Ekstrapulmonal TB Multiresistant TB · 2017. 5. 23. · Potts Disease . Old companion! Klassiske beskrivelsen først i 1779 av Percival Pott, ... tuberculous osteomyelitisSource:

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





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


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



Culture-confirmed tuberculous osteomyelitis Source: IUATLD, HL Rieder

Joint tuberculosis Site of involvement

25%

20%

12%

10%

9%

9%

8% 7%



Intracranial tuberculosis


• Sixth cranial nerve is affected • the resulting squinting gradually disappeared with

chemotherapy

Tuberculous (basal ) meningitis


Dpt. Infection and Tropical Medicine, Sheffield

Teaching Hospitals

miliary TB on MRI scan tuberclomas on CT scan


Abdominal TB Site of involvement

Anorectal

Mesenteric

Adenitis

Peritoneal

Ileocecal


Genito-urinary tuberculosis

• Frequent cause of female sterility

• Half of cases are only urinary

• Endometrium and epididymis are most frequently affected


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


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)


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

Documents

Ekstrapulmonal TB Multiresistant TB · 2017. 5. 23. · Potts Disease . Old companion! Klassiske beskrivelsen først i 1779 av Percival Pott, ... tuberculous osteomyelitisSource: