Unit 6 Diagnosing TB: B Family Case Botswana National Tuberculosis Programme Manual Training for...

Unit 6 Diagnosing TB: Unit 6 Diagnosing TB: B Family Case B Family Case

Botswana National Tuberculosis Programme Manual Training for Medical Officers

Unit 6: Case Studies

B Family BackgroundB Family Background

Recall that:

• Mrs. B visits a clinic after noticing a cough her husband had for a few weeks and suspecting that he might be engaging in behaviors risky for HIV

• She tests positive for HIV and is started on IPT

• Contact tracing is initiated


Case: B FamilyCase: B Family

• Mr. B, a 32 year old man, presents to the clinic with a cough he has had for 1 month

• He is not severely ill and can be evaluated in an ambulatory setting


B FamilyB Family Case: Question 1 Case: Question 1

What questions do you ask

about his history?


B FamilyB Family Case: Answer 1 Case: Answer 1

Ask questions regarding his history of smoking and occupational exposures


B FamilyB Family Case: Question 2 Case: Question 2

What signs and symptoms do you

look for when examining him?


B FamilyB Family Case: Answer 2 Case: Answer 2

• Cough for 2-3 weeks• Usually sputum

productive• May be

bloodstained• Chest pain• Dyspnoea

• Night sweats• Loss of appetite• Weight Loss• Fatigue

Evaluate him for tuberculosis symptoms:


B FamilyB Family Case: Question 3 (1) Case: Question 3 (1)

During examination, Mr. B:• Denies experiencing dyspnoea, chest pain, fever,

shortness of breath, loss of appetite, chronic diseases, smoking or taking any medications

• Reports having no prior history of TB, but reports having had contact with a TB positive uncle

• Reports coughing for 1 month, weight loss over the past few months, night sweats and fatigue


B FamilyB Family Case: Question 3 (2) Case: Question 3 (2)

• T 37

• Wt 58kg

• R 18

• P 82

• Pt looks thin, wasted

• Crepitations to auscultation

• Cervical lymphadenopathy

• Otherwise, exam normal

What do you do next for Mr. B?

During examination, health worker finds:


B FamilyB Family Case: Answer 3 (1) Case: Answer 3 (1)

• Obtain relevant contact history• When was the exposure?• Is the patient on treatment?• What was the duration of exposure, etc.?

• Take a spot sputum test today• When obtaining the spot sputum, have the patient rinse

his mouth with water first• Stand outside with him, behind the direction he is facing,

and have him cough

• Counsel Mr. B and test him for HIV today


B FamilyB Family Case: Answer 3 (2) Case: Answer 3 (2)

• Send Mr. B home with another specimen jar for a morning specimen and ask him to return the following day

• Pending results, prescribe amoxicillin, 500mg TDS x 5 days, for presumptive bacterial pneumonia

• Provide him with Panado, 1000 TDS x 5 days, for pain

• NOTE: ESR is a non-specific test and cannot be used to prove or exclude TB

Unit 6 Diagnosing TB:Unit 6 Diagnosing TB:Additional CaseAdditional Case

Botswana National Tuberculosis Programme Manual Training for Nursing Officers


Additional CaseAdditional Case

• PD, a 27 year old woman, is brought to the hospital by her family • She was sleeping much of the time and it became difficult

to wake her up • She has had 2 weeks of fever, sweats and headache • Temperature of 39ºC • She appears thin• She is sleepy but arousable• She has a small cervical, axillary and inguinal lymph nodes

and a stiff neck • The rest of her exam is normal • A malaria smear is negative


Additional Case: Question 1Additional Case: Question 1

She is empirically started on IV antibiotics by the medical officer

1. Why is she started on antibiotics? What is her most likely diagnosis?

2. What organisms could be causing her symptoms?

3. What is the differential diagnosis for PD?

4. What tests do you order and why?


Additional Case: Answer 1 (1)Additional Case: Answer 1 (1)

1.Meningitis

2.None (aseptic), bacterial, viral, tuberculosis, cryptococcus neoformans, syphilis



3.Differential diagnosis for PD• Tuberculous meningitis• Cryptococcal meningitis

• When completing a lumbar puncture, measure opening pressure for elevated pressure

– AIDS-defining illness in HIV positive patients

• Bacterial meningitis



3. (cont.)• Viral meningitis

• Rarely prolonged• Neurosyphilis• Subacute or chronic lymphocytic meningitis• Other infections such as trypanosomiasis, leptospirosis,

Amoebic encephalitis may be considered, but are much less common than those listed above



4. Cerebral Spinal Fluid (CSF) evaluation (AFB and routine culture) after lumbar puncture

• Glucose, protein WBC• Gram stain• India ink • Culture• Cryptococcal antigen • VDRL

• Blood tests• HIV test• FBC• Blood cultures• RPR• Cryptococcal antigen

• A CXR or biopsy of lymph node (if lymph node is suspiciously large)


Additional Case: Answer 1 (5)Additional Case: Answer 1 (5)Test Normal Bact. Viral Cyrptococcal TB

Opening Pressure

<200mm water

Increased Normal INCREASED Variable

WBC 0-5 cells/uL

>1000 <100 Low Low

Differential PMN’s Lymphs Lymphs Lymphs

Protein 15-45 mg/dL

INCREASED

Increased Increased Increased

Glucose Ratio

CSF 60-70% of blood

LOW Decreased Decreased Decreased


Additional Case: Question 2Additional Case: Question 2

1. If TB meningitis is one of the likely diagnoses, when should treatment begin?

2. What is necessary to diagnose TB meningitis?


Additional Case: Answer 2Additional Case: Answer 2

1. Treatment should begin right away when TB meningitis is one of the likely diagnoses

2. Diagnosis of TB meningitis can be supported by:

• CSF showing lymphocytic meningitis AND negative India Ink

• CSF AFB culture (which may be positive, but may take three to eight weeks for a result)

• Evidence of TB disease elsewhere in the body

Unit 6 Diagnosing TB: B Family Case Botswana National Tuberculosis Programme Manual Training for...

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