Download TB_6-2 - I-Tech

Unit 6 Diagnosing TB:
B Family Case
Botswana National Tuberculosis Programme
Manual Training for Medical Officers
B Family Background
Recall that:
• Mrs. B visits a clinic after noticing a cough her
husband had for a few weeks and suspecting
that he might be engaging in behaviors risky
for HIV
• She tests positive for HIV and is started on
IPT
• Contact tracing is initiated
Unit 6: Case Studies
Slide 2
Case: B Family
• Mr. B, a 32 year old man, presents to the clinic
with a cough he has had for 1 month
• He is not severely ill and can be evaluated in
an ambulatory setting
Unit 6: Case Studies
Slide 3
B Family Case: Question 1
What questions do you ask
about his history?
Unit 6: Case Studies
Slide 4
B Family Case: Answer 1
Ask questions regarding his history of
smoking and occupational exposures
Unit 6: Case Studies
Slide 5
B Family Case: Question 2
What signs and symptoms do you
look for when examining him?
Unit 6: Case Studies
Slide 6
B Family Case: Answer 2
Evaluate him for tuberculosis symptoms:
•
Cough for 2-3 weeks
• Usually sputum
productive
• May be
bloodstained
• Chest pain
• Dyspnoea
Unit 6: Case Studies
•
•
•
•
Night sweats
Loss of appetite
Weight Loss
Fatigue
Slide 7
B Family Case: Question 3 (1)
During examination, Mr. B:
• Denies experiencing dyspnoea, chest pain, fever,
shortness of breath, loss of appetite, chronic
diseases, smoking or taking any medications
• Reports having no prior history of TB, but reports
having had contact with a TB positive uncle
• Reports coughing for 1 month, weight loss over the
past few months, night sweats and fatigue
Unit 6: Case Studies
Slide 8
B Family Case: Question 3 (2)
During examination, health worker finds:
•
•
•
•
T 37
Wt 58kg
R 18
P 82
• Pt looks thin, wasted
• Crepitations to
auscultation
• Cervical
lymphadenopathy
• Otherwise, exam normal
What do you do next for Mr. B?
Unit 6: Case Studies
Slide 9
B Family Case: Answer 3 (1)
•
Obtain relevant contact history
•
•
•
•
Take a spot sputum test today
•
•
•
When was the exposure?
Is the patient on treatment?
What was the duration of exposure, etc.?
When obtaining the spot sputum, have the patient rinse
his mouth with water first
Stand outside with him, behind the direction he is facing,
and have him cough
Counsel Mr. B and test him for HIV today
Unit 6: Case Studies
Slide 10
B Family Case: Answer 3 (2)
• Send Mr. B home with another specimen jar for a
morning specimen and ask him to return the
following day
• Pending results, prescribe amoxicillin, 500mg TDS x
5 days, for presumptive bacterial pneumonia
• Provide him with Panado, 1000 TDS x 5 days, for
pain
• NOTE: ESR is a non-specific test and cannot be
used to prove or exclude TB
Unit 6: Case Studies
Slide 11
Unit 6 Diagnosing TB:
Additional Case
Botswana National Tuberculosis Programme
Manual Training for Nursing Officers
Additional Case
• PD, a 27 year old woman, is brought to the hospital
by her family
• She was sleeping much of the time and it became difficult
to wake her up
• She has had 2 weeks of fever, sweats and headache
• Temperature of 39ºC
• She appears thin
• She is sleepy but arousable
• She has a small cervical, axillary and inguinal lymph nodes
and a stiff neck
• The rest of her exam is normal
• A malaria smear is negative
Unit 6: Case Studies
Slide 13
Additional Case: Question 1
1.
2.
3.
4.
She is empirically started on IV antibiotics by
the medical officer
Why is she started on antibiotics? What is
her most likely diagnosis?
What organisms could be causing her
symptoms?
What is the differential diagnosis for PD?
What tests do you order and why?
Unit 6: Case Studies
Slide 14
Additional Case: Answer 1 (1)
1. Meningitis
2. None (aseptic), bacterial, viral, tuberculosis,
cryptococcus neoformans, syphilis
Unit 6: Case Studies
Slide 15
Additional Case: Answer 1 (2)
3.Differential diagnosis for PD
• Tuberculous meningitis
• Cryptococcal meningitis
• When completing a lumbar puncture, measure opening
pressure for elevated pressure
– AIDS-defining illness in HIV positive patients
• Bacterial meningitis
Unit 6: Case Studies
Slide 16
Additional Case: Answer 1 (3)
3. (cont.)
• Viral meningitis
• Rarely prolonged
• Neurosyphilis
• Subacute or chronic lymphocytic meningitis
• Other infections such as trypanosomiasis, leptospirosis,
Amoebic encephalitis may be considered, but are much
less common than those listed above
Unit 6: Case Studies
Slide 17
Additional Case: Answer 1 (4)
4. Cerebral Spinal Fluid
• Blood tests
(CSF) evaluation (AFB
• HIV test
and routine culture)
• FBC
after lumbar puncture
• Blood cultures
•
•
•
•
•
•
Glucose, protein WBC
Gram stain
India ink
Culture
Cryptococcal antigen
VDRL
Unit 6: Case Studies
• RPR
• Cryptococcal antigen
• A CXR or biopsy of
lymph node (if lymph
node is suspiciously
large)
Slide 18
Additional Case: Answer 1 (5)
Test
Normal
Bact.
Viral
Cyrptococcal
TB
Opening
Pressure
<200mm
water
Increased
Normal
INCREASED
Variable
WBC
0-5
cells/uL
>1000
<100
Low
Low
PMN’s
Lymphs
Lymphs
Lymphs
Differential
Protein
15-45
mg/dL
INCREASE
D
Increased
Increased
Increased
Glucose
Ratio
CSF 6070% of
blood
LOW
Decreased
Decreased
Decreased
Unit 6: Case Studies
Slide 19
Additional Case: Question 2
1. If TB meningitis is one of the likely
diagnoses, when should treatment begin?
2. What is necessary to diagnose TB
meningitis?
Unit 6: Case Studies
Slide 20
Additional Case: Answer 2
1. Treatment should begin right away when TB
meningitis is one of the likely diagnoses
2. Diagnosis of TB meningitis can be supported
by:
•
•
•
CSF showing lymphocytic meningitis AND
negative India Ink
CSF AFB culture (which may be positive, but
may take three to eight weeks for a result)
Evidence of TB disease elsewhere in the body
Unit 6: Case Studies
Slide 21