Çapa dahiliye günleri
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Çapa Dahiliye Günleri. Tüberküloz Olgu Sunumu Cerrahpaşa Tıp Fakültesi Enfeksiyon Hastalıkları ve Klinik Mikrobiyoloji AD Dr Uluhan Sili 2.Nisan.2009 Prof Dr Ali MERT’in bir olgusundan u yarlanmıştır. Olgu. 23 y, erkek hasta 4 hafta önce sistemik lupus eritematozus (SLE) tanısı konmuş - PowerPoint PPT PresentationTRANSCRIPT
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Çapa Dahiliye GünleriTüberküloz Olgu SunumuCerrahpaşa Tıp Fakültesi Enfeksiyon Hastalıkları ve Klinik Mikrobiyoloji AD
Dr Uluhan Sili
2.Nisan.2009
Prof Dr Ali MERT’in bir olgusundan uyarlanmıştır.
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Olgu 23 y, erkek hasta
4 hafta önce sistemik lupus eritematozus (SLE) tanısı konmuş Ateş, halsizlik, iştahsızlık, kilo kaybı, bulantı/kusma Sistemik LAP, splenomegali Trombositopeni, lökopeni, ESR (60mm/saat), CRP:N,
proteinüri, mikroskopik hematüri, piyüri, ALT ve AST Anti-dsDNA (+), ANA (-), C3 ve C4 Böbrek bx: mezengioproliferatif lupus nefriti
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Klinik kötüleşme... Steroid tedavisinin 4. haftasında
Klinik yanıt alınmaya başlandığı sırada kötüleşme Ateş, kuru öksürük CRP (x20) Kültürlerde üreme yok Akc PA: N
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SLE reaktivasyonu düşünülerek... Pulse steroid + siklofosfamid başlanıyor
Bu tedavinin 2. haftasında klinik yanıt yok
Haftalık çekilen akc grafisi ve YÇBT ile takip ediliyor
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Tanı: Miliyer TB BAL: ARB (-)
Empirik anti-TB (İNH/RİF/PZA/EMB) başlanıyor
BAL ve TB hemokültürde pansensitif M. tuberculosis üremesi
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Anti- TB tedavinin 4. ayı içinde...
Biraz düşme eğiliminde olan ateşleri tekrar
Hafifleyen öksürükleri artıyor ve dispne ekleniyor
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YÇBT: Miliyer odaklarda ilerleme Sayıları ve büyüklükleri artmış
Üst loblardaki nodüllerde kaviteler gelişmiş
BAL: ARB ve PCR (-), kültür (-)
TB hemokültür (-)
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Paradoksal Reaksiyon Yol: tedaviye devam
Anti-TB tedavinin 6. ayında ateşleri düşüyor ve taburcu ediliyor
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Taburcu edildikten 1 ay sonra
Birden bıçak batar gibi ciddi sol yan ağrısı
Gittikçe artan solunum darlığı
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TANI: Pnömotoraks(Paradoksal reaksiyon sonucu) Dren konulup akc genişlemesi sağlanıyor
Anti-TB tedavini 8. ayında PPD (+)’leşiyor
Tedavi 12 ay sürdürülüyor
Tedavi bitiminin 12. ayında miliyer odaklar kayboluyor
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Sonuç olarak...Miliyer TB, yeni ateşi gelişen tüm immün düşkün hastalarda mutlaka akla getirilmelidir.
“Bir derlemede miliyer TB olgularının %20’sine tanı post mortem konmuş” UpToDate
Miliyer infiltratlar saptanır saptanmaz anti-TB tedavi başlanmalıdır. Mert A, 2001, Respirology
İlginiz için teşekkürler!
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Maartens,1990
Kim,1990
Munt,1971
Percentage of total patients with any identifiable underlying condition 38 66 70
Percentage of total patients with stated underlying condition• Alcohol abuse 16 37 38• Corticosteroids or other
immunosuppressive medication 6 8 -• Connective tissue disease (with or
without medication) 3 18 4• Diabetes mellitus 4 5 -• Renal failure - 10 -• Malignancy 4 8 14• Pregnancy or postpartum state 8 8 14
Underlying medical conditions in patients with miliary tuberculosis (UpToDate)
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Symptoms in patients with miliary tuberculosis (UpToDate) Symptom Maarten
s, 1990Kim, 1990
Gelb, 1973
Munt, 1971
Proudfoot, 1969
Biehl, 1957
Fever and/or night sweats 96* 89 85 83 83 35
Anorexia 92 78 87 91 - 42Weight loss 92 66 87 85 75 61Weakness or malaise 92 - - 92 78 40Respiratory (cough, dsypnea, pleuritic chest pain)
72 55 69 78 18 91
GI (abdominal pain, nausea, vomiting, diarrhea)
21 - - 12 - 32
Headache or central nervous system 25 5 16 10 - 27
Musculoskeletal 13 - - - - -
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HRCT (UpToDate)
more sensitive for miliary TB than plain chest radiography
numerous, 2 to 3 mm nodules can be visualized, distributed throughout the lung
However, while sensitive these findings are not necessarily specific.
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Differential diagnosis of febrile illness with miliary chest x-ray infiltrates (UpToDate)Infectious DiseasesMycobacterialMycobacterium tuberculosis, atypical mycobacteriaFungalEndemic fungi (histoplasmosis, coccidioidomycosis, blastomycosis,
paracoccidioidomycosis)BacterialLegionella micdadei infection, NocardiosisStaphylococcus aureus, Haemophilus influenzae and other pyogenic bacteriaPsittacosis, Tularemia, Bartonellosis, Brucellosis, MeliodosisViralVaricella, Cytomegalovirus, Influenza, MeaslesParasiticToxoplasmosis, Strongyloidiasis, Schistosomiasis,
Neoplastic diseasesLymphoma, Lymphangitic spread of carcinoma, Mesothelioma
Other diseasesSarcoidosis, Amyloidosis, Hypersensitivity pneumonitis, PneumoconiosesForeign-body induced vasculitis related to injection drug use
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Frequency of positive smear or culture in patients with miliary tuberculosis Site Maartens, 1990 Kim, 1990Sputum smear 33* 36Sputum culture 62 76BAL smear 27 9BAL culture 55 54Gastric aspirate smear 43 0Gastric aspirate culture 100 75Urine smear 14 7Urine culture 33 59CSF smear 8 0CSF culture 60 0Serosal smear 6 0
Serosal culture 44 14
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PCR for diagnosis of miliary TB (UpToDate) more sensitive than standard techniques in some series examining respiratory specimens, CSF, bone marrow, or liver biopsy specimens.
PCR of the blood was positive in 100 percent of a small number of patients with disseminated disease (defined as involvement of two or more noncontiguous extrapulmonary organs), and in no controls (healthy patients or patients with positive PPDs).
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Treatment (UpToDate) Isoniazid and rifampin are then administered for at least six months
Tailored to the underlying immune status of the host, the burden of infection as well as the clinical and microbiologic response Longer therapy should be considered in the following patients with miliary TB:
Children and immunocompromised hosts, including those with HIV infection and iatrogenic immunosuppression
Those with lymphadenitis, a site of early relapse in anecdotal reports
large organism burden, for example those with anergic or non-reactive tuberculosis
slow microbiologic or clinical response