Download Tuberculosis - Wellington ICU

Tuberculosis
26/8/10
OH
-
devastating world wide disease
organisms: Mycobacterium tuberculosis, M. bovis, M. africanum, M. microtti, and M. canetti
all of these organisms are acid fast bacilli
once infected there are 4 potential outcomes:
1.
2.
3.
4.
immediate clearance
primary disease
latent infection
reactivation of disease
RISK FACTORS
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HIV
silicosis
DM
CRF
malnutrition
solid organ transplant
gastrectomy
jejunoilieal bypass
drug abuse
chronic pulmonary disease
prolonged steroid use
institutional living
poverty
smoking
CLINICAL FEATURES
-
fever
night sweats
unexplained weight loss
fatigue
anorexia
can effect any organ system!
Tuberculosis Pneumonia
-
cough and sputum
haemoptysis
chest wall pain
SOB
crackles (apical)
recurrent pneumonia
pleural effusions
spontaneous pneumonthorax
Jeremy Fernando (2011)
Tuberculosis Meningitis
-
contact history
vague illness for 2-8 weeks
headache
neck stiffness
cranial nerve palsies
papilloedema
hemiplegia
seizures
Tuberculosis Emergencies
-
massive haemoptypsis
respiratory failure
pericardial tamponade
small intestinal obstruction
tuberculous meningitis
status epilepticus due to tuberculomas
INVESTIGATIONS
- CXR: patchy/nodular shadowing in upper zones, cavitation, calcification, hilar or mediastinal
lymphadenopathy, diffuse millary shadowing
- 3-6 sputum samples -> acid fast bacilli
- quantiferon test: confirms exposure and possibly disease
- bronchial washings
- gastric lavage
- aspiration of collections
- pleural fluid – send for total protein, glucose, WCC and differential, pH, adenosine deminase
(if > 70U/L -> highly suggestive of Tb)
- pleural biopsy
- mediastinoscopy -> lymph node resection
- LP: smear examination or bacterial culture
- CT or MRI: thickening and enhancement of meninges in basilar region
- nucleic acid amplication: amplify target nucleic acid regions that uniquely identify the M.
tuberculosis complex -> useful in ruling in Tb rather than ruling out.
MANAGEMENT
Patient
-
ID consult!
patients are infective while coughing until after 2 weeks of treatment
check bronchial washing for smear positive -> if positive then highly infectious
8 month course:
->
->
->
->
rifampicin
isoniazid
ethambutol
pyrazinamide
Jeremy Fernando (2011)
- steroids in pericardial disease and meningitis
- if organisms are resistant -> IV aminoglycosides (streptomycin, amikacin) and
fluoroquinolones (ciprofloxacin).
ICU Environment
-
aerosol isolation + standard contact isolation
room: private, door closed, negative pressure (12 air changes/hour)
mask: N95 or N100
bacterial filter and closed suction on circuit
warning signs on doors
bronchoscopy: minimise aerosols (paralyze, consider apnoeic ventilation during procedure)
education for staff on symptoms
staff screening: CXR, mantoux (baseline and 2 months)
early ID involvement in staff exposed
Jeremy Fernando (2011)