Tuberculosis in the Traveler Waterloo-Wellington Cardiovascular Respiratory Conference April 27 th, 2016 The Beat on Breathing Watch, Treat or Admit?
disclosures No Potential for conflict of interest Staffed the Region of Waterloo TB clinic since 1990! no financial support or in-kind support Owe my life to Tuberculosis!
Tuberculosis History
Tuberculosis epidemiology & control 8.8 million cases worldwide in 2010; 1.4 million deaths; 128/100,000
Tuberculosis Control Promptly diagnose and treat active cases to reduce further transmission Identification and treatment of people with latent disease (LTBI) to prevent reactivation and transmission
M.D. 30 yr old Nov. 20 th 2013 Dry Cough x 1 month then productive yellow to green to brown x 1 month; no blood Delayed SMA-No family doctor and thought secondary to smoking 25-30 lb weight loss!? Fever and night sweats in last two weeks Finally Left chest pain non-pleuritic UCC CXR 15/11/2013 WBC 10.4 Hgb 127 N LFT, and referral was made
M.D. 30 yr old Nov. 20 th 2013
M.D. 30 yr old Nov. 20 th 2013 SMGH ER subacute NO isolation No fever CT scan done before:?langerhans cell histiocytosis (LCH)
M.D. 30 yr old CT Scan Nov. 20 th 2013
M.D. 30 yr old Nov. 20 th 2013 BUT produced really purulent phlegm AND travel history South Korea for three years and Mongolia for 10 months teaching English; travelled to SE Asia (Vietnam, Cambodia, Thailand) for 6 weeks annual CXR s Weight loss, anemia and questioned fever and night sweats
M.D. 30 yr old Nov. 20 th 2013 SMGH ER subacute now in isolation Sputum 4+ acid fast bacilli!! Daily INH 300mg, rifampin 600mg pyrazinamide1500mg, ethambutol 1200mg
M.D. 30 yr old Nov. 20 th 2013 Langerhans cell histiocytosis (LCH) Cough very productive Tree in bud Too thick walled
M.D. 30 year old ISOLATED At Home for 5 months! Jan 22,2014: Responding, Cough, weight gain, no anemia and CXR better but hemoptysis and still AFB 3+ Pansensitive and adherent (not DOT)--9mos Contacted Dr. Michael Gardam + moxi 400mg March 2014: still AFB 3+ and growth at 27 days April 2014: no AFB and no growth out of isolation! Bilateral Achilles tendonitis!- d/c moxifloxacin 12 months therapy! Wife 9 months isoniazid 300mg od!
M.D. 31 =Bilateral Cavitary TB in Traveler, slow to respond Final CT Scan
R.N. 32 Respirologist s office, Feb 5, 2014 Non-productive cough x 6 months in atopic non-smoker after moved in and renovated home (July 2013) CXR normal both Nov 19, 2013 & Dec 18, 2013 Productive mucoid in Oct then yellow and rattling and purring in Jan 2014; no SOB zithromycin, clindamycin, ciclesonide, ventolin, mometasone nasal, no help-hydrocodone qhs PFT s normal Jan 2014
R.N. 32 Respirologist s office, Feb 5, 2014 No rhinosinusitis or reflux; bilateral wheeze-? Asthma despite normal PFT Δ to budesonide/formoterol, continue nasal spray,? dust?repeat allergy testing NB. no constitutional but mild night sweats
Left chest pain Purulent green cough, no fever, WBC 10.4 d dimer 466-CT scan Levofloxacin750mg od Extended to 21 days by NP! Felt 100% Noted inspiratory wheeze L>R &L pleural rub! R.N. 32 GRH ER Mar 23, 2014
R.N. 32 GRH ER Mar 23, 2014
R.N. 32 repeat consult Respirologist s office, April 30, 2014 ½ cup yellow phlegm /day, wt loss 5lbs, night sweats FVL no obstruction 7mm Nodules & hilar/ap nodes? Lymphoma, sarcoma, NE tumour Less likely infection?aspiration should have cleared, fungal, COP, sarcoid Bronchoscopy?OLBx CXR left sided Δ improved
R.N. 32 bronchoscopy, BAL, TBBx, May 8, 2014 Lab negative for vasculitis Tracheal vesicular nodules, L main and LUL diffuse erythematous friable; LLL normal BAL apical post and 4 TBBx lingula Epinephrine and CXR
R.N. 32 respirologist office, May 20, 2014 CXR marked improved Cough better, no phlegm, no fever or night sweats, regained 5 lbs But supine rattling and something there Biopsy multi-nucleated giant cells?poorly formed granuloma?infectious Δ post pneumonia,?aspirated No further antibiotics; methacholine on inhalers CXR one month?ct
R.N. 32 Waterloo Regional TB clinic July 8, 2014 PH lab report June 6, 2014 :AFB but growth at 27 days, pan sensitive TB!! Started INH 300,Rif 600, Eth 1200, PZA 1500 Feels better Travel history South Korea 2004-5, 2008-12, Africa 2009 x2mos, India 2010 x2mos,vietnam/cambodia ; no TST Husband 12mm on INH 300mg x 9 mos
Waterloo Region TB Clinic, Jan 5, 2015 Note progressive dyspnea, L inspiratory noise Dr. Jackson bronchoscopy = 50% L main stem stricture June 25, 2015 bronchoscopy & dilation at TGH TB tracheobronchitis with 2 nd bronchostenosis
Tuberculosis in the Traveler Waterloo Regional TB clinic July 8, 2014 Second case in a traveler?increasing issue with increased travel abroad Delayed diagnosis as not in typical risk group What are recommendations for screening travelers?
* * Opportunities in our cases
Identification of Patients with Respiratory TB Disease within Hospitals
Diagnose active Tuberculosis the curve ball Suspicion in high risk groups Cough for three weeks initially non-productive Fever and night sweats common Hemoptysis, anorexia, weight loss, chest pain in more advanced disease CXR: apical posterior upper lobes, superior segment lower lobes; volume loss ;cavitation, pleural effusion Sputum x 3?induced bronchoscopy
Diagnosis & Treatment of Latent Tuberculosis (LTBI) The selection of people for targeted LTBI screening and treatment is based on: 1. their risk of prior TB exposure 2. their risk of reactivation 3. balanced against the likelihood of safe completion of treatment, including the risk of hepatotoxicity, which increases with age. TST Tuberculin skin test (TST) or interferon gamma release assay (IGRA)
TST All TST <65 yrs Homeless, IDU, immigrants & refugees Only <50 yrs
Travelers to Canada
Which Countries are High risk?
Travelers to Canada with Active TB Most foreign-born groups undergo a mandatory medical examination prior to arrival in Canada, which includes chest radiography to detect active TB. Those found to have active TB must be treated prior to arrival to ensure that they are no longer infectious (.05-2%) Citizenship and Immigration Canada (CIC) requires that individuals with previously treated TB and those with abnormal chest radiographs but without active TB detected in this program undergo TB surveillance after arrival. (1.3%) Only a small proportion (2-15%) of all cases of active TB diagnosed in the foreignborn after arrival in Canada are detected during the immigration post-landing surveillance program. This underscores the need for additional screening programs for subgroups of the foreign-born at increased risk of TB reactivation. Risks beyond the first 5 years! (only 44% within 5 years)
Challenges to LTBI screening & treatment of immigrants 1. Large number 2. Immigrants return home for prolonged periods without travel advice 3. Patient barriers: stigma, linguistic, economics, risk perception/bcg 4. Provider barriers: knowledge 5. Focus on higher risk
Immigrants returning Home 20% cases in U.K. were in immigrants returning to India 56% TB cases in Moroccans in Netherlands associated with recent travel to Morocco
Health Care Worker
Health Care Worker
What about our cases? M.D. 30 year old South Korea x 3 years & Mongolia x 10months??TST 2 months after return and education before Diagnosis delayed due to patients factor (eg. Smoking and no family MD)
Travel: South Korea 2004-5, 2008-12 (90/100,000) Africa (?countries) 2009 x 2 months India 2010 x?2 months (168/100,000) Vietnam x?(200/100,000) What about our cases? Cambodia x? (442/100,000) R.N. 32?TST 2 months after return; education before Delayed diagnosis also due to initial Normal CXRs; pneumonia response to prolonged levofloxacin; lower lobe disease but significant travel history missed!
Problem with Treatment of LTBI
Problem with Treatment of LTBI only 26% complete! 1. Only 69% screened 2. Exclude active disease 3. Only 77% offered 4. Refused ( 83% accepted----target 80%) 5. Not completed (71%completed---target 80%) 6. toxicity
Tubersol Free Publically funded Tubersol is still available from Public Health for testing : 1. Contacts of active cases of TB and healthcare workers at high risk of TB exposure 2. Medically indicated individuals that are at increased risk of developing active TB (diabetes, HIV, renal failure, immunosuppressant medications) or to evaluate symptoms suggestive of TB 3. Individuals requiring admission to treatment rehabilitation centres 4. Resident admissions to Long-Term Care facilities 5. Recent arrivals Immigrants / Refugees within five years of arrival Tubersol is not available to GP s for 3 rd party testing such as educational institution, employment or volunteering Referral form and other links are available of the Public Health Website http://chd.region.waterloo.on.ca/en/healthylivinghealthprotection/tuberculosis.asp Public Health Main # 519-575-4400 ask for TB program
Questions??