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TB – Presentation, Investigation and Overview. Paul McWhinney, Infectious Diseases, BRI. An Old Friend. Well adapted to life with humans Severe Disease in Host is not useful It’s all a terrible mistake….. Most primary cases are asymptomatic. Primary Infection.

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Tb presentation investigation and overview l.jpg
TB – Presentation, Investigation and Overview

Paul McWhinney, Infectious Diseases, BRI


An old friend l.jpg
An Old Friend

  • Well adapted to life with humans

  • Severe Disease in Host is not useful

    • It’s all a terrible mistake…..

  • Most primary cases are asymptomatic

  • 2


    Primary infection l.jpg
    Primary Infection

    • Close, extended contact…..(mostly)

    • Pulmonary

      • Resolution (for a while)

        • Primary Complex

      • Local Spread

        • Bronchopneumonia

      • Distant Spread

        • Milliary

        • Focal disease

    • GI – hopefully non-UK or historical

    3


    Post primary l.jpg
    Post-Primary

    • Relapse

    • Re-Infection

    • Disease developing in a person with some immunity .

    4


    Why bother l.jpg
    Why Bother?

    • Risk to that person

      • Acute Inflammatory Illness

        • Severe sepsis

      • Meningitis, Osteomyelitis, Pyelonephritis etc

      • Late Complications

        • Lung damage

        • Other organ destruction

    • Risk to others

      • So, it is notifiable

    5


    Problems l.jpg
    Problems

    • An illness that is history

    • Explainable feature

    • Diversity of presentation

    • Chronicity

    • Misplaced faith in BCG

    • Dread diagnosis

      • Poor appreciation of efficacy of treatment

  • Lack of Public Awareness

  • Socially Stigmatising

  • 6


    Presentation l.jpg
    Presentation

    • Patient from Risk Group

      • (but NOT always)

  • Fever

    • Night sweats

  • Weight Loss

  • Chronic Chest Infections

    • Several Months, not responding well to usual antibiotics

    • Occasionally years (esp abdominal)

  • Lymphadenopathy (eg cervical)

  • 7


    Protean l.jpg
    Protean…

    • Skin

    • Joints

    • Spine

    • Bowel Upset

      • Recurrent symptoms with very non-specific features

  • Cold Abscess

    • Not hot / erythematous

    • Weeks rather than days

    • Well for size of lesion

  • 8


    Similar illnesses l.jpg
    Similar Illnesses

    • Lymphoma

    • HIV

    • Bronchiectasis

    • Cancer

    • Inflammatory Bowel Disease

    • Anything

    • The Unexpected & Serendipity

    9


    What to do l.jpg
    What to do….

    • Confirm the diagnosis

    • Don’t muddy the water…

      • Quinolones (& linezolid)

      • Steroids etc

  • TB team will consider empirical treatment after specimens sent

  • 10


    Why confirm the diagnosis l.jpg
    Why Confirm the Diagnosis

    • Because we should & people want to know….

    • Treatment is extended, toxic and awkward

      • Response may be slow

      • Patient may be intolerant of drugs

  • Isolate may be resistant

    • And become more so

  • Reason to trace contacts

    • And stratify risk

  • (It might not be TB…..)

  • 11


    Tests l.jpg
    Tests

    • CXR (etc)

    • Sputum x3

    • EMU if wcc present unless immunocompromised

    • Biopsy everything & send for AFB culture

    • No clever tests…

      • (perhaps a Mantoux test)

    12


    What else to do l.jpg
    What else to do

    • Especially if unwell or pulmonary, TALK to the TB office

      • Delay can be bad for the patient AND contacts

  • Weigh them

    • To calculate doses and Monitor response

  • LFT, U&E, FBP

  • Vitamin D?

  • HIV test (+B&C while ‘there’)

  • 13


    Who to talk to l.jpg
    Who to talk to

    • TB office

      • A good place to start

  • Respiratory Physicians

    • Chest disease

  • ID Physicians

    • Non-pulmonary disease

    • HIV related disease

  • Paediatricians! (Dr Moya)

  • Neck nodes etc: ENT

  • 14


    Treatment l.jpg
    Treatment

    • Usually:

      • 2 months 4 drugs then 4 months of 2 drugs

      • All dispensed by hospital & whole prescription given at once

  • Sometimes:

    • Steroids

      • Then need bone protection

  • 15


    Slide16 l.jpg
    Also….

    • Check for immunocompromise

    • Explain need to comply

      • (none of this concordance business)

  • Warn about effects of drugs…

    • Including baseline eye check

  • & Check for interactions

  • Warn may take 2 weeks to start to respond

    • AND some things may get worse first

  • 16


    And then l.jpg
    And Then….

    • Patient attends regularly

      • & TB nurses are able to visit

    • taking all their tablets

    • without side effects

    • and with a good response

    • while their contacts attend for screening

    • (well, some peoples patients might…)

    17


    When they come back l.jpg
    & when they come back….

    • Relapse / Re-Infection

      • Really important to get the isolate

  • Consequences of organ damage

    • Recurrent chest infections

    • Bowel Obstruction

  • Aspergillus infection

  • 18



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