tuberculosis...establishing a diagnosis imaging - pulmonary: cxr – cavitation, consolidation etc...
TRANSCRIPT
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TUBERCULOSIS lll
Signs, Symptoms and Treatment
Dr Veronica White, BSc MBBS MSc MD FRCP
Consultant Physician
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TB in East London
700 cases across merged Trust
250 seen at LCH; 150 notified in Tower
Hamlets
1/3 pulmonary; 2/3 non-pulmonary
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2013
Patients still dying of TB in Tower Hamlets
Patients still presenting in A&E with advanced
disease
Health professionals still missing diagnosis
Patients and public still afraid of TB
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Demographics of patients
Aged 16-35
75% born aboard
25% have been in UK less than 3 years
Interactions with medical services maybe poor
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Barriers to diagnosis
Access to health care
Language barriers
Expressing/picking up subtle symptoms
Experience of health professionals
Health beliefs and stigma
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Risk factors
Socioeconomic deprivation
Patient from an ethnic minority with a high incidence of TB
iv drug and/or alcohol abuse
Family or personal History of TB
Immunocompromised
Recent visit to high prevalence area
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However….
Some of our sickest TB patients are:
UK born, BCG positive, HIV negative, teetotal,
and ‘middle class’!!!!
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Presentation of Tuberculosis
Important history and symptoms to consider:
Cough +/- haemoptysis
Fever
Night sweats
Weight loss
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Non-pulmonary sites
Pleurisy (pleural space) - presents with pleural
effusion
Lymph node 'scrofula'
Bone – osteomyelitis, Pott’s fracture - spine
Brain - meningitis, tuberculoma
Skin – 'lupus vulgaris'
Genitourinary tract - kidneys, prostate, uterus
Heart - TB pericarditis
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Beware the atypical presentation
Unexplained weight loss, anorexia or fevers
Confusion with lung cancer
Swollen lymph nodes
Recurrent chest or water infections
Back pain or joint pain and swelling
Non-healing ulcers or sinuses
Recurrent abdominal pain
‘Tension headache' or depression
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Establishing a diagnosis
Bloods tests:
FBC (may be anaemic) , ESR (may be normal),
U&E, LFT (baselines)
Bone profile, Vit D
HIV, Hepatitis screen
Mantoux testing and IGRAs are not done
routinely
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Establishing a diagnosis
Imaging - Pulmonary: CXR – cavitation,
consolidation etc
Non-pulmonary – imaging modality appropriate
for organ e.g. US scan (nodes), MRI (bone/
brain), CT (abdomen/intra thoracic nodes)
Microbiology – FOR AFB! Sputum, pus, biopsy
of bone, skin, lymph node etc
Histology - granulomas
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Establishing a diagnosis
Samples, samples, samples
Make sure they go for AFB, AFB, AFB…!
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Lymph node TB
25% of cases
Lymph nodes are enlarged, red/purple, often
fluctuant, but cold (‘cold’ abscess)
50% cervical; can be mediastinal & elsewhere
Can present without systemic symptoms; can
mimic sarcoidosis/lymphoma
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Making a diagnosis
CXR – any mediastinal nodes? CT
FNA for cytology and AFB
Open biopsy if unsure (or EBUS)
Important to rule out lymphoma/cancer
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Treatment
Same as pulmonary TB
Lymph nodes sometimes get bigger on
treatment – warn patients!
Nodes may burst and discharge
May need steroids (double dose)
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Pleural tuberculosis
In differential diagnosis of any patient with a unilateral pleural effusion
In a young person, DON’T assume it’s TB
CT scan and pleural biopsy
VATS if unsure
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Abdominal TB
Fever, weight loss, abdominal swelling and
ascites
Again – can mimic cancer
Laparoscopic or radiologically guided biopsies
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Abdominal TB
Liver TB – granulomas on biopsy
Splenic lesions
Abdominal lymphadenopathy
Adrenals
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TB of bone
TB can cause chronic discharging abscesses
Treated with antibiotics, but not settled
Often forget to send pus samples for AFB
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TB of bone
Drainage of abscess is helpful
MRI to exclude osteomyelitis
Abscesses often dry up quickly on starting
treatment
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Spinal TB
Back pain (95%)
40-50% neurological symptoms – weakness,
paresthesia, bowel symptoms
40-50% with systemic symptoms – fever, night
sweats, weight loss
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Spinal TB
Specialist clinic at Barts and the London
Can carry considerable morbidity
Often associated with psoas abscess(es)
May need surgery to stabilise spine
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Spinal TB
Generally good outcome
Particularly with multilevel disease we may treat for 1 year
Often given steroids
Can be left with chronic back pain
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Cerebral TB
TB meningitis and cerebral tuberculosis
Subtle presentations: headache, depression,
psychosis
Less subtle: sudden loss of consciousness,
seizures
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Cerebral TB
MRI is imaging of choice: meningeal
enhancement, tuberculoma
Lumbar puncture, LP, if safe
Avoid brain biopsy unless diagnosis unclear
Often treated on a clinical diagnosis with results
following….
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Cerebral TB
Outcome – variable
An associated cerebral vasculitis can occur; hydrocephalus not uncommon
Often treated with very high doses steroids
TB treatment for at least one year
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Ophthalmic TB
Close links with Moorfields
Clinical diagnosis
Rarely have biopsy samples
Treat for 1 year
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Ophthalmic TB
Also: eye disease related to but not directly
caused by TB – ‘Eales’ disease’
Look for active TB in other parts of the body
Sometime treat empirically for six months;
often 1 year
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In addition….
Miliary
Pericardial
Genitourinary
Cutaneous/Laryngeal/tonsillar
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In addition….
May be multifocal:
i.e head and foot; chest and hand, spine lymph
nodes
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Treatment
Department of Health recommendation:
Drug treatment of TB should be supervised
by a hospital physician with a special interest
in the disease, (normally a respiratory or
infectious disease consultant).
Where organs other than the lungs are involved,
shared specialist care (e.g. with neurosurgeons)
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Treatment
Six month drug regime
Isoniazid 300mg od 6 months
Rifampicin 600mg od 6 months
Pyrazinamide 2g od 2 months
Ethambutol 15mg/kg od 2 months
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Side Effect
Nausea and vomiting
Itching
Skin rash Steven Johnson syndrome
Hepatotoxicity
Peripheral neuropathy
Arthralgia
Optic neuritis blindness
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Side Effects
Common issues and remedies:
Nausea – anti-emetics (check LFTs)
Itching – anti-histamines
Arthralgia - paracetamol
Jaundiced – STOP medication and ring us!
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Treatment
Lots of tablets for at least six months !
Patients get bored once they get better
Inadequate treatment can lead to drug resistant
disease
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Summary
Symptoms can be insidious
Ask about systemic symptoms – often
forgotten (by patient and medics)
Multi- organ disease ; TB can occur at any site
Samples/biopsies are crucial
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Summary
Treatment is for at least 6 months
Steroid doses may be high (double dose with
rifampicin)
Patients require prolonged medical and social
support
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Questions?