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Pearls of WisdomSharing TB Medical Management

Best Practices

William Randall M DWilliam Randall, M.D.State Pulmonologist

Center for TB Control and PreventionInfectious Disease & Environmental Health Administration

Maryland Department of Health and Mental Hygiene

MD DHMH Mission• To improve the health of Marylanders by reducing the

transmission of infectious diseases, helping impacted persons live longer, healthier lives, and protecting individuals and communities from environmental health hazards

• We work in partnership with local health departments, providers, community based organizations, and public and private sector agencies to provide public health leadership in the prevention, control, monitoring, and treatment of infectious diseases and environmental health hazards.

Presentation Overview

• Clinical Presentations of TB– Typical – Atypical– Extrapulmonary

• Treatment Challenges

Clinical PresentationsClinical Presentations

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The Chest X-ray and the Differential Diagnosis

• Common vs. Atypical Presentations• Miliary • Primary vs Secondary TB• Primary vs. Secondary TB• Extrapulmonary Presentations• Differentiating TB on Chest X-ray from

– Sarcoid– Carcinoma

Apical Lordotic

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Atypical TB Lung Presentations

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Miliary TB

• SymptomsCo gh– Cough

– Fever– Fatigue

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Extrapulmonary TB

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Renal TB TB Meningitis

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Sarcoidosis

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Cancer or TB?

Bronchoscopy

• IndicationsIndications• Post Bronchoscopy Sputum

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Treatment Challenges Drug Holidays and Rechallenges

TB and Other Co-morbidities; Drug/Drug InteractionsDrug/Drug Interactions

Abacillary vs Superprophy

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Indication for Steroid Use

• Pericardial Effusion• Meningitis• Pleural Effusion• Use of Rifampin

– Advanced/Miliary TB• Failure to Thrive

Renal Failure Dialysis

• Treatment– Pts on hemodialysis, medication should be

given x3/day after dialysisg y y• INH 15mg/kg (900mg)• RIF10mg/kg (600mg)• PZA 25-35mg/kg• EMB 15-25mg/kg

Atypical Mycobacteria

• M kansasi• MAI (MAC)• MAI (MAC)• M scrofulaceum

Corrections Issues

• Tx of case– Monthly conference call

• Contact investigations• Contact investigations• TLTBI• Post release follow-up

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Hospitalization

• Acute vs Deer’s Head

Questions?

Resources• “Apical Lordotic.” UMDNJ, 13 Oct. 2011. NJ Medical School Global Tuberculosis

Institute. Microsoft Powerpoint. 13 Oct. 2011• “Volume Loss.” UMDNJ, 13 Oct. 2011. NJ Medical School Global Tuberculosis

Institute. Microsoft Powerpoint. 13 Oct. 2011.• “Calcified Granuloma.” UMDNJ, 13 Oct. 2011. NJ Medical School Global

Tuberculosis Institute. Microsoft Powerpoint. 13 Oct. 2011.• “Nodal Lesion.” UMDNJ, 13 Oct. 2011. NJ Medical School Global Tuberculosis

Institute. Microsoft Powerpoint. 13 Oct. 2011.• “Miliary TB.” UMDNJ, 13 Oct. 2011. NJ Medical School Global Tuberculosis

Institute. Microsoft Powerpoint. 13 Oct. 2011.• “Primary TB.” UMDNJ, 13 Oct. 2011. NJ Medical School Global Tuberculosis

Institute. Microsoft Powerpoint. 13 Oct. 2011.• Casey. "What Is Community Acquired Pneumonia?" TrialX - Enabling Patients to

Find New Treatments. Cure Bytes, 03 July 2011. Web. 9 Nov. 2011. <http://trialx.com/curebyte/2011/07/03/what-is-community-acquired-pneumonia/>.

Resources• Alavi, MD, Asif, and Zab Mosenifar, MD. "Solitary Pulmonary Nodule Workup."

Medscape Reference. 11 Sept. 2009. Web. 13 Oct. 2011. <http://www.google.com/imgres?q=Lower+lobe+TB&hl=en&biw=1920&bih=845&gbv=2&tbm=isch&tbnid=dhGQhFGiCNG-5M:&imgrefurl=http://emedicine.medscape.com/article/304534-workup&docid=yjjfUIBELGy4QM&imgurl=http://img.medscape.com/pi/emed/ckb/workup&docid yjjfUIBELGy4QM&imgurl http://img.medscape.com/pi/emed/ckb/pulmonology/295571-304534-4662tn.jpg&w=189&h=200&ei=8Da8Tt2bEKXc0QH45-HeCQ&zoom=1&iact=rc&dur=117&sig=116108611940107329655&page=1&tbnh=151&tbnw=143&start=0&ndsp=39&ved=1t:429,r:15,s:0&tx=104&ty=78>.

• Mukesh, Harisinghani G., Theresa C. McLoud, Jo-Anne O. Shepard, Jane P. Ko, Manohar M. Shroff, and Peter R. Mueller. "Tuberculosis from Head to Toe." RadioGraphics. Radiological Society of North America, Inc (RSNA), Mar. 2000. Web. 10 Nov. 2011. <http://radiographics.rsna.org/content/20/2/449/F45.expansion.html>.

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Resources• “Mediastinal Lymphadenopathy.” UMDNJ, 13 Oct. 2011. NJ Medical School Global

Tuberculosis Institute. Microsoft Powerpoint. 13 Oct. 2011.• “Extrapulmonary-Bone.” UMDNJ, 13 Oct. 2011. NJ Medical School Global

Tuberculosis Institute. Microsoft Powerpoint. 13 Oct. 2011.• “Extrapulmonary.” UMDNJ, 13 Oct. 2011. NJ Medical School Global Tuberculosis

Institute. Microsoft Powerpoint. 13 Oct. 2011.p• “Sarcoidosis.” UMDNJ, 13 Oct. 2011. NJ Medical School Global Tuberculosis

Institute. Microsoft Powerpoint. 13 Oct. 2011.• “Lympadenopathy.” UMDNJ, 13 Oct. 2011. NJ Medical School Global Tuberculosis

Institute. Microsoft Powerpoint. 13 Oct. 2011.• “Pleural Effusion.” UMDNJ, 13 Oct. 2011. NJ Medical School Global Tuberculosis

Institute. Microsoft Powerpoint. 13 Oct. 2011.• "BlablaDoctor - Group Profile - Atelectasis." BlablaDoctor - Home Page. Web. 13

Oct. 2011. <http://www.blabladoctor.com/group/35181/Atelectasis>.• Catanzano, MD, Tara M., and Eugene C. Lin, MD. "Primary Tuberculosis Imaging."

Medscape Reference. 22 July 2011. Web. 13 Oct. 2011. <http://emedicine.medscape.com/article/358610-overview>.

Resources• Sethi, MD, Nitin. "CNS Infection." Brain Diseases. Nitin Sethi, M.D. Web. 9 Nov.

2011. <http://www.google.com/imgres?q=CT+scan+picture+of+TB+meningitis&hl=en&sa=G&biw=1920&bih=845&gbv=2&tbm=isch&tbnid=DsU2ViBPRI1dUM:&imgrefurl=http://braindiseases.info/cns_infections&docid=9gr3iwF26v7rCM&imgurl=http://braindiseases.info/yahoo site admin/assets/images/Fig 1 CT scan.53133503 stdaindiseases.info/yahoo_site_admin/assets/images/Fig_1_CT_scan.53133503_std.jpg&w=512&h=512&ei=cuW6Tq6GEsTo2gWu58nJBw&zoom=1&iact=hc&vpx=922&vpy=145&dur=1419&hovh=225&hovw=225&tx=160&ty=112&sig=116108611940107329655&page=1&tbnh=161&tbnw=149&start=0&ndsp=38&ved=1t:429,r:5,s:0>.

• Sarcoidosis of the Lungs, X-ray." Science Photo Library. Zephyr/Science Photo Library. Web. 13 Oct. 2011. <http://www.sciencephoto.com/media/105664/enlarge>.

• "Lung Cancer Symptoms – Difficult But Must Be Addressed." Health Tips Centre. Healthtipscentre.com. Web. 12 Oct. 2011. <http://www.healthtipscentre.com/lung-cancer-symptoms-difficult-but-must-be-addressed.html>.