Sumatran Surprise An Intriguing Indonesian

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Sumatran SurpriseAn Intriguing Indonesian

• Infectious Diseases
• Dr. M. Wansborough-Jones firm
• Kathryn Brain
• Norzehan Hj Md Saini
• Jeremy Rampling
• Nikunj Shah

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MR. A

• 26 years old, Indonesian, male
• 8 years in the U.K
• Speaks little English
• Delivery man at a takeaway in Battersea

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PC

• Productive cough
• Lymphadenopathy
• Weight loss
• Swollen left knee

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HPC

• 1 month Hx of productive cough, grey sputum,
  worse in last 2 weeks, associated SOB
• An episode of haemoptysis, last Easter, more than
  a spoonful of blood mixed with mucus
• 2 weeks ago - fever, shivering, night sweat, took
  paracetamol, resolved spontaneously

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HPC cont.

• Post-prandial nausea, vomited food eaten 2 weeks
  ago but has good appetite
• Weight loss (how much, since when?)
• 1 month Hx of general malaise
• Occasional headache with vertigo after walking a
  certain distance, last incident a week ago, had
  to keep his head up to prevent from fainting,
  passed out once few months before developed cough

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HPC cont.

• SOB on exertion
• Lumps in neck for a year, submandibular and on
  both sides, ? in size, went to see his GP in Jan
  2003 was referred to CIU but failed to turn up
  for appointments few times
• Swelling of left knee with lesion sinus
  discharging occasionally below the left knee for
  3 months, tender and painful to move, lost
  balance as a result, pain has been there for a
  year

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SE

• No palpitations, central chest pain, oedema
• No neck stiffness, photophobia
• No fits, numbness, pins and needles, muscle pain
• No genitourinary symptoms
• No other GI symptoms

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PMH

• No significant illnesses
• Vaccinated for BCG but no scar found

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DRUG Hx

• Nil
• No known allergies

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FAMILY Hx

• Nil

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SOCIAL Hx

• Came to the U.K IN 1994
• Went to Saudi Arabia for a month in 97
• Went back to Indonesia for 2 months in 98
• Both parents and two younger sisters in Indonesia
  - fit and well
• Lives in 4 bedrooms detached house in Tooting
  with 3 other people, all fit and well
• Works as delivery man in an Indian takeaway

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Social Hx cont.

• Occasional smoker and drinker
• Single
• Never been in any sexual relationship
• Denies any i.v drug use

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Physical examination

• Cachectic, looking unwell
• No pallor, jaundice, clubbing, cyanosis,
  koilonychia
• Temp. - 37.1 C
• Sat. - 98 on air
• Lymph nodes enlargement - submandibular and
  submental, several in anterior cervical chain and
  a single LN in left axilla

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Physical examination cont.

• CVS
• Pulse - 130 bpm
• BP - 106/80 mm Hg
• HS - I II 0
• Respiratory
• Right lower zone - dull on percussion, harsh
  bronchial breathing
• Crackles on the left base

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Physical examination cont.

• Bowel
• Soft, non-tender, normal bowel sound,
• No organomegaly
• CNS
• Grossly intact

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Physical examination cont.

• Left knee - fluctuant swelling sinus below the
  knee (dry)

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Differential diagnosis

• TB (Post-primary gt Primary)
• Lymphoma
• Carcinoma of the lung
• Atypical pneumonia

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Ix at admission 13/5

• FBC (including CRP)
• UE
• LFT
• Blood culture
• Sputum microscopy (AFB)
• Swab from leg
• CXR

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Blood results

• Hb 11.8 Na 133? Bilirubin 9
• WBC 7.9 K 4.9 ALT 42
• Neut 6.7 Urea 5.9 ALP 92
• Platelets 240 Creatinine 90 Albumin 25?
• MCV 77 ? Glucose 5.3 Gamma GT 34
• CRP 144.5? Adj Ca2 2.25
• PO4 1.24
• CXR - R lobar consolidation

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Admitted 13/5

• Iv hydration
• Erythromycin po 500g qds
• Cefotaxime iv 1g bds

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CXR
CXR - closeup
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The following day...

• Ix
• X ray left knee
• FNA submental submandibular lymph nodes
• TB blood cultures

• Management
• Ibuprofen po 400mg tds

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Knee
Knee - closeup
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15/5 BINGO!!!

• Microscopy- AFB positive
• Legionella/ pneumococcal antigen not detected
• DIAGNOSIS- Tuberculosis - pneumonia and
  osteomyelitis

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Ziehl-Nielsen Stain Bannister, Begg Gillespie
(2000)
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Anti-TB therapy begins 15/5

• 12 months course
• Rifater 4 tablets daily
• (Rifampicin Isoniazid Pyrazinamide)
• Ethambutol 700 mg po od
• Paracetamol 1g po (QDS max) as required

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15/5 Contact tracing

• Close family members and work colleagues
• If unwell gt rigorous TB Ix
• If well, CXR and tuberculin test
• AdultgtCXR childrengt tuberculin
• Isoniazid prophylaxis if suggestive, or if lt1
  y.o.

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Epidemiology

• Leading infectious cause of death world wide.
• Increasing in the far east and Africa especially
  in association with AIDS.
• Increasing in London and the UK
• 40x more likely to have in lifetime if of Asian
  origin.

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Pathology

• Infection with Mycobacterium tuberculosis.
  Mainly in upper of lobe of lungs.
• Initial infection in childhood, primary
  infection. This heals and becomes calcified.
• Reactivation when host becomes immunosuppressed.

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Manifestations

• Miliary TB acute diffuse dissemination of
  tubercle bacilli via the blood stream.
• Presents very non specifically, weight loss ill
  health fever.
• Mantoux test is normally ve though can be -ve in
  severe disease.

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Adult post primary pulmonary TB

• General onset of non specific symptoms.
• Main features fever, cough, weight loss.
• Sputum mucoid, purulent or blood stained.
• Pleural effusion or pneumonia.
• Finger clubbing is present with advanced disease.

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Investigations

• Chest X-Ray patchy nodular shadows in upper zone.
• Staining Ziehl-Nielson culture takes 4-8 weeks.
• Bronchoscopy if no sputum.
• Biopsy of lymph nodes.
• Direct testing for rapid result using PCR.

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Management

• Sensitive organisms use.
• Rifampicin, S/E inducer of liver enzymes, should
  be stopped if bilirubin is elevated.
• Isoniazid, can cause a polyneuropathy at high
  doses. Can cause nausea and vomiting.
• Pyrazinamide reduces renal excretion of urate and
  an precipitate hyperuraemic gout. Can cause
  hepatotoxicity.
• If resistant use ethambutol or myambutol. These
  can cause optic retro bulbar neuritis. All
  patients must be seen by an ophthalmologist prior
  to treatment.

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Control and prevention

• TB is a notifiable disease.
• All close contacts are screened with a mantoux
  test and a chest X-Ray.
• Prevention is with immunisation with BCG
  vaccination administered at 12-13 in the UK
• Administered at birth to groups at high risk