TB Intensive :: Extrapulmonary TB :: San Antonio, TX ... for diagnosis • Neurosurgeon for shunt...
Transcript of TB Intensive :: Extrapulmonary TB :: San Antonio, TX ... for diagnosis • Neurosurgeon for shunt...
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TB IntensiveApril 5‐8, 2016San Antonio, TX
ExtrapulmonaryTBLindaDooley,MDApril7,2016
• No conflict of interests
• No relevant financial relationships with any commercial companies pertaining to this educational activity
Linda Dooley, MD has the followingdisclosures to make:
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• Treated the same as pulmonary TB: same meds, DOT necessary
• May be harder to diagnose; AFB culture often negative
• Can be (almost) anywhere
• Some patients have unsuspected pulmonary disease and may be infectious
Generalizations about Extrapulmonary TB
• Sometimes treat longer: meningitis, miliary
• Extrapulmonary TB more common in immune suppressed patients (HIV, TNF blockers)
• More common in Asian patients
More generalizations
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Distribution of Extrapulmonary TB
LymphaticPleuralMeningitisGIBone and jointMiliaryGenitourinaryOther
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Patients with extrapulmonary TB may also have pulmonary involvement, even
with a normal chest x‐ray
ALWAYS GET SPUTUM FOR AFB EVEN IF THE CHEST X‐RAY IS NORMAL
• 2nd most common form of extra‐pulmonary TB (15‐20%)
• In most of the world, TB is the most common cause of pleural effusions
• Higher incidence in HIV+ patients
• Commonly a manifestation of primary TB
• May progress from an exudative effusion to an empyema or bronchopleural fistula
Pleural Tuberculosis
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Pleural TB
TB Empyema
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• Thoracentesis with pleural biopsy• 30% yield for MTB from pleural fluid• Exudative fluid with lymphocyte
predominance, protein more than 4 g/l ; glucose varies
• Pleural biopsy and culture may double yield of + culture
• Adenosine deaminase not sensitive nor specific
Diagnosis
Tuberculous pleural effusions often resolve without treatment but high risk for later pulmonary
disease: treat as TB disease anyway since can progress to
pulmonary disease
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• Same as pulmonary TB
• 6 months adequate if no drug resistance or immune problems
• Drop PZA at 2 months and leave EMB in regimen if cultures negative
Treatment
• Initial diagnosis: thoracentesis and pleural biopsy
• More rarely for repeat thoracentesis if pleural fluid re‐accumulates
• Chest tube placement and possible decortication if empyema develops
(surgery, cardiovascular surgery)
Surgical/ Specialist Involvement(surgeon, ER, radiology, hospitalist)
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Lymphatic TB
• Most common form of extra-pulmonary TB (30-40%)• Most common sites are cervical (scrofula) or mediastinal but can affect any node
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• Fine needle aspirate or open biopsy
• Culture for AFB
• Don’t forget CXR and sputum
• More common in women, Asian population, immune suppression (HIV, TNF blockers)
• Treat like pulmonary TB
• Immune reconstitution may occur even with HIV negative patients
Diagnosis and Treatment
• Site determines specialist:
• ENT for cervical, pulmonary, radiology for hilar; surgeon for other LN
• Initial diagnosis by fine needle aspirate or biopsy
• Repeat I&D if swelling worsens
• Immune reconstitution can cause obstruction
Surgical/Specialist Involvement
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• 300‐400 patients annually in US
• 1% of TB disease
• Even with effective treatment, case fatality high: 15‐40%
• Early diagnosis both difficult and critical
TB Meningitis
• TB granuloma spills into subarachnoid space producing inflammation, proliferative arachnoiditis, vasculitis and communicating hydrocephalus
• Localized initially to base of brain
Pathogenesis
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Necrotizing granulomatous changes in arachnoid and blood vessels
Basilar meningitis
• Presentation may mimic bacterial meningitis: acute, rapidly progressive
• May be a slowly progressive dementia over months with personality change, social withdrawal or memory deficits
Diagnosis
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• Lumbar puncture: AFB stain and culture, PCR, NAAT, low CSF glucose, high protein, lymphocyte predominance
• Serial examination of the CSF by AFB stain and culture is the best diagnostic approach
• Use last fluid obtained; higher yield for larger volume CSF (10‐15cc)
CSF examinationNegative results do NOT exclude the
diagnosis
• Typically elevated protein, low glucose, and lymphocyte predominance
• Early CSF may be relatively acellular or PMN predominant
• Smears and cultures may yield positive results days to weeks after therapy has been initiated or may be negative
CSF studies
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Nov
CT and MRI helpful in diagnosis
Multiple tuberculomas along enhanced dural reflections
Basilar enhancement and hydrocephalus
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• Treat if TB meningitis suspected
• Early treatment essential
Treatment
• 9‐12 months for drug sensitive disease
• 18 months if no PZA
• Extend to 18‐24 months for severe illness, slow clinical response, or immune suppression
• No guidelines for length of treatment for MDR or XDR TB: expert consult essential
Treatment
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CSF Penetration of TB Meds
GOOD FAIR POOR
Isoniazid * Rifampin * Streptomycin *
Pyrazimamide Ethambutol Capreomycin *
Ethionamide Quinolones * Amikacin *
Cycloserine Kanamycin *
Linezolid *
* Can Be Given IV
• Adjunctive corticosteroids may be beneficial and are recommended for all children and adults being treated for TB meningitis
• Doses– Children: 2‐4 mg/kg prednisone tapered over 4 weeks
– Adults: 60 mg/d prednisone tapered over 6 weeks or .4 mg/kg/day dexamethasone IV tapered to .1 mg/kg/day
– May need longer slower taper
Steroids
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• ER doc, radiologist or hospital doc for initial LP for diagnosis
• Neurosurgeon for shunt placement if needed later: surgery need can be urgent
Surgical/Specialist Involvement
Neurosurgical Involvement
• Hydrocephalus may require urgent shunting.
• Serial LP and steroid therapy may suffice for Stage I patients awaiting response to antibiotics
• Shunting should not be delayed in patients with stupor, coma or progressive neurologic signs
Nov 2009
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• Fine needle aspirate: granulomatous tissue
• Normal CXR
• Consultant recommended LN biopsy for better chance MTB and sensitivities
• Pt declined: did not have $8000 required down payment
• Abnormal CT head; no LP done
Case: 20 yo Pakistani woman with severe headache and swollen neck
nodes
• Observed induced sputum collection done by NCM had positive NAAT
• Drug sensitive MTB from sputum
• One month later also grew TB from neck aspirate
• Headache resolved on TB therapy
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Pericardial TB
Pericardial TB
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• Uncommon and difficult diagnosis
• Presents with acute or insidious onset; nonspecific symptoms
• Ultrasound helpful; acid fast studies may not be positive
• Surgery for progressive tamponnade or recurrent effusions on TB Rx
• Steroids reduce mortality and need for surgery or repeat pericardiocentesis: start at 60 mg/d 1st month and reduce over 11 weeks
Pericardial TB
• Cardiothoracic surgeon: essential for initial diagnosis as well as for management of recurrent effusion or tamponnade
• May require urgent management
• Pericardial stripping may be needed
Surgical/Specialist Involvement
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Bone and Joint TB
• Spinal TB (Pott’s disease) most common location: 40%
• Next most common: hip (40%) and knee (10%)
• Can be anywhere
• Frequently delayed diagnosis
• X‐ray not helpful in distinguishing other infectious destructive etiology
Skeletal TB
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• Joint aspiration: WBC may be granulocytes or lymphocytes
• WBC count varies widely
• Protein 4‐6 g/dl; glucose may be low
• Acid fast culture yield high (up to 80%)
• Presence of positive smear much lower (20%)
Diagnosis
• Standard TB therapy with extended treatment
• 6‐12 months: extend therapy for slow or uncertain response
Treatment of TB Osteomyelitis
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• Orthopedist, primary care, or rheumatologist may do initial arthrocentesis for diagnosis
• Surgery may be needed if bone/joint stabilization required or if prosthesis needs to be removed
• With spinal TB, neurosurgery or spine surgeon involvement essential for spine stabilization (external or surgical)
• Effective treatment may preclude need for surgery
Surgical/Specialist Involvement
Soft Tissue TB
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• Often adjacent to bony and may be direct spread from bony structure or may erode into bone: can be difficult to know if bone involved
• If not sure if bone involved, treat like skeletal TB (longer duration)
• I&D of abscess will only be diagnostic if acid fast cultures done
• Surgical involvement for diagnosis and management of large abscesses: type depends on site
Soft Tissue TB
• Peritoneal TB 10% extra‐pulmonary
• GI tract: any site possible but more common terminal ileum and cecum then rest of colon
• Often delayed diagnosis
• TB bacilli may be ingested rather than inspired: consider early if patient drank or ate unpasteurized milk products
• Acid fast cultures frequently negative: pathology caseating necrotizing granulomas
Gastrointestinal and Peritoneal TB
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Peritoneal TB
Laparoscopic view of peritoneal granulomas
Peritoneal TB: laparoscopic view of spiderweb adhesions
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• If cultures negative or pending, assume PZA resistance
Treatment
Esophageal TB Duodenal TB
Consider the age of your patient and possible childhood exposure to M. bovis
84 yo man with normal CXR
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• Gastroenterologist or general surgery may make initial diagnosis
• Patient may need paracentesis for initial diagnosis or management of recalcitrant ascites
Surgical/Specialist Involvement
Urogenital TB
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• 10‐15% extrapulmonary TB
• Often insidious onset, subtle nonspecific symptoms, delay in diagnosis
• Hematogenous spread from primary site, often years after infection
• Any part of GU tract may be affected
Genitourinary TB
Ureteral abnormalities (multiple “beading” strictures); may be virtually diagnostic of renal TB
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• May have pyuria or hematuria or both
• Acid fast cultures of urine for sterile pyuria
• May need more than 3 specimens of first morning urine collection
• Urine AFB studies not always positive
• NAAT testing may be helpful but negative result does not preclude diagnosis
• Surgery or stenting for obstruction
Renal TB
Prostatic TB
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Testicular TB
Uterine TB
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• With Fallopian tube involvement, unlikely that preservation of fertility possible since usual scarring
• Often diagnosed by pathology after hysterectomy: treat even if involved organ removed
Female Genital TB
• Urology or gynecology involved in initial diagnosis
• Urologist essential if renal obstruction develops for ureteral stent placement and removal
• Obstruction may develop after therapy underway: immune reconstitution
Surgical/Specialist Involvement
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Other TB
Laryngeal TB
Tuberculous Otitis Media
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TB Mastoiditis
Adrenal TB
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• May have unsuspected adrenal involvement alone or with disseminated TB
• Assessment of adrenal function if slow response or hypokalemia, hyponatremia, hypotension
• Don’t forget adrenal insufficiency possiblity if steroids were stopped after long use
Adrenal insufficiency and TB
Ocular TB
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• Diagnosis made by ophthalmologist
• Diagnosis of exclusion: patient should be followed by ophthalmology during TB treatment
• Usually no cultures available
• Treat same as pulmonary TB
TB of the Eye
Dermatologic Tuberculous
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• May be hematogenous or direct spread
• May be injection: accidents in pathology or microbiology lab
• Treatment same as pulmonary TB
TB of the Skin
What’s left??
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TB Everywhere
• Tiny lesions spread throughout the body
• Distinctive pattern on CXR or CT
Miliary or Disseminated TB
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• Pulmonary involvement may not be present
• Frequently subacute presentation with fever and weight loss
• More rarely can be a fulminant sepsis‐like presentation with acute onset and rapid deterioration (usually fatal)
• Liver biopsy may be helpful
• Blood cultures may be positive if acid fast studies done
• All AFB may be negative
Miliary TB
• Usually prolonged treatment needed: 9‐12 months or more
• Cultures may be negative: paucibacillary disease
• Don’t let negative cultures or normal CXR tempt you to shorten therapy
Treatment of Disseminated TB
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Thank you
Don’t forget to get sputum AFB even if you think only extrapulmonary TB