View
4
Download
0
Category
Preview:
Citation preview
Ekstrapulmonal TB Multiresistant TB
Tehmina Mustafa
Kst. overlege, Lungeavdelingen, HUS
Professor, Senter for internasjonal helse, UiB
TB can affect any organ
Center for International Health, Department of Global Public HEalth &
Primary Care
Organfordeling
Ca. 40% ekstrapulmonal TBC – tall fra 2010
Diagnostiske utfordringer
• Lokal symptomer +/- Generell symptomer
• Paucibacillary
• Syrefast-farging-mikroskopi: lav sensitivitet (0-10%)
– deteksjonsgrense 10000 bacilli/ml
• Dyrkning: lav sensitivitet (0-22%), 4-8 uker
– deteksjonsgrense 10-100 bacilli/ml,
• Histologi: sensitiv, ikke spesifikk
– Differentiell diagnose andre granulomatøs betennelse
– HIV co-infeksjon- atypisk histologi
• Diagnostiske algoritm basert på symptomer, kliniske funn- ikke spesifikk
Diagnostiske utfordringer (2)
• Interferon-gamma release assays (QuantiFERON® and T-
SPOT®):
– kan ikke skille mellom latent og aktiv sykdom
• PCR: relativ lav sensitivitet
– Kontaminering? kostbar?
Extrapulmonary TB
Challenges:
• Often associated with delay in diagnosis- did not think TB- missed
• Global: Diagnosis without lab support leads to over-diagnosis
Characteristics of TB lymphadenitis
Characteristics:
Matted
Frequently multiple
Painless at outset
Most in anterior cervical triangle
Cold
Source: IUATLD, Chiang
Source: IUATLD, HL Rieder
Source: IUATLD, HL Rieder
Source: IUATLD, HL Rieder
Source: IUATLD, HL Rieder
Source: IUATLD, HL Rieder
Tuberculous pleurisy
Source: IUATLD
Source: IUATLD
Source: IUATLD
Potts Disease
Old companion!
Klassiske beskrivelsen først i 1779 av Percival Pott, en engelsk kirurg.
4000 f.Kr. egyptiske mumier bemerket med typiske trekk
Source: IUATLD, HL Rieder
Case report from Norway
• 45 yrs old female- somalia- 6 months pain lumbar region-referred to the oncology due to paravertebral mass – Mantoux test 16mm – Not known exposure to TB – Negativ chest x-ray – Negativ sputum – Did not receive profylaxis for latent TB due to low risk 6 years ago
Physical examination
• Overweight: 85 kg • Temp 37,4, Puls 90, BT 91/68. • Physical examination: unremarkable
• Growth of M.tuberculosis from abscess • Treatment with anti-TB drugs
Source: IUATLD, HL Rieder
Source: IUATLD, HL Rieder
Culture-confirmed tuberculous osteomyelitis Source: IUATLD, HL Rieder
Joint tuberculosis Site of involvement
25%
20%
12%
10%
9%
9%
8% 7%
Source: IUATLD, HL Rieder
Source: IUATLD, HL Rieder
Intracranial tuberculosis
Source: IUATLD, HL Rieder
• Sixth cranial nerve is affected • the resulting squinting gradually disappeared with
chemotherapy
Tuberculous (basal ) meningitis
Source: IUATLD, HL Rieder
Dpt. Infection and Tropical Medicine, Sheffield
Teaching Hospitals
miliary TB on MRI scan tuberclomas on CT scan
Source: IUATLD, HL Rieder
Abdominal TB Site of involvement
Anorectal
Mesenteric
Adenitis
Peritoneal
Ileocecal
Source: IUATLD, HL Rieder
Genito-urinary tuberculosis
• Frequent cause of female sterility
• Half of cases are only urinary
• Endometrium and epididymis are most frequently affected
Source: IUATLD, HL Rieder
Dpt. Infection and Tropical Medicine,
Sheffield Teaching Hospitals
Renal tuberculosis (may have few or no
symptoms) leading to autonephrectomy
Implementation of the MPT64 antigen detection test in Norway
Example of use 1:
• A 50-year-old man with multiple abscesses in kidney
• Nephrectomy performed
• Specimen sent to Department of Pathology
• Histopatholgy showed necrotic granulomas
• MPT64 antigen detection test positive
• N-PCR positive
• No sample sent for culture
Dpt. Infection and Tropical Medicine,
Sheffield Teaching Hospitals
35 female African – systemically well - hand and foot lesions present for 6 months – MTB grown on biopsy by plastic
surgeons (HIV neg)
Response to chemotherapy of tuberculosis verrucosa cutis
(Histologically compatible diagnosis)
At diagnosis After 1 month After 3 months Source: IUATLD, HL Rieder
Multidrug resistant TB
«Finding a way around»
DRUG Resistence gene
Occurs as mutants e.g. 1/1000.000 bac.
The strategy of tubecle bacilli
Slide from Prof. Gunnar Bjune
Fitness of MDR strains
Fitness of M. tuberculosis of the W-Beijing family
The mean time necessary to reach 200 units of growth:
susceptible 143.9 hours (95%CI 133.9-153.9)
resistant 154.8 hours (95%CI 143.4-166.3) Р = 0.17
Slide from Prof. Gunnar Bjune
MDR is preventable
Two possibilities only:
• Mtb develops resistence through episodes of monotherapy (adherence problems) «Acquired MDR»
• MDR-TB infects susceptible persons (nococomial infection) «Primary MDR»
Slide borrowed from Prof. Gunnar Bjune
43
• Protect rifampicin
• Never alone / Never for dis. other than TB and leprosy / obligatory prescription drug !
Preventing drug resistance
Directly observed therapy
Health system based DOT
MDR acquired or spread?
..but where? Cox HS (2010)
Slide from Prof. Gunnar Bjune
MDR-TB- nosocomial infection
What can be done?
Conclusion MDR- Globally
• Mostly due to infection rather than acquisition
– Do not blame patients
– Look for «hot spots»
• Most likely nococomial
– New TB pats. exposed while waiting for DOT
• Decentralize and organize DOT
– DOT distribution sites at health post level
– Fixed appointments
– Home treatment
Recommended