Another Surprise?

Dr M Wansbrough-Jones

Matthew Drake

Mark Rooney

Andrew Ladwiniec

History 1

38 year, Somali refugee (UK: 1989)– Unemployed

4/52 Hx– Cough– Sputum & 1 episode haemoptysis– Night sweats– Weight loss

History 2

Cough– Slowly increasing– Wakes at night

Sputum– Green– 1 episode of haemoptysis (fresh blood)

No chest pain or SOB

History 3

Weight loss– Little over 1st couple of weeks then sudden loss– Approx 10kg in total

Night sweats– Every night– Clothes and bed sheets dripping

History 4

Moved house 6/52 ago from cold, damp dirty flat in Streatham. House mate well.

Non-smoker, teetotal Unaware of exposure to TB or other

infections– Believes some contacts within community may

have TB

No recent foreign travel

Examination

Mildly wasted/cachectic HR 114 Bpm. Lungs

– ® upper zone dull to percussion– ® upper zone tactile fremitus– ® upper zone vocal resonance– ® upper zone bronchial breath sounds– Widespread bilateral inspiratory crackles

Investigations

FBC, U&E, LFT, Bone Profile, Clotting Blood cultures Sputum culture & examination for acid fast

bacilli Chest X-Ray

Full Blood Count

Hb 9.8 (13.5-18g/dL) WCC 8.7 (4-11x1012/L) Platelets 384 (150-400x109/L) MCV 81 (76-96fl) Normocytic anaemia (?anaemia of chronic

disease)

Clotting

INR 1.0 (0.9-1.2) APTT 38 (35-45s) TT 12 (10-15s) D-Dimers 3.44 (<0.5 mg/L)

Urea & Electrolytes

Na+ 133 (135-145mmol/L) K+ 4.0 (3.5-5.0mmol/L) Cl- 97 (95-105mmol/L) Urea 1.8 (2.5-6.7mmol/L) Creatinine 17 (70-150mol/L)

Liver Function Tests/Bone Profile Bilirubin 16 (3-17mol/L) ALT 39 (5-35u/L) ALP 107 (30-150u/L) Albumin 26 (35-50g/L) Gamma GT 61 (11-51u/L) Corrected Ca++ 2.49 (2.12-2.65mmol/L) PO4

--- 1.06 (0.8-1.45mmol/L)

CRP 249.4 (<10mg)

Sputum examination

Upper respiratory tract flora (++ growth) Coliforms (Scanty growth) Acid Fast Bacilli +++

Management

Admitted + Isolated Rifater (Rifampicin, Isoniazid, Pyrazinamide) -before breakfast Ethambutol Pyridoxine

TB Epidemiology

UK incidence = 7000 new cases/year Higher in immigrant populations: -Indian subcontinent: x 40

-West-Indies: x 4

frequency in developing world• Worldwide TB since mid-80’s due to:

-HIV, migration

TB Pathology

Mycobacterium tuberculosis (Aerobic, acid-fast bacillus)

1ry TB (usually no symptoms): Infection, macrophage ingestion, T-cell response Cellular immunity in 3-8 weeks Caseating granuloma form, heal, may calcify 20% calcified 1ry lesions contain tubercle bacilli

TB Pathology 2

Post-1ry TB (often years later) Reactivation of remaining M.tb/reinfection susceptibility due to: -Immunosupprssion (e.g. drugs, HIV, lymphoma) -Malnutrition -DM Typically, cavitation at apex/upper zones

Management

Hospitalise if smear positive (stop spread) Most important factor = good compliance -If poor, directly observed therapy Standard 6 month regimen: -Rifampicin -Isoniazid +Pyridoxine (vit. B6) -Pyrazinamide (first 2 months) -Ethambutol (first 2 months)* Follow-up (check compliance) Contact tracing

Drug side-effects + precautions

Rifampicin -Warn about orange secretions -OCP ineffective -Regular LFTs, stop if: bilirubin/3x transferases Isoniazid -Polyneuropathy: give pyridoxine (vit. B6) Pyrazinamide - urate excretion, can precipitate gout Ethambutol -Optic retro-bulbar neuritis: see opthalmologist before treatment

Drug Resistance

1ry -infected with D.R. TB (mainly immigrants)

2ry -poor compliance (developed in patient)

Medication: Use at least 3 drugs to which it is sensitive Resistance to 1 of 4 main drugs, use other 3 Use of second line agents

Treat for up to 2 years

Vaccination

BCG ‘Bacille Calmette-Guerin’ -Live attenuated vaccine -Developed from M.bovis Protective efficacy ~50% Gives 1ry immunity Prior Heaf/Mantoux test (ppd), if 1ry immunity -CXR Normally given at 13 years ?some areas with high immigrant population given to

infants?