Clinical Diagnosis Nov2009

7/25/2019 Clinical Diagnosis Nov2009

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Clinical Presentationand Diagnosis ofTuberculosis

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International Standards 1-5


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ISTC TB Training Modules 2009

Clinical Presentation and Diagnosis of TB

Objectives:At the end of this presentation,participants ill be able to!

Describe the signs/s"mptoms and ris# factors thatshould raise suspicion for the diagnosis of TB

$nderstand the importance of sputum smearmicroscop", as ell as the need to obtainspecimens for microbiologic e%amination frome%trapulmonar" sites

&ecognize that C'& alone is not sufficient for thediagnosis of TB

(ist criteria used for the diagnosis of smear)negati*e TB


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International Standards 1 2 ! " and 5

Overvie#: +eneral considerations

igns and s"mptoms

&ole of A-B smear

&adiographicpresentation

A-B smear)negati*ediagnosis


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tandards for Diagnosis


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&apid, accuratediagnosis is essential

for indi*idual and

public health

Despite technical

ad*ances, clinical

acumen ith a high

inde% of suspicion

remains *ital to the

diagnosis of TB T$in% TB

-undamental Principles


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.Classic TB Clinical Presentation

Insidious onset and chronic course Chest s"mptoms

Cough 0usuall" producti*e1

2emopt"sis Chest pain 0usuall" pleuritic1

3onspecific constitutional s"mptoms

0more common in children and 2I41 5%trapulmonar" s"mptoms 0if in*ol*ed1


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3onspecific "stemic "mptoms

-e*er in 67)89: of cases

Chills/night seats

-atigue/malaise

Anore%ia/eight loss

However, ;9)


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Diagnosis of TB in 2I4

Cannot rel& on 't&(ical) indicators o* TB -e*er and eight loss are important

s"mptoms

Cough is less common

Chest radiographic pattern more *ariable

More e%trapulmonar" and disseminated TB

Differential diagnosis is broader


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tandard ;! Prolonged Cough

All persons ithotheriseune%plained

producti*e coughlasting to)threeee#s or more

should bee*aluated fortuberculosis


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Prolonged Cough

T$in% TB:Prolonged Cough0


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Clinical Presentation! &is# -actors

+is% *or +ecent In*ection Contact ith acti*e TB case

ccupational ris# eg healthcare or#er

Croded conditions eg @ails, institutionalresidences

&ecent sta" in a healthcare facilit"


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Clinical Presentation! &is# -actors

+is% o* ,rogression to ctive TB 2I4 infection

Abnormal C'& suggesti*e of prior TB 0ithinadeuate treatment1

Children 0less than 7 "ears of age1

$nderl"ing medical conditions

Immunosuppressi*e therap" Malnutrition

Diabetes, renal failure, and other conditions

Tobacco use, in@ection drug use 0E1


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Clinical Presentation! Ph"sical 5%amination

Ma" be normal in mildmoderate disease

Chest! rales, rhonchi? absent breath soundsand dullness to percussion if pleural fluid ispresent

5%trapulmonar" 0site specific1! adenopath",s#in lesions, bone tenderness, nec# stiffness,etc

The ph"sical e%amination is nonspecific, butit is helpful to identif" e%trapulmonar" sites ofin*ol*ement


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tandard

for microscopice%amination in a ualit")assured laborator">hen possible, at least one earl" morningspecimen should be obtained


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putum Microscop"

To pro*e a diagnosis of TB, e*er" effort mustbe made to identif" the causati*e agent

The .B s/earin high)pre*alence areas is!

2ighl" specific for TB Most rapid method for determining TB diagnosis

Identifies those at greatest ris# of d"ing from TB

Identifies those most li#el" to transmit disease


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Mase &, Int J tuberc Lung Dis


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5"-&ear-old /an #it$

t$ree /ont$s o* *ocal

lo#-bac% (ain

Can this be TBE


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5"-&ear-old /an #it$

t$ree /ont$s o* *ocal

lo#-bac% (ain

Can this be TBE 5%trapulmonar"

'Potts disease

igns and s"mptoms of e%trapulmonar" TB are sitespecific

ampling of e%trapulmonar" sites for smear, culture, andhistopatholog" ma" confirm diagnosis


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tandard =! 5%trapulmonar" pecimens

-or all patients0adults, adolescents,and children1

suspected of ha*inge%trapulmonar" TB,appropriate

specimens from the suspected sitesofin*ol*ement should be obtained formicroscop", culture, andhistopathological e%amination


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Pulmonar", F;:

5%trapulmonar",


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5%trapulmonar" Tuberculosis


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&adiographicPresentation

of TB


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tandard G! 5*aluation of Abnormal C'&

All persons ithchest radiographicfindingssuggesti*e

of tuberculosisshould ha*e sputumspecimens

submitted formicrobiologicale%amination

ISTC Training Modules 2004


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Can this be TBE


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6istribution Apical / posterior

segments of upper lobes

uperior segments ofloer lobes

Isolated anterior segmentin*ol*ement is unusual

Can this be TBE

T&(ical ,attern:+eactivation,ost-(ri/ar& TB


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&eacti*ation/Post)primar" TB

,atterns o* disease Air)space consolidation

Ca*itation, ca*itar"

nodule Miliar"

-ibro)nodular densities

3odule 0Tuberculoma1 Pleural effusions


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Can this be TBE


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Can this be TBE

Distribution!An" lobein*ol*ed 0slight loer lobepredominance1

Air)space consolidation

Ca*itation is uncommon0J ;9:1

Adenopath" is common0esp in children and 2I41

Miliar" pattern

t&(ical (attern:,ri/ar& TB


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Can this be TBE


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Can this be TBE Miliar" TB


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Can this be TBE


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Can this be TBE

.indings suggestive o*(rior TB

CaK granuloma +hon lesion

CaK granuloma and hilarnode calcification &an#ecomple%

Apical pleural

thic#ening-ibrosis and

*olume loss


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C'& Issues

&eliance on chest radiograph aloneresults in both o*er)diagnosis and misseddiagnosis of TB and other diseases

&adiograph" needs to be held to highstandards of technical ualit" andinterpretation

&esults of poor imaging ualit" ma" beharmful to patient care


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5*aluation of Abnormal C'&

Stud& *ro/ India:2229 out(atients evaluated b& C;+8culture

f


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The diagnosis of s(utu/ s/ear-negativepulmonar"tuberculosis should be based on the folloing criteria!

At least to negati*e sputum smears 0including atleast one earl" morning specimen1

Chest radiograph" findings consistent ithtuberculosis

(ac# of response to a trial of broad)spectrumantimicrobial agents

03ote! Because the fluorouinolones are acti*e against M.tuberculosiscomple%, and thus ma" cause transient impro*ement inpersons ith tuberculosis, the" should be a*oided1

tandard 7! mear)negati*e Diagnosis

0; of


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0Continued1 -or such patients, sputum cultures should

be obtained

In persons ho are seriousl" ill or ha*e#non or suspected 2I4 infection, thediagnostic e*aluation should be e%peditedand if clinical e*idence strongl" suggests

tuberculosis, a course of antituberculosistreatment should be initiated

tandard 7! mear)negati*e Diagnosis

ISTC Training Modules 2004

0< of


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Clinical assess/ent I test;

s(utu/ s/ear /icrosco(&

t least 2 s(utu/ s(eci/ens .B negative

I < and8or severe illness2

I- /ild8/oderate illness2

; &ecommended in countries or areas ith adult 2I4 pre*alence L;: orpre*alence among TB cases L7:


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I < and8or severe illness

S,7T7M SM=+-=>TI= TB

Clinical/radiographic findingsOTsuggestiveof TB

3egati*e culture

Consider ot$er diagnoses

ot TB

Clinical/radiographic findingssuggestiveof TB

Positi*e or negati*e culture

Treat 0empiric TB treatment before confirmeddiagnosis if se*ere illness1

I staging ?=valutate *or +s ?C,T (ro($&la@is

&epeat clinical assessment Chest radiograph putum culture 0or other test1

Parenteral broad)spectrumantimicrobials 0e%cludingfluorouinolones1

TB Diagnostic Algorithm

TB


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IA /ild8/oderate illness

S,7T7M SM=+-=>TI= TB

Broad-s(ectru/ anti/icrobials0e%cluding anti)TB drugs and fluorouinolones1

Consider ot$er diagnosis

&epeat clinical assessment Chest radiograph putum culture 0or other test1

Treat

TB Diagnostic Algorithm

OIM,+O=M=T

ot TB ot TBTB

Clinical/radiographic findingsOT suggestive of TB

3egati*e culture

Clinical/radiographicfindingssuggestive of TB

Positi*e culture

IM,+O=M=T


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dditional (oints: "mptoms/se*erit"! none to o*erhelming

Tempo of illness! ranges from indolent to fast

TB can in*ol*e an" organ or tissue

igns/s"mptoms ma" be both local ands"stemic

Consider 2I4 testing in the diagnostice*aluation

TB is capable of presenting in man" a"s


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Su//ar&: T$in% TB A prolonged duration of cough should raise TB

suspicion and trigger a diagnostic e*aluation

TB ris# factors and e%posure increase le*el ofsuspicion

A-B smear in high)pre*alence areas is highl"specific and most rapid tool for diagnosing TB

&adiographic patterns ma" help in TB diagnosisif suspicion high and A-B smear is negati*e, buta radiograph alone is not enough to ma#ediagnosis


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O Abbre*iated *ersions

ummar"! ITC tandards Co*eredO

Standard 1:$ne%plained producti*e cough lasting


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ummar"! ITC tandards Co*eredO

O Abbre*iated *ersions

Standard ":All persons ith chest radiographicfindings suggesti*e of TB should ha*e sputumspecimens submitted for microbiologicale%amination

Standard 5:The diagnosis of smear)negati*epulmonar" TB should be based on the folloing!at least to negati*e sputum smears 0including atleast one earl" morning specimen1? C'& finding

consistent ith TB? lac# of response to broad)spectrum antibiotics 0a*oid fluorouinolones1, andculture data 5mpiric treatment if se*ere illness


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lternate Slides

Purpose of ITC


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Purpose of ITC

ITC P i t


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ITC! e" Points


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udience:all health care practitioners,public and pri*ate

Sco(e:diagnosis, treatment, and publichealth responsibilities? intended tocomplement local and national guidelines

+ationale:sound tuberculosis controlreuires the effecti*e engagement of all

pro*iders in pro*iding high ualit" careandin collaborating ith TB control programs

ITC! e" Points


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uestions

Cli i l P t ti d Di i f TB


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1A =< "ear)old man complains of cough andmalaise for the past three ee#s 2is ife iscurrentl" being treated for acti*e tuberculosis fthe folloing choices, "our *irst ste(ould be!

A Begin an empiric trial of treatment ith afluorouinolone antibiotic for a possible communit")acuired pneumonia

B btain a chest film to confirm "our suspicion for TBhich ill ma#e sputum testing unnecessar"

C btain to sputum specimens for A-B microscop"0including at least one earl" morning specimen1

D Both ansers A and C



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2In high pre*alence areas, the A-B sputummicroscop" smear!

A Is highl" specific for TB

B Identifies those at greatest ris# of d"ing from TB

C Identifies those most li#el" to transmit disease

DAll of the abo*e



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!A 7G "ear)old oman complains of cough, fe*er,and une%pected eight loss o*er the pastmonth he admits smo#ing ;9 cigarettes perda" for o*er

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Clinical Diagnosis Nov2009