And You Thought You Had Consumption Problems: TB Cases from Siouxland 20002009

1
And You Thought You Had Consumption Problems TB
Cases from Siouxland 2000-2009

• SLRMC Pulmonary Conference
• 20 February 2009
• Dr. Thor Swanson
• Siouxland Medical Educational Foundation
• U of Iowa Clinical Assistant Professor of FM
• Handout

2
Educational Objectives as stated in brochure

• Identify the symptoms (patient complaints)
  associated with tuberculosis
• Learn the signs (physical exam findings)
  associated with tuberculosis
• Review the radiology findings and lab tests
  associated with tuberculosis
• Understand some basic facts about treatment of
  tuberculosis
• Use community cases of TB in Siouxland over the
  last 8 years to do the above

3
Expanded Overview of TB Information in
Presentation

• Introduction to TB
• Definition
• History
• Worldwide and US incidence/relevance
• Diagnosis of TB
• Symptoms and Signs of TB
• Medical History and Social History
• Mantoux skin test
• Chest radiograph
• Bacteriologic or histologic exam
• Treatment of TB
• Treatment of Latent Tuberculosis
• Treatment of Active Tuberculosis
• Problems of Drug Resistance and Drug reactions
• Other TB Issues
• Extrapulmonary TB
• HIV and TB
• HIV and the Pediatric patient

4
A Brief Introduction of TB- Consumption

• Consumption- the name for Tuberculosis 100-200
  years ago.
• Death Certificate- William Guentzel, 1888 at age
  37 in Oak Creek, Wisconsin
• When I saw this death certificate in about 1977,
  I thought he died of alcoholism- he consumed
  alcohol to death.
• When we hear of consumption problems today in
  2009, we think of obesity.
• 100-200 years ago, when they heard of consumption
  problems, it was someone who had wasting disease-
  their body was being consumed by tuberculosis.

5
Basic Definition of TB

• Tuberculosis- Disease caused by the organism
  Mycobacterium tuberculi
• Mycobacterium Genus of bacteria
• M. Tb- spread by pulmonary droplets
• Dissemination- after entry into the lungs, can
  then disseminate and affect multiple different
  body systems

6
Common Sites of TB Disease

• Lungs
• Pleura
• Central Nervous System
• Lymphatic System
• Genitourinary System
• Bones and joints
• Disseminated (miliary TB)

7
Reported TB Cases United States, 19822007
No. of Cases
Year
Updated as of April 23, 2008.
8
Case Number 1 AD
9
Case AD

• AD was a 49 year old man who presented to the
  SCHC in July 2001 with sore throat, persistent
  cough with green phlegm for greater than 3
  months, and 17 pound weight loss over 3 months.
  He also complained of problems swallowing.
• PMH () glaucoma, () emphysema, () anxiety
• SH 2-3 PPD for 30 years, Drinking a 6 pack a
  day Wife died of cirrhosis last marijuana use 6
  months prior PPD (-) 1 year prior
• PE Severe wasting and cachexia ()
  Lymphadenopathy of the neck Lungs with bilateral
  rhonchi.

10
Case AD Radiology Results

• Chest X-Ray 10 July 2001-
• Severe/essentially end-stage lung disease with
  evidence of severe fibrosis with cicatrical
  changes most prominent in the upper lobes
  bilaterally
• Enlargement of the right hilum suspicious of
  co-existent/superimposed malignancy vs.
  lymphadenopathy
• 5 cm in diameter cavity vs. necrotic malignancy
  right upper lobe
• Extensive bronchiectases right lower lobe
• End-stage lung disease and pulmonary fibrosis due
  to sarcoidosis, TB with reactivation of disease
  and large cavity in the upper lobe to be
  considered. Fungal infection must be ruled out
  as well.

11
Case AD Radiology Results

• Does this patient have TB, yes or no? Why or why
  not?
• Does this patient have HIV, yes or no? Why or
  why not?

12
Signs and Symptoms of Pulmonary TB

• What are the local and systemic symptoms of
  pulmonary TB?

13
Signs Local and Systemic Symptoms of Pulmonary TB

• Productive, prolonged cough (duration greater
  than 3 weeks)
• Chest pain
• Hemoptysis

• Fever
• Chills
• Night Sweats
• Appetite Loss
• Weight Loss
• Easy Fatiguability

14
Physical Exam Findings in TB

• Findings depend on site
• Larynx- Hoarseness
• Lung- Abnormal lung sounds
• Bone- Pain, fractures, neuropathy
• Abdomen- Abdominal pain
• CNS- headache

15
Case 2 CN
16
Case CN

• CN was a 58 year old Hispanic man who presented
  to MHC ER on 1/20/04 with phlegm production,
  increasing fevers, weight loss, night sweats,
  increased sputum production, SOB and right leg
  pain. Long history of smoking, but quit several
  years before. Unsure if having hemoptysis as
  nearly blind and didnt see well. Family had
  noticed large weight loss in previous 3 months.
  Had been seen at SLRMC ER on 12/30 with similar
  complaints and sent home.
• PMH
• 1. () Diabetes on oral meds,
• 2. s/p below the knee amputation for poor
  circulation in 6/03
• 3. () legally blind in both eyes from cataracts
  and surgery
• 4. High Cholesterol

17
Case CN

• SH Married, 5 children h/o smoking h/o
  alcoholism but none recently immigrant to US
  from Mexico 8 months prior no current alcohol
  use. History of 3 lifetime female sexual
  partners and no male
• Meds
• 1. Gluctorol 5mg PO QD
• 2. Glucophage 500 mg 1BID
• 3. Pravachol 40 mg po qhs
• 4. Aspirin 81 mg 1 QD
• FH Mother and father both deceased Brother
  died of Gall bladder disease

18
Case CN

• PE VS BP 140/70, afebrile, RR 20, P 60
• HEENT Lentic opacity in left eye Temporal
  wasting No adenopathy in neck and no
  thryoidmegaly
• CV S1 and S2 normal, PMI not palpable no
  murmurs gallops or thrills. Neck veins not
  distended
• Abd Soft, non-tender, no hepato-splenomegaly

19
Case CN

• Labs 1/20
• Sodium 135, Potassium 3.3, Chloride 95, Glucose
  82, BUN 13, Cr 0.9, ALk Phos 214, ALT 29, AST 29,
  Total bili 0.65, Alb 1.9,
• WBC 8.17, RBC 4.11, Hg 11.2, Hct 34, MCV 83, MCH
  27, MCHC 33, RDW 14.6, Plat 108, 93 Neut, 4
  Lymph, 3 Mono, 0 Eosinophils
• Urine clear, neg glucose, neg ketones, neg bili,
  neg blood, neg leuk ester, neg nitrite, neg
  protein.
• Influenza A and B negative
• AFB Smears to be done 1/21-1/23

20
Case CN Radiology

• 1/20/04 Chest X-Ray- diffuse micronodular
  consolidation of both lungs sparing the left
  upper lobe associated with a cavity in the RUL.
  Consider TB, fungal infection. The abnormality
  is most likely infectious.

21
Case CN CT Report 21 Jan 04

• CT Report 1/21/04
• Diffuse decreased interstitial markings
  bilaterally with fine nodular and reticulonodular
  pattern throughout except for some scarring of
  the anterior segment of the left upper lobe and
  miliary-like appearance of the infiltrates . . .
  Presence of small calcified lymph nodes in the
  right hilar and infracranial regions. . .
• Large cavity (5x 7x7 cm) with nodularity of the
  posterolateral and superior walls in the apical
  segment of the right upper lobe. . .

22
Medical History

• History of TB exposure, infection, or disease
• Past TB treatment
• Medical conditions that increase risk for TB
  disease

23
Social History

• Demographic risk factors for TB. Is this patient
  from a high risk group?

24
TB Case Rates, United States, 2007
D.C.
lt 3.5 (year 2000 target)
3.64.4
gt 4.4 (national average)
Cases per 100,000.
25
Reported TB Cases by Age Group, United States,
2007
lt15 yrs (6)
gt65 yrs (19)
1524 yrs (12)
2544 yrs (32)
4564 yrs (30)
26
Reported TB Cases by Race/Ethnicity United
States, 2007
American Indian or Alaska Native (1)
White (17)
Asian (26)
Native Hawaiian or Other Pacific Islander (lt1)
Hispanic or Latino (29)
Black or African-American (26)
All races are non-Hispanic. Persons reporting
two or more races accounted for less than 1 of
all cases.
27
Countries of Birth of Foreign-born Persons
Reported with TB United States, 2007
Mexico (24)
Other Countries (39)
Philippines (12)
Rep. Korea (3)
Viet Nam (7)
Haiti (2)
India (8)
China (5)
28
Case 3 DW
29
Case DW MH 318507

• DW is a 60 year old man who presented to the SCHC
  in May 2002. He was a known diabetic and
  hypertensive who had been out of care for 3 and ½
  years. He made his way to an ENT physician who
  saw him for a hoarse voice and sore throat of
  several months duration. He was taken to
  surgery. He was referred for primary care
  follow-up of his multiple medical problems. to
  the office with hoarse voice and sore throat for
  several months. Patient denied any cough, fever,
  night sweats.
• PMH, 1. () Diabetes, A1C 8.8
• 2. () chronic alcoholism,
• 3. () COPD,
• 4. () HTN,

30
Case DW MH 318507

• SH Divorced ate at nearby food establishment
  every noon ½ PPD for 40 years Long-time alcohol
  use. 2 children in Lincoln and has occasional
  contact with them.
• FH Father died at age 65 of stomach cancer.
  Mother died at age 85 of old age. Two brothers
  and two sisters are alive.

31
Case DW MH 318507

• PE Slightly unkept BP 142/84
• HEENT TMS clear, PERRLA, EOMI
• CV RRR
• Lungs clear
• Abd BS, soft, non-tender
• Neuro CN 2-12 intact (except voice hoarse),
  Sensory and motor grossly intact.

32
Case DW MH 318507

• Labs 5/17
• Sodium 134, Potassium 4.2, Chlor 97, CO2 23,
  Glucose 222, BUN 10, Cr 0.8, ALT 32, AST 53
• Hep B Surf antigen and antibody negative. Hep C
  antibody negative
• TSH 1.04
• WBC 4.1, Hg 15.5, Hct 46, MCV 92,

33
Case DW Radiology Report

• 5/21/02 Chest X-Ray- Infiltrate Right Upper Lobe
  Nodularity and increased reticular pattern in
  the remainder of the Right Lung suggesting
  Co-existent Bronchopneumonia
• No CT done.

34
Latent TB Infection (LTBI)

• LTBI is the presence of M. tuberculosis
  organisms (tubercle bacilli) without symptoms or
  radiographic evidence of TB disease.

35
Terminology

• Treatment of latent TB infection replaces the
  terms preventive therapy and chemoprophylaxis
  to promote greater understanding of the concept
  for both patients and providers.
• Targeted tuberculin testing is used to focus
  program activities and provider practices on
  groups at the highest risk for TB.

36
LTBI vs. Pulmonary TB Disease

• Latent TB Infection
• TST or QFT positive
• Negative chest radiograph
• No symptoms or physical findings suggestive of TB
  disease

• Pulmonary TB Disease
• TST or QFT usually positive
• Chest radiograph may be abnormal
• Symptoms may include one or more of the
  following fever, cough, night sweats, weight
  loss, fatigue, hemoptysis, decreased appetite
• Respiratory specimens may be smear or culture
  positive

tuberculin skin test QFT (QuantiFERON-TB and
QuantiFERON-Gold) is a blood test to detect M.
tuberculosis infection.
37
Factors That May Cause False-Positive TST
Reactions

• Nontuberculous mycobacteria
• Reactions caused by nontuberculous mycobacteria
  are usually ? 10 mm of induration
• BCG vaccination
• Reactivity in BCG vaccine recipients generally
  wanes over time positive TST result is likely
  due to TB infection if risk factors are present

38
Case 4 HN
39
Case HN

• H. N. was a 49 year old African American man who
  presented to the MHC ER on January 29th, 2004
  with fever, cough productive of brown phlegm,
  chills night sweats, and weakness for 2-3 months.
  Also had lost 40 pounds in last 12 months.
• PMH () h/o gunshot wound (-) HIV test 2 years
  prior
• SH Divorced Homeless in and out of SC Gospel
  mission, Smoked 1 PPD for 25 years but quit
  smoking 6 months prior occ. Alcohol use h/o IV
  drug use Lifetime sexual partners about 4.
  Negative HIV screen 2 years prior.
• FH Mother with MI in late 50s.

40
Case HN

• ROS no sore throat, hearing or visual loss
  poor dentition some SOB and some pleuritic
  chest pain. No constipation, diarrhea, loose
  stools, blood in stool or black stools. No
  abdominal pain no GU symptoms no headaches.
• PE BP 105/76, Pox 96 on room air, RR 30, Pulse
  112.
• HEENT PERRLA, EOMI, Oropharynx clear
• Neck Mild anterior cervical adenopathy
• Resp Bilateral rhonchi and crackles in bases
• CV RRR, no murmur
• Abd soft no organomegaly
• Ext trace pitting edema
• Neuro CN 2-12 intact, sensory and motor intact
  to all 4 extremities.

41
Case HN

• Labs 1/29 Sodium 134, Potassium 3.1, Chlor 97,
  BUN 9, Cr 0.5, ALT 27, AST 39, Alk Phos 76, Iron
  12, TIBC 116, Hep B and C studies negative WBC
  4.31, Hg 9.2, Hct 31, MCV 77, RDW 18.1, Plt
  256,000
• Acid fast stains ordered
• HIV ordered

42
Case HN Radiology Reports

• 1/29/04- Extensive consolidative infiltrates
  having the appearance of an acute pneumonia
  confined mostly to upper lobes and right middle
  lobe

43
Chest Radiograph

• Abnormalities often seen in apical
• or posterior segments of upper
• lobe or superior segments of
• lower lobe
• May have unusual appearance in
• HIV-positive persons
• Cannot confirm diagnosis of TB

Arrow points to cavity in patient's right upper
lobe.
44
Radiological Presentation of Primary TB

• Lobar Pneumonia
• Bronchopneumonia
• Hilar and mediastinal adenopathy
• Pleural or pericardial effusion
• Miliary Tuberculosis

45
Specimen Collection

• Obtain 3 sputum specimens for smear examination
  and culture
• Persons unable to cough up sputum, induce sputum,
  bronchoscopy or gastric aspiration
• Follow infection control precautions during
  specimen collection

46
Smear Examination

• Strongly consider TB in patients with smears
  containing acid-fast bacilli (AFB)
• Results should be available within 24 hours of
  specimen collection
• Presumptive (only) diagnosis of TB possible with
  smear

47
Cultures

• Use to confirm diagnosis of TB
• Culture all specimens even if smear negative
• Results in 4 to 14 days when liguid medium
  systems used

48
Case 5 CR
49
Case CR

• C. R. was a 29 year old AA male who presented to
  the ER at SLRMC on 8/23/04 with fever, weight
  loss, productive cough, and weakness. Patient
  also with moderate headache.
• PMH () childhood asthma
• SH Grew up in ghetto of Midwestern city
  Previous prison time Living with girlfriend and
  her 2 children
• PE Temp. 102 Wasted/Cachetic Oral thrush Dry
  cough

50
CR

• Are you worried about TB, why or why not?
• Are you worried about HIV, why or why not?
• Are you worried about his headache, why or why
  not? Would you do a spinal tap?

51
Antituberculosis Drugs
First-Line Drugs
Second-Line Drugs

• Isoniazid
• Rifampin
• Pyrazinamide
• Ethambutol
• Rifabutin
• Rifapentine

• Streptomycin
• Cycloserine
• p-Aminosalicylic acid
• Ethionamide
• Amikacin or kanamycin
• Capreomycin
• Levofloxacin
• Moxifloxacin
• Gatifloxacin

Not approved by the U.S. Food and Drug
Administration for use in the treatment of TB
52
Whats New-2005

• Treatment of LTBI
• HIV-negative persons INH for 9 months preferred
  regimen
• HIV-positive persons and those with fibrotic
  lesions on chest x-ray (consistent with previous
  TB) INH should be given for 9 months
• For all persons RIF for 4 months is an option

53
Whats New- 2005

• Clinical and laboratory monitoring
• Routine baseline and follow-up monitoring not
  required except for
• HIV-infected persons
• Pregnant women or those in early postpartum
  period
• Persons with chronic liver disease or who use
  alcohol regularly
• Monthly monitoring for signs or symptoms of
  possible adverse effects

54
Case 6 J C-D
55
Case J C-D

• J C-D was a 49 year old Hispanic man who
  presented to the ER at SLRM on 6/23/02 with
  cough, fevers, shortness of breath, weight loss
  and fatigue.
• PMH
• SH Divorced Immigrant from Mexico many years
  before Heavy alcohol drinker intermittently
  working at meat-packing plant
• PE Temp. 102 Rhonchi with prolonged expiratory
  phase

56
Case J Radiology Report

• 6/23/02 Chest X-Ray-Bilateral pulmonary
  inflitrates most severe right upper lobe. These
  findings are suspicious for TB or other
  opportunistic infection.

57
Case J Lab Results

• WBC 8.3, Sed Rate 109 H/H 14.0/41.5 Plt.
  74,000 SGOT 52 SGPT 36 INR 1.26

58
Antituberculosis Drugs
First-Line Drugs
Second-Line Drugs

• Isoniazid
• Rifampin
• Pyrazinamide
• Ethambutol
• Rifabutin
• Rifapentine

• Streptomycin
• Cycloserine
• p-Aminosalicylic acid
• Ethionamide
• Amikacin or kanamycin
• Capreomycin
• Levofloxacin
• Moxifloxacin
• Gatifloxacin

Not approved by the U.S. Food and Drug
Administration for use in the treatment of TB
59
When to Consider Treatment Initiation

• Positive AFB smear
• Treatment should not be delayed because of
  negative AFB smears if high clinical suspicion
• History of cough and weight loss
• Characteristic findings on chest x-ray
• Emmigration from a high-incidence country

60
Baseline Diagnostic Examinations for TB

• Chest x-ray
• Sputum specimens ( 3 obtained 8-24 hours apart)
  for AFB microscopy and mycobacterial cultures
• Routine drug-susceptibility testing for INH, RIF,
  and EMB on initial positive culture

61
Treatment Regimens

• Four regimens recommended for treatment of
  culture-positive TB, with different options for
  dosing intervals in continuation phase
• Initial phase standard four drug regimens (INH,
  RIF, PZA, EMB), for 2 months, (except one regimen
  that excludes PZA)
• Continuation phase additional 4 months or (7
  months for some patients)

62
Case 7 SS
63
Case SS

• S. S. is a 19 year old immigrant from SE Asia who
  presented to the ER at MHC in 2001 after coughing
  up blood for 2 to 3 weeks in increasing amounts.
  He denied SOB, fevers, chills, sweats or weight.
  He had had some recent pleuritic-type chest pain
  which is worse with cough.
• PMH No previous hospitalizations or surg.
• SH Lives with parents and 2 brothers born in
  SE Asia. Immigrated to America at young age.

64
Case SS Radiology Report

• Chest X-Ray 5/18/01 Large right paratracheal
  suprahilar mass. Neoplastic etiology including
  malignancy to be considered and ruled out.

65
Case SS Labs

• PPD was read at 30 mm.
• CT done on 6/14/01 showed 5 cm in diameter smooth
  in outline mediastinal mass consistent with
  malignancy, most likely lymphoma or metastasis
  until proven otherwise
• Sputums on 5/23, 5/24 and 5/25 negative for
  acid-fast bacilli

66
Primary MDR TBUnited States, 19932007
No. of Cases
Percentage
Updated as of April 23, 2008. Note Based on
initial isolates from persons with no prior
history of TB. MDR TB defined as resistance to
at least isoniazid and rifampin.
67
Case 8 LG
68
LG 2/22/2008

• Patient was a 23 year old Ethiopian Oromo male
  who presented to the MHC ER in Sioux City stating
  that he had a swelling on his neck for awhile.
  Interpreter serves were poor, but he denied pain.
  He recalled no injury or scratch. He denied any
  fevers, lightheadedness, or syncope.

69
LG 2/22/2008

• VS- Temp 97.7, BP 141/80, Pulse 90, RR 16
• HEENT- TMs normal, oral mucosa slightly
  erythematous, no tonsillar edema or pustules, no
  cervical lymphadenopathy or occipital adenopathy.
• Neck- significant swelling at the left lateral
  neck area- about 4x3 cm in diameter. Mildly
  tender to palpation.
• Lymph- no supracervcial or axillary
  lymphadenopathy.
• Lungs- Clear
• Heart- nl S1, S2
• Abd- nl bowel sounds, no organomegaly

70
LG 2/22/2008

• Labs CRP 11.2, WBC 6.07, RBC 5.32, Hg 14.3, Hct
  44, Platelets 284,000. Group B strep- negative

71
LG 2/22/2008

• Assessment Acute lymphadenopathy, left cervical
  chain. Placed on Keflex 500 QID for 10 days with
  recheck. If not improving plan to refer on.

72
LG 2/25/2008

• Patient returned to the MHC ER on 2/25 for
  recheck of his lymphadenopathy. He now notes
  that at home he has been running a few fevers.
  The very astute nurse practitioner working there
  thought this was not a run of the mill case so
  called Dr. Swanson to see the patient.

73
LG 2/25/2008

• HPI Noted to be a 23-year old African immigrant
  to the United States. He is a member of the
  Oromo tribe from Southern Ethiopia. He
  immigrated to America in December 2006 and works
  at the Tyson meat packing plant. He now
  describes a 10-day history of slow-enlarging neck
  mass. He reports some tingling feelings on the
  left side of his neck that radiate into his left
  arm. He denies every having this problem before.

74
LG 2/25/2008

• SH Oromo immigrant from Southern Ethiopia.
  Muslim religion. Immigrated to US in late 2006.
  Works at Tyson. Unmarried.
• PMH No hospitalizations, no surgeries.

75
LG 2/25/2008

• VS Temp 98.2, P 91, RR 16, BP 147/63
• HEENT PERRLA, TMs clear bilaterally, oropharynx
  clear without erythema or exudate. Dentition
  good. Approximately 7 cm mass in left
  mid-anterior part of the neck that is painful to
  the touch.
• CV RRR
• Resp CTA
• Abd BS, soft, non-tender

76
LG- 2/08 CT Neck soft Tissue

• Enlarged left posterior auricular lymph nodes (at
  level of C1, 2.4x 1.2 cm posterior node showing
  partially cystic center at C3-C4 a 2.1 x 4 cm
  node with a liquid or cystic center and a second
  smaller 2.2 x 1 cm node with cystic center). The
  second, larger group of two sets of lymph nodes
  does compress and displace the left internal
  jugular vein.
• Parotid and submandibular glands appear normal.
• No abnormal nodes are seen in the right side of
  the neck.

77
LG- 2/08 Chest x-ray report

• No active lung disease very prominent left hilum
  with no previous studies for comparison heart
  is normal

78
LG- 2/08 Chest Ct report

• 3 x 3.5 cm irregular mass in the left upper lobe,
  in the left suprahilar area. The mass is
  contiguous with the superior mediastinum.
  Density indicates a solid mass as opposed to a
  cyst or fat.
• The remaining portions of the lungs are normal.

79
LG- Labs

• WBC 5.56, Hgb 13.7, Hct 42, MCV 80, Plt 293,000,
  ESR 21
• PPD Induration 25 (0-10)
• Glucose 132, BUN 12, Cr 0.9, GFR 134.48,
  Potassium 3.6, Chloride 99, CO2 28, Anion Gap 9,
  AST 29, ALT 67

80
LG- Labs

• 2/26 Lymph Node Aspiration
• Moderate WBCs, no bacteria found
• No aerobes, no anaerobes
• No acid fast bacilli
• 2/26 Lymph node aspirate
• Negative for malignancy Contains lymphocytes.
• 2/26 Urine- no acid-fast bacilli noted.
• 2/26 Sputum Lung- no acid fast bacilli found
• 2/26 Sputum Lung- Candida krusei
• 2/26 Serum Crag- negative
• Lung Sputum Gram Stain- Few WBCs, Few gram
  positive cocci, few gram positive bacilli
• 2/28 Bronchial washings- no WBCs, no bacteria
  found
• 2/28 Left Upper Lobe Washings- Rare inflammatory
  and epitherlial cells. Negative for malignancy.
• 2/28 Neck Biopsy
• No WBCs found, no bacteria found, no aerobes
  isolate, no anaerobes isolated.

81
LG 2/22/2008

• What is your diagnosis and what would you do?
• A) HIV-related Lymphadenitis
• B) Tuberculosis
• C) Lymphoma
• D) Reactive Lymphadenopathy
• E) Other

82
Causes of Localized adenopathy

• From www. Wrongdiagnosis.com/bookimages/8/2630.2.p
  ng

83
Differential Diagnosis of Lymphadenopathy in an
Immigrant

• Generalized adenopathy
• Acute HIV
• Many viral infections
• Rickettsial infections
• Leptospirosis
• Brucellosis
• Relapsing Fever
• Others
• Several Protozoan Infections
• Trypanosomiasis
• Leishmaniasis
• Toxoplasmosis

• Local adenopathy
• Tularemia
• Leishmaniasis
• Plague
• Cat-scratch disease (Bartonella)
• Syphilis
• Primary Herpes Simplex
• LGV
• Rickettsial infections
• Credits Guerrant et al., Essentials of Tropical
  Infectious Diseases, 2001, p. 7.

84
Case 9 JM
85
Case JM

• HPI Patient was a 33 year old Hispanic male who
  was admitted to MHC on 10/17/01 by Dr. Swanson.
  He had been diagnosed with HIV in June (06/01) at
  a nearby Family Practice office. He had had a
  long history of bouts of low blood pressure,
  dizziness, blurry vision, fatigue. He also had
  oral candidiasis on that day he was seen there.
• He was subsequently seen on SCHC for entry labs
  on 9/17/01 and he was found to have a CD4 count
  of 50, HIV RNA Viral Load of 241,230.
• He then came to SCHC for a new patient visit on
  9/27. He was found to have an elevated temp up
  to 101.9 and some slightly enlarged lymph nodes.
  Rapid Strep was negative.

86
Case JM-MHC

• On 9/27, he was started on Combivir (AZT/3TC) one
  tab BD and Kaletra (Loprinavir/ritonavir) three
  tabs BD.
• He was seen on 10/12 and by then had enlarged
  lymph nodes and a painful throat. His temp was
  100.3. He was placed on Keflex.
• He was seen again in the late PM of 10/16 and
  nodes still enlarged and temp 101.1.
• The decision was made to admit him the next day
  for workup of fever of unknown origin.

87
Case JM-MHC

• PMH
• Medications
• Combivir (Epivir/AZT) 1 tab BD
• Kaletra (Lopinivir/Ritonavir) 3 tabs BD
• Zithromax
• Family History
• Social History
• Married for 9 years wife in Mexico, 1 son and 1
  daughter
• Born in Mexico, in America for 15 years
• Smokes 4 cigarettes per day
• Lives with friends.
• No blood transfusion, no IV drug use or snorting
  of cocaine.
• History of 3 sexual partners but none since
  marriage

88
Case JM

• VS Pulse 60, Temp 101, Wt. 133
• HEENT TMs clear bilaterally, PERRLA, EOMI,
  Oropharynx showed slightly enlarged tonsils but
  no white pus. No thyroidmegaly
• Lymph Enlarged cervical lymph nodes on both
  sides of the neck.
• Cardiovascular RRR, no murmur
• Resp CTA
• Abd Positive Bowel Sounds, soft, non-tender
• Rectal Guiac positive on 9/27/01, not repeated
• Neuro CN 2-12 intact Sensory intact to
  sharp-dull on all 4 extremities, Motor 5/5 on all
  4 extremities.

89
Case JM

• Labs (Office 9/17/01) Hep B Surf Antigen, Core
  antibody and Surf antibody negative CMV IgG
  positive but IgM negative, Hep C Antibody
  negative, Toxo IgM negative.
• Labs (Office 10/1/01) ALT 12, AST 31, Alk Phos
  56, Total Bili 0.4, Alb 3.2, Cr 1.1 24 Hour
  Urine showed CC of 44 and 24 Hour protein of 230.
• Labs (Office 10/16/01)
• WBC 2.3, Hg 10.0, Hct 29, MCV 80, Plt 355,000,
  Glu 109, BUN 14, Cr 0.9, Sodium 131, Potassium
  4.2, Chloride 97, Bicarb 22, Calcium 8.3
• Blood Culture- no growth

90
Case JM

• Radiology Results
• Chest X-ray without active infiltrate
• Normal Abdominal X-rays
• CT of neck- swelling at the left base of the
  tongue and oropharnyx and bilateral
  lymphadenopathy.
• Abd CT splenomegaly, periaortic and caval
  lymphadenopathy.

91
Case JM

• Patient was admitted to MHC on 10/17 and placed
  on Zinacef, Levaquin, and Bactrim while results
  were pending. On 10/19 Zithromax was added. He
  became febrile to 103.2 on 10/20, 101.6 on 10/21,
  102.8 on 10/22, 102.7 on 10/23 and 100.4 on
  10/24.

92
Case JM-MHC

• Lab Results
• Bun 11, Cr 0.8, Sodium 127, Potassium 3.7, Cl 98,
  CO2 26, Calcium 7.6, Total Protein 6.4, Alb 2.2,
  AST 63, Alk Phos 68, Total Bili 0.38, ALT 45, WBC
  3.58, Hg 9.0, Hct 26, Plt 184,000,
• 10/17 Blood Cultures x2, no growth
• 10/19 Blood Cultures x2, no growth
• 10/21 and 10/23 Blood Cultures, no growth
• Crypto Antigen negative Stool Culture negative
  for Salmonella, Shigella, E. Coli or
  Campylobacter.
• O and P Stool negative x 3
• Urine TB and Culture negative.
• PPD Negative

93
Audience vote what does this patient have?

• A) M. Tuberculosis
• B) Pneumocystis Pneumonia
• C) Bacterial Pneumonia
• D) M. Avium
• E) Histoplasmosis Fungal Pneumonia
• F) HIV Related Lymphoma or Kaposis Sarcoma
  (Cancers)
• G) I dont know, Ive never seen HIV before!

94
Review of Educational Objectives

• Identify the symptoms (patient complaints)
  associated with tuberculosis
• Learn the signs (physical exam findings)
  associated with tuberculosis
• Review the radiology findings and lab tests
  associated with tuberculosis
• Understand some basic facts about treatment of
  tuberculosis
• Use community cases of TB in Siouxland over the
  last 8 years to do the above

95
Additional TB Resources

• Dept. of TB Elimination at the Center for Disease
  Control at www.cdc.gov/tb/

96
Part 2 Answers and Info

• SLRMC Pulmonary Conference
• 20 February 2009
• Dr. Thor Swanson
• Siouxland Medical Educational Foundation
• U of Iowa Clinical Assistant Professor of Family
  Medicine

97
Case AD Treatment

• Pt received INH for 3 weeks (7-18-01 to 8-8-01)
  until resistance patterns came back ,along with
  Rifampin, PZA, ETH, and Vit. B.
• Original cultures showed MTB resistant to INH.
• Pt then received (8-9-01 to 10-9-01) Levoquin 500
  QD, Rifampin, PZA, ETH, and Vit B6 for 2 months.
• Pt then received (10-10-01 to 12-10-01) LEV, RIF,
  ETH, and Vit. B6 for 2 months.
• Pt then received (12-11-01 to 1-02-02) RIF, PZA,
  ETH, and Vit. B6 for 1 month.
• Pt then received (1-3-02 to 9-19-02) PZA, ETH,
  LEV and Vit B6 for 9 months
• Pt. had positive sputums for 4 months after
  starting treatment, but the cultures never grew
  anything.

98
Case AD Treatment

• What does it mean that the patient had positive
  sputums for 4 months, but the cultures were
  repeatedly negative?
• Patient was coughing up dead bacterium for months.

99
Case AD Follow-up

• Patient was cured of active tuberculosis but
  continued to smoke and died of end-stage lung
  disease in 2005 at age 53.

100
Case AD Key Take Home Points

• Resistant TB exists in the US
• Homelessness is a risk factor for TB
• Alcoholism is a risk factor or TB

101
Case CN MH 392957 SL 17633359

• CN was a 58 year old Hispanic man who presented
  to MHC ER on 1/20/04 with phlegm production,
  increasing fevers, weight loss, night sweats,
  increased sputum production, SOB and right leg
  pain. Long history of smoking, but quit several
  years before. Unsure if having hemoptysis as
  nearly blind and didnt see well. Family had
  noticed large weight loss in previous 3 months.
  Had been seen at SLRMC ER on 12/30 with similar
  complaints and sent home.
• PMH
• 1. () Diabetes on oral meds,
• 2. s/p below the knee amputation for poor
  circulation in 6/03
• 3. () legally blind in both eyes from cataracts
  and surgery
• 4. High Cholesterol

102
Case CN Treatment and Follow-up

• Pt. hospitalized from 1/20 until 1/27. Multiple
  AFB smears came back positive for acid-fast
  organisms. Drug therapy (4 drug INH, RIF, ETH,
  and PZA from 1/22/04 until 3/10/04 3 drug
  therapy INH, RIF, PZA from 3/11 until 3/25 2
  drug therapy from 3/26 until 5/27).
• Culture of mycobacteria did grow M TB in the
  state lab.
• Pt. was rehospitalized from 2/10 until 2/20 at
  SLRMC for wasting and malnourishment. Peg Tube
  placed.
• Patient got 4 months of treatment. Moved back to
  Mexico and took 1 month of meds with him
  Contact made with hospital in Mexico.
• He has not resurfaced in Sioux City since 2004.

103
Case CN Key Points

• Pts. can have active TB even with a negative PPD.
• Immunocompromised patients (here with Diabetes)
  are more likely to get TB
• TB is more common in immigrants, because they
  come from areas with endemic TB
• TB can present in a miliary (disseminated)
  picture and also with large cavities.

104
Case DW MH 318507

• DW is a 60 year old man who presented to the SCHC
  in May 2002. He was a known diabetic and
  hypertensive who had been out of care for 3 and ½
  years. He made his way to an ENT physician who
  saw him for a hoarse voice and sore throat of
  several months duration. He was taken to
  surgery. He was referred for primary care
  follow-up of his multiple medical problems. to
  the office with hoarse voice and sore throat for
  several months. Patient denied any cough, fever,
  night sweats.
• PMH, 1. () Diabetes, A1C 8.8
• 2. () chronic alcoholism,
• 3. () COPD,
• 4. () HTN,

105
Case DW Treatment and FollowUp

• Multiples sputums came back positive for
  acid-fast bacilli which were subsequently
  identified as M. Tb at the state hygenic lab.
• Patient was started on 4 drug therapy including
  INH 300 QD, Rifampin 600 QD, Pyrazinamide 1500
  QD, and Ethambutol 1600 QD Also vitamin B6,
  Glucophage (for diabetes), HCTZ and Accupril (for
  hypertension), and an ASA QD (for CAD
  prophylaxis).
• PT did 2 months of 4 drug TB therapy 4 further
  months of INH and Rifampin Sputums and cultures
  turned negative for M. TB and X-Ray normalized.
  Patient was cured of active TB.
• PT did however continue to drink alcohol heavily.

106
Case DW Follow-Up

• 1 year from start of diagnosis, patient developed
  epigastric pain EGD was done and biopsy of
  Esophageal lesion showed Adenocarcinoma
  (Barretts esphagus). Further workup showed
  metastases in the liver. Patient lived several
  months and died of metastatic esophageal cancer.

107
Case DW Key Take Home Points

• TB can present in places other than the lungs, in
  this case it was the larynx.
• TB is more prevalent in medically non-compliant
  and compromised people- he not only had
  uncontrolled diabetes and alcoholism, but also an
  occult esophageal cancer.
• You can still have active TB in a pt. with a
  negative PPD.
• Homelessness/poor living conditions are a flag
  for TB

108
Case HN MH 082144

• H. N. was a 49 year old African American man who
  presented to the MHC ER on January 29th, 2004
  with fever, cough productive of brown phlegm,
  chills night sweats, and weakness for 2-3 months.
  Also had lost 40 pounds in last 12 months.
• PMH () h/o gunshot wound (-) HIV test 2 years
  prior
• SH Divorced Homeless in and out of SC Gospel
  mission, Smoked 1 PPD for 25 years but quit
  smoking 6 months prior occ. Alcohol use h/o IV
  drug use Lifetime sexual partners about 4.
  Negative HIV screen 2 years prior.
• FH Mother with MI in late 50s.

109
Case HN Treatment and Follow-up

• Pt. was admitted on 1/29/04. Pt. started 1/29 on
  Ceftriaxone and Zithromax.
• Acid fast stains were positive with an organism
  that grew M. Tb on culture.
• 2/01, Pt. started with 4 drug therapy- INH, RIF,
  ETH, PZA with acid-fast stains.
• 2/02 to ICU and intubated
• 3/04 Thoracic Resection for persistent TB- Right
  thoracotomy with bilobectomy including resection
  of the RUL and RML, as well as drainage of a
  right lower lobe abscess.
• 4 drug therapy 2-1-04 until 4-13-04.
• Finally discharged from Mercy Hospital on
  4-30-04.
• 3 drug therapy (INH, RIF, ETH) from 4-14 until
  5-18 2 drug therapy from 5-19 until 10-07.

110
Case HN Treatment and Follow-up

• Patient lived for at least several years after.
• Hospital charges in excess of 350,000.

111
Case HN Key Points

• Pt. had () PPD 2 years prior and refused
  prophylactic therapy
• Pt with risk factors including malnutrition,
  homelessness, and time at homeless shelter.
• Sometimes severe cavitary TB is treated with
  surgical resection. After resection, they can do
  well.

112
Case CR SL 40746970 MH401379

• C. R. was a 29 year old AA male who presented to
  the ER at SLRMC on 8/23/04 with fever, weight
  loss, productive cough, and weakness. Patient
  also with moderate headache.
• PMH () childhood asthma
• SH Grew up in ghetto of Midwestern city
  Previous prison time Living with girlfriend and
  her 2 children
• PE Temp. 102 Wasted/Cachetic Oral thrush Dry
  cough

113
Case CR Other Labs

• PPD ()
• Sputum Culture 8/24ff.- Positive for acid-fast
  bacteria. Later () for INH resistant M. TB.
• Spinal Tap- () Acid-Fast organisms in the CSF
  Later culture () for M. TB
• HIV (-)

114
Case CR Treatment

• Patient started on 4 drug therapy- INH, Rif.,
  Ethambutol, and PZA.
• M. TB. Found to be resistant to INH.
• Then, Rifampin caused Acute Renal Failure.
  Subsequent kidney tests showed underlying
  nephropathy with proteinuria
• Patient readmitted to hospital (MHC) in 11/04 for
  Levofloxacin, ETH, PZA and Streptomycin shots.
• Pt. continued on daily LEV, ETH, PZA and 3/week
  Streptomycin shots for 18 months, at the
  suggestion of the Iowa state TB specialist.
• Pt. continued with routine hearing screening and
  vision screening (semi-compliant) while on
  Ethambutol.

115
Case CR Take-Home Points

• Inner-cities and prisons are both high-risk
  locales for TB.
• TB treatment can be complicated by resistance,
  underlying medical conditions (nephropathy), and
  non-adherence.
• TB meningitis can present with headache.
• TB can present in multiple sites simultaneously-
  here lung and CNS.

116
Case J C-D SL 17416196

• J C-D was a 49 year old Hispanic man who
  presented to the ER at SLRM on 6/23/02 with
  cough, fevers, shortness of breath, weight loss
  and fatigue.
• PMH
• SH Divorced Immigrant from Mexico many years
  before Heavy alcohol drinker intermittently
  working at meat-packing plant
• PE Temp. 102 Rhonchi with prolonged expiratory
  phase

117
Case J Lab Results

• Sputum Culture () for Acid-Fast Organisms that
  later grew M. TB.
• HIV test (-)

118
Case J Treatment

• Patient was hospitalized 5 days. He was started
  on Levaquin.
• 4 Drug therapy was initiated on 6/29 until 8/2/02
  (INH, RIF, ETH, PZA). 3 Drug therapy from 8/2
  until 8/26(INH, RIF, ETH). 4 Drug therapy from
  8/26 until 10/03 (INH, RIF, ETH, Biaxin). 3 Drug
  therapy from 10/04 until 12/31 (INH, RIF,
  Ciprofloxacin), 2 Drug therapy from 1/1/03 until
  2/19/03 (INH, RIF)
• Thus, patient got multi-drug therapy for about 8
  months

119
Case J C-D Follow-up

• Patient did well and moved away from the
  community. About 2 years later, ca. 2004-5, I
  met his niece in Sioux City and she said he was
  alive and well in Florida.

120
Case J Key Points

• Patient had previous treatment for active
  tuberculosis Watch such patients closely (if
  they are compliant), and look for recurrence.
• Immigrants have a higher incidence of TB.

121
Case SS MH 053499

• S. S. is a 19 year old immigrant from SE Asia who
  presented to the ER at MHC in 2001 after coughing
  up blood for 2 to 3 weeks in increasing amounts.
  He denied SOB, fevers, chills, sweats or weight.
  He had had some recent pleuritic-type chest pain
  which is worse with cough.
• PMH No previous hospitalizations or surg.
• SH Lives with parents and 2 brothers born in
  SE Asia. Immigrated to America at young age.

122
Case SS Treatment

• Patient started on INH, RIF, PZA, and ETH.
• Pt took PZA and ETH for 2 months, INH and RIF for
  total of 6 months.
• Pt and his father refused biopsy of the
  mediastinal mass.

123
Case SS Treatment

• Repeat CT scan was done after 6 months with total
  disappearance of the mass.
• Patient is alive and well in Siouxland.

124
Case SS Key Points

• Thousands of cases of Sputum and biopsy (-) TB
  are treated every year in the world.
• Immigrants are at higher risk for TB, even many
  years after arrival.
• Patient may also have been infected with atypical
  mycobacterium.

125
LG 2/22/2008

• Patient was a 23 year old Ethiopian Oromo male
  who presented to the MHC ER in Sioux City stating
  that he had a swelling on his neck for awhile.
  Interpreter serves were poor, but he denied pain.
  He recalled no injury or scratch. He denied any
  fevers, lightheadedness, or syncope.

126
LG- Treatment

• Patient started on 4 drug TB therapy on 2/29/08
  by Dr. Swanson. On 3/26, culture of lymph node
  aspirate identified as M.TB, so this patient did
  have Tuberculosis.

127
LG- Labs

• Patient started on 4 drug TB therapy on 2/29/08.
  Completed 2 months of 4-drug therapy (Directly
  observed therapy) and 4 more months of 2 drug
  therapy (2 times weekly, DOT). He also did
  Vitamin B6 for 6 months.

128
TB of the Lymph Nodes

• Patients with lymphatic TB usually present with
  signs and symptoms related to their site of
  disease, although, as with TB anywhere, symptoms
  may be nonspecific (constitutional) or they may
  be absent.
• Hilar and mediastinal lymphadenopathy are common
  features of primary TB infection, but they also
  may be present in reactivation TB.
• Enlarged intrathoracic lymph nodes may compress
  airways, creating focal wheezing or bronchial
  obstruction.
• Source John Bernardo Chapter 19, Tuberculosis,
  in Patricia Walker and Elizabeth D. Barnett,
  eds., Immigrant Medicine, Philadelphia Elsevier
  Saunders, 2007 p. 262.

129
TB of the Lymph Nodes

• Infected lymph nodes may enlarge further during
  treatment, in a phenomenon often attributed to a
  reconstitution of the cellular immune response,
  as with TB/AIDS patients who are undergoing
  treatment for both diseases.
• Cervical lymph nodes are commonly the primary
  site of disease.
• Aspiration of infected material or biopsy are
  often required to differentiate TB lymphadenitis
  from other causes of lymph node enlargement in
  the neck.
• As with TB adenitis anywhere, treatment with
  multiple drugs is effective, but enlargement of
  involved lymph nodes during treatment, especially
  early, is common.
• Source John Bernardo Chapter 19, Tuberculosis,
  in Patricia Walker and Elizabeth D. Barnett,
  eds., Immigrant Medicine, Philadelphia Elsevier
  Saunders, 2007 p. 262.

130
Take Home Points- Case LG

• 1. TB is common amongst immigrants.
• 2. gt20 of TB cases in immigrants present as
  extrapulmonary TB.
• 3. In immigrants and Africans, the TB and HIV
  epidemics are linked, so patients with TB need an
  HIV test.
• 4. Cervical TB, scrofula, is still seen in the
  US, especially amongst immigrants.

131
Case JM

• HPI Patient was a 33 year old Hispanic male who
  was admitted to MHC on 10/17/01 by Dr. Swanson.
  He had been diagnosed with HIV in June (06/01) at
  a nearby Family Practice office. He had had a
  long history of bouts of low blood pressure,
  dizziness, blurry vision, fatigue. He also had
  oral candidiasis on that day he was seen there.
• He was subsequently seen on SCHC for entry labs
  on 9/17/01 and he was found to have a CD4 count
  of 50, HIV RNA Viral Load of 241,230.
• He then came to SCHC for a new patient visit on
  9/27. He was found to have an elevated temp up
  to 101.9 and some slightly enlarged lymph nodes.
  Rapid Strep was negative.

132
Case JM

• After admission on 10/17, fevers remained high.
  On 10/22, acid-fast sputums came back positive,
  so patient was started on INH, Ethambutol,
  Pyrazinamide, and Rifabutin on 10/22 to treat
  presumed tuberculosis.
• On 10/20, a surgeon was consulted to biopsy
  cervical lymph node Surgeon declined noting
  Patient has evidence of fevers. Doubt that he
  has any significant malignant adenopathy at this
  time. Would recommend that he be treated for an
  infectious source for his symptoms and if he has
  persistent adenopathy, despite other measures,
  over the next week or two, could reconsider
  biopsy at that time.
• Correct answer Presumably A Mycobacteria TB, but
  cannot rule out D Mycobacteria Avium

133
Case JM

• After starting on TB meds (10/22), pt defervesced
  (starting 10/25). He received Epogen and
  Neupogen and by 11/9, his WBC was up to 3370 and
  his H/H 9.9. By 11/9 patient he had 3 negative
  acid-fast sputums and was sent home on 4 drug TB
  treatment INH, PZA, ETH, and Rifabutin. During
  that time, he continued on Combivir and Kaletra.
• Over the next 2 months, Mycobacterial cultures
  came back positive for Mycobacterium Avium.
• So real correct answer D) Mycobacterium Avium

134
Mycobacteria Avium (MAC)

• Results from disseminated infection with
  Mycobacterium avium-intracellulare.
• Although prior to the AIDS epidemic, disseminated
  MAC infection had been reported only rarely, this
  infection became one of the most important
  opportunistic infections associated with AIDS in
  many parts of the world.
• Disseminated MAC occurs almost exclusively in
  AIDS patients with an absolute CD4 count lt50
  however localized MAC infection can occur at
  higher CD4 counts, especially among patients with
  advanced AIDS who have been immune reconstituted
  by ART.
• In 1992 (before multidrug ART), in the West
  disseminated MAC had an incidence among Americans
  with AIDS of 10 per 100 patient-years by 1998,
  that incidence had declined to 2 per 100
  patient-years as a result of ART.
• Disseminated MAC has been less common in parts of
  the world where tuberculosis is more prevalent.

135
Mycobacteria Avium- Clinical manifestations

• Symptoms are nonspecific and include fever,
  drenching sweats, wasting, and fatigue.
• Enlargement of the liver, spleen, and abdominal
  lymph nodes are also seen.
• Anemia, neutropenia, and thrombocytopenia occur
  with bone marrow involvement, and diarrhea,
  malabsorption, and abdominal pain indicate GI
  infection.
• There have also been reports of localized
  disease, including diarrhea/malabsorption,
  cervical lymphadenitis, pneumonitis,
  pericarditis, osteomyelitis, skin or soft tissue
  abscesses and genital ulcers.
• Rapid CD4 rebounds due to ART have produced
  Immune reconstitution Associated MAC

136
Mycobacteria Avium-Radiology

• Involvement of pulmonary parenchyma results in
  diffuse, heterogenous interstitial patterns with
  or without lymphadenopathy.
• No definite patterns distinguish this or other
  species of mycobacteria from TB on chest films.
• Also, acid fast sputum stains do not distinguish
  M. avium from M. Tb. A culture is needed to
  delineate the species of Mycobacteria.

137
Mycobacteria Avium-Treatment

• Induction Macrolide such as clarithromycin 500
  mg BID or azithromycin 500-600 mg PO QD combined
  with either ethambutol 15 mg/kg po QD, or
  rifabutin 300 mg po QD, or perhaps both agents
  for 1 year with discontinuation after immune
  restoration to CD4 count greater than 100.
• Prophylaxis Azithromycin 1200 mg po Q week or
  Clarithromycin for all HIV patients with CD4
  count less than 50.