Health Seattle & King County Case 1: Clinical Presentation 29 y/o Mexican male 30 pounds weight loss, fever, dry cough, back pain over the past 3-4 months Left wrist ulcer for 3 weeks; no response to treatment with TMP/SMX No prior TB diagnosis or treatment Entered US 4 years ago Itinerant work in the fields 1
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Case 1: Laboratory Findings TST 00mm/QFT negative Sputum smear and NAAT negative BAL AFB-smear, NAAT negative BAL and sputum fungal smears negative TBBx non necrotizing granulomata Wrist wound necrotizing and nonnecrotizing granulomata Fungal serology pending Case 1: Management INH/RIF/PZA/EMB started Case 1: Final Diagnosis Coccidioides immitis/posadasii recovered from skin wound, BAL, sputum, and spinal lesion Cocci titer 1:1024 Histo Ab negative Fluconazole started TB medications discontinued 4
Case 2: Clinical Presentation 48 y/o African American female Homeless, schizophrenic Smoking 1ppd since age 20 Coughing for 20 years Not losing weight (6-3 ; 145lbs, BMI 18) Denies fever, night sweats Case 2: Chest Radiograph Case 2: Laboratory Findings TST 07mm Sputum smear negative x3 NAAT negative x1 Discharged on empiric 4-drug therapy to TB control follow-up 5
Case 2: Final Diagnosis AFB cultures negative 5-pound weight loss Follow-up CXR unchanged CT guided needle biopsy: adenocarcinoma of the lung Case 3: Clinical Presentation 55 y/o Peruvian woman Cough, sputum, blood streaked sputum, weight loss, fatigue Started 4-drug anti-tb therapy 2 months ago in Peru No clinical improvement Case 3: Chest CT 6
Case 3: Final Diagnosis Sputum AFB smears and TB PCR negative Sputum sample processed for ova and parasites showing a paragonimus species egg Rx: Praziquantel 75 mg/kg/day in three divided doses, for three days Case 1-3: Lessons Learned TB has a lot of overlap with other serious conditions Many patients with confirmed TB start out with negative smears and NAAT, but it s a setting in which to be skeptical If empiric treatment is started, it should be accompanied by ongoing evaluation and monitoring for other causes until TB is confirmed Differential Diagnosis Community acquired pneumonia Malignancy Lung abscess Non-TB mycobacteria Fungal infection Parasite (e.g., paragonimiasis) Sarcoidosis Rheumatologic disease (e.g., Wegener s, RA) Other systemic infections (e.g., brucellosis, melioidosis, relapsing fever, etc.) 7
Case 4: Fatigue 43 y/o HIV-negative male with fully-sensitive sputum smear-positive pulmonary TB Baseline CBC/DIFF/CMP normal 4 week follow-up AFB smears negative Weight up 2 lbs Fatigue and dizziness Case 4: Next Steps LFTs normal Treatment continued Still fatigued and LFTs normal again at 6 weeks Telephone call from primary care at 7 weeks Case 5: Fatigue Revisited 34 y/o Korean male with inactive pulmonary TB Started INH 2 ½ months ago Last clinic visit 2 weeks ago. Adverse events checklist negative. Month 3 dispensed Now reports his family told him to come to clinic because his eyes look yellow Has not noticed much except feeling a lot more tired than usual for about 4-6 weeks and loss of appetite for about 2 weeks 8
Case 5: Next Steps INH stopped and LFTs drawn. ALT 950, AST 700, total bilirubin 4.2 Severe isoniazid liver injury Hospitalized and transferred to transplant center Peak ALT ~2000, peak bilirubin 25 Recovered. 6 weeks to normal LFTs Subsequently completed RIF x 4 months Case 5: Post-event Interview At month 1 and 2 clinic visits was asked a list of questions to which the answer was no Reported never being reminded after the first visit what side effects to watch for Understood less English than he portrayed Never had nausea, vomiting or abd pain Did a Google search on his symptoms Cases 4&5: Lessons Learned Fatigue and anorexia may be more sensitive indicators of liver injury than nausea/pain Fatigue may be due to something serious other than liver injury (e.g., anemia, myocardial ischemia, malignancy) Remind patients what side effects to look for at each encounter and to report all side effects promptly Nodding yes may mean I want to be cooperative but do not understand you. If you think about searching the Internet for symptoms, please hold medications and call the clinic. Do not re-start until told to do so. 9
Questions? Comments? christopher.spitters@kingcounty.gov 10