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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
TB – Presentation, Investigation and Overview

Paul McWhinney, Infectious Diseases, BRI

an old friend
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
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
Post-Primary
  • Relapse
  • Re-Infection
  • Disease developing in a person with some immunity .

4

why bother
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
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
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
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
Similar Illnesses
  • Lymphoma
  • HIV
  • Bronchiectasis
  • Cancer
  • Inflammatory Bowel Disease
  • Anything
  • The Unexpected & Serendipity

9

what to do
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
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
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
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
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
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
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
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
& 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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