icky infectious diseases - citc - tuberculosis (tb) education
TRANSCRIPT
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SubacuteAdenitisSubacuteSubacuteAdenitisAdenitisAnn M. Loeffler, MDAnn M. Loeffler, MD
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Lymphadenitis• Swelling and hyperplasia of sinusoidal
lining cells • Infiltration of leukocytes• +/- abscess formation• Granulomatous or non-granulomatous
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Pyogenic adenitis• Typically:
– Acute onset– Neck lymph nodes (inguinal or axillary)– Usually solitary node– Over days, becomes red, warm, and
tender
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Pyogenic adenitis
Strep adenitis
• Typically:– Worsens in days– Associated with
systemic symptoms– Pre-school aged
children
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Pyogenic adenitis• Staph aureus and Group A Strep are
most common pathogens (GBS in young infants)
• Early treatment may avoid surgical drainage
• Partially treated pyogenic adenitis can mimic indolent adenitis
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Indolent adenitis• Rare causes:
– Sporothrix– Tularemia– BCG adenitis– Bubonic plague– Toxoplasmosis
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Venereal inguinal buboes
• Chancroid• Lymphogranuloma venereum (LGV)• Primary genital herpes• Syphilis
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“The big three”• Cat Scratch Disease (CSD)
– Bartonella henselae• Atypical mycobacteria• M. tuberculosis
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Cat Scratch Disease• Follows animal contact
– Usually a kitten– With fleas– Who spends time outdoors– Born in the spring estrus
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Cat Scratch Disease• Most common in
children 2 – 14 yrs • Inoculation papule
or pustule may be found
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Cat Scratch Disease• Regional lymphadenopathy
– Axillary– Cervical / Submandibular– Preauricular– Epitrochlear– Inguinal
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Cat Scratch Disease• 50% more than one
node
• Multiple sites 20%
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CSD Adenopathy• Follow cat scratch by several weeks• Nodes gradually enlarge, become
tender• Overlying skin is initially normal,
becomes dusky red and indurated
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CSD Adenopathy• 10 – 40% suppurate• Occasional sinus tract formation• Nodes enlarge for 4 – 6 weeks• Eventually spontantously resolve
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CSD Adenopathy• Diagnosis
– Exposure to kitten– Scratch slow to heal– Inoculation papule or pustule– Negative Tuberculin Skin Test (TST)
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CSD Adenopathy• Diagnosis
– Failure to respond to antibiotics– Aspiration cultures, AFB studies
negative– Pathology – caseating granulomata– Serologies: B. henselae and B. quintana
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CSD Treatment• Supportive care
– Needle aspiration for very tender node– Excisional biopsy if other diagnosis strongly
considered• Malignancy• Nontuberculous mycobacteria
– Medical management• Azithromycin with or without rifampin (not proven to
help)
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CSD - other manifestations
• Perinaud’s oculoglandular syndrome• Osteomyelitis• FUO - Hepatic or splenic granulomata• Skin lesions• Eye disease• Encephalopathy
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Mycobacterialscrofula
• Nontuberculous mycobacteria (NTM)– MAC– M. scrofulaceum– M. kansasii– Others
• M. tuberculosis complex (TB)– M. tb & M. bovis
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Mycobacterial scrofulaNontuberculous TB
TST reaction Modest Larger
TB exposure Absent PresentRace / ethnicity Any Minority
Age 1 – 4 years Typically older
Location Submandibular Cervical / other
Response to Tx Scant Good in kids
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PPD DistributionAll Culture Results
0123456789
10
#
0-9 mm 10-14 mm 15-19 mm 20-24 mm 25 mm+
M. TbNTMCult neg
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Mycobacterialscrofula
• Gradually enlarging nodes (not the normal modestly enlarged, not changing lymph nodes)
• Nodes suppurate / become fluctuant• Skin looks dusky / pink – purplish• Skin thins and flakes• Node adheres to the overlying skin• Draining sinus sometimes follows
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Mycobacterialscrofula
• Treatment– If suspected NTM, ask most
experienced pediatric neck surgeon to resect the entire node
– If TB suspect seek a source case with an abnormal radiograph. If cultures from the source case are imminent –forgo surgical intervention
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Mycobacterialscrofula
• If the diagnosis is uncertain, the node can usually be aspirated without creation of a sinus tract
• Avoid incision / drainage of a suspected scrofula
• AFB smears and cultures frequently negative (NTM > TB)
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Mycobacterialscrofula
• If excisional surgery IMPOSSIBLE (facial nerve risk) – Consider empiric medical therapy
• Four drug TB therapy • Three drug NTM therapy (clarithromycin, rifampin or
rifabutin, ethambutol)• Sometimes use 5 drugs to cover both• Rapid improvement on TB therapy +/- clarithromycin
suggests TB
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Start of therapy
NTM Case Photo courtesy of Robert G. Allison, MD.
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End of therapy
NTM Case
Photo courtesy of Robert G. Allison, MD.
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Mycobacterialscrofula
• Treatment regimens– TB treatment by directly observed
therapy• INH, rifampin, pyrazinamide and ethambutol
5 – 7 days per week for 2 months• Followed by INH and rifampin twice weekly
for 4 more months• M. bovis inherently resistant to PZA –
minimum 9 months
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Mycobacterialscrofula
• Treatment regimens– NTM
• Clarithromycin or azithromycin, rifampin or rifabutin, ethambutol daily for 3 months
• Clarithromycin daily for three more months• Monitor hearing and vision
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Summary• Many infectious and non-infections
etiologies cause lymphadenitis• Pyogenic, CSD and mycobacterial
disease are most common causes of indolent adenitis
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Summary• Diagnosis is made on clinical /
demographic grounds with aid of TST and CSD titers
• Treatment is primarily surgical for atypical mycobacteria
• Treatment is primarily medical for TB
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Summary• Medical treatment is sometimes used
for NTM scrofula which is inoperable• CSD nodes usually resolve without
cosmetic sequelae– Serial drainages may be needed– Medical management rarely indicated