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J i t Clinical
Joint
Cli i l M
Meeting
ti
A Case of fever
January 2008
Dr. Cheng Hei Wan Lian
NDH
1
HKCEM_JCM_NDH
2 Jan 2008
D
Demographic
hi d
data
t
38/F
| Indonesian Maid
| Working
g in Hong
g Kong
g for 5 yyears
| c/o fever x 2/7
|
2
HKCEM_JCM_NDH
2 Jan 2008
At triage
ti
Ambulatory
| Alert & conscious
| Temp
p 39.2̓C
| BP 124/80, P 106
| RR 16 S
SpO2
O2 98% ((room air)
i)
|
3
HKCEM_JCM_NDH
2 Jan 2008
H
How
tto approach
h thi
this patient?
ti t?
History
| Physical Examination
| Investigation
g
| Treatment
|
4
HKCEM_JCM_NDH
2 Jan 2008
Hi t ?
History?
|
Chief complaint
z
|
Fever
Any other history ?
Fever
z Headache
z Vomit & Vomitus details
z Associated symptoms
y p
z Travel history
z Past medical history
z
5
HKCEM_JCM_NDH
2 Jan 2008
Fever
|
Definition
Oral temp :> 37
37.5
5̓C
C
z Anal/ tympanic temp: > 38̓C
z
|
Grading
Low grade 37.3 – 38̓C
z Moderate grade: 38-39̓C
z High
g g
grade: 39.1-41̓C
z Hyperthermia fever > 41̓C
z
6
HKCEM_JCM_NDH
2 Jan 2008
Continuous
Temp varies < 1’C over
several days
Pneumoia, UTI,
typhus
Biphasic
Recurs only once
Dengue,
l
leptospirosis
i
i
Relapsing
Recurrent over days or
weeks
Malaria,
lymphoma
Remittent
Temp do not return to
normal each day
TB, endocarditis,
TB
endocarditis
typhoid
Intermittent Elevated temp for some Abscess, malaria
hours of the day
Pulse-temp Pulse slower than
Typhoid
dissociation normal temperature rise rickettsia
2 Jan 2008
HKCEM_JCM_NDH
7
F
Fever
pattern
tt
Every 24 hrs
8
Every 36 hrs
HKCEM_JCM_NDH
Variable
2 Jan 2008
Hi t
History
|
|
|
|
|
|
|
|
|
|
9
Diffuse headache
headache, myalgia & malaise
Vomiting > 10 times, undigested food and fluid
N abdominal
No
bd i l pain/
i / di
diarrhea
h
No LOC/seizure/ HI
No URI symptoms
No urinary symptoms or PV discharge
No rash
No bite/ sting
g
TOCC –ve
Unremarkable past health
HKCEM_JCM_NDH
2 Jan 2008
Ph i l E
Physical
Examination
i ti
|
|
|
|
|
|
|
10
Temp (tym) 39.2̓C
Non to
toxic
ic looking
BP 124/80, P 106, Hydration fair
No LN, no skin rash/lesion
HS dual
dual, no murmur
RR 16 Chest clear
Abdomen soft, non-tender, no mass
HKCEM_JCM_NDH
2 Jan 2008
Ph i l E
Physical
Examination
i ti
|
|
|
|
11
Alert neck soft, no stiffness
C
Cranial
nerves grossly normal
Motor & sensoryy normal
Fundi no papilloedema
HKCEM_JCM_NDH
2 Jan 2008
I
Investigation
ti ti in
i A&E?
WBC 5.6
| Neu 81.3%, Lym 13.6%
| Hb 13.2,, Plt 296
| RLFT, albumin normal
| Amylase
A l
265
| CXR clear lung
g field, no hilar mass
| Urine multistix WBC 2+
|
12
HKCEM_JCM_NDH
2 Jan 2008
CXR
13
HKCEM_JCM_NDH
2 Jan 2008
Diff
Differential
ti l di
diagnosis
i
Gastroenteritis
| Flu
| Genitourinary
y causes e.g.
g UTI/ PID
| Meningitis/ encephalitis
| Systemic
S t i infection
i f ti
|
14
HKCEM_JCM_NDH
2 Jan 2008
Diff
Differential
ti l di
diagnosis
i
|
|
? UTI
Pyuria
y
UTI
Urethritis
TB
Renal or bladder calculi
Glomerulonephritis
Chemical cystitis
Contamination
( false +ve)
Pelvic appendicitis
15
HKCEM_JCM_NDH
2 Jan 2008
M
Management
t
|
Antipyretic
|
?Discharge home
|
?Admit observation room
|
?Admit to medical unit
16
HKCEM_JCM_NDH
2 Jan 2008
Progress
Admitted to observation room
| Treatment:
T t
t
|
z
panadal, gravol, oral Augmentin
Fluctuating temp, up to 39.6̓C
| Still p
persistent headache with malaise
| Vomited once
|
|
17
How will you manage this patient?
HKCEM_JCM_NDH
2 Jan 2008
P
Progress
D2/D3
|
|
|
|
|
|
18
Admitted to Medical ward
Initial ddx : fever/ ? URTI
IV Augmentin started
Still persistent Fever+
Nausea & vomiting
What
a further
u e Investigation
es ga o ?
( D5 fever)
HKCEM_JCM_NDH
2 Jan 2008
F th Investigation
Further
I
ti ti
ESR 42, CRP<1
| NPA –ve
ve, sputum AFB smear –ve
ve
| MSU
|
moderate no
no. of WBC ( 10,000-100,000),
10 000 100 000)
z insignificant growth
z
EMU AFB -ve
| Blood C/ST –ve
| Malaria, widal test –ve
| CT brain performed
|
19
HKCEM_JCM_NDH
2 Jan 2008
CT brain
b i
20
HKCEM_JCM_NDH
2 Jan 2008
P
Progress
D4
Fever persisted, up to 40̓C
| Headache, nausea & vomiting
| Vomiting
g 1-2 times p
per day,
y, fluid
|
Whatt other
Wh
th ddx?
dd ?
| What other investigation?
g
|
21
HKCEM_JCM_NDH
2 Jan 2008
M i iti
Meningitis
|
Neck stiffness
|
Kernig’s sign
z
|
Brudzinski’s sign
z
22
Severe stiffness of the hamstrings causes an
inability to straighten the leg when the hip is
flexed to 90 degrees
Severe neck stiffness causes a patient's hips
and knees to flex when the neck is flexed.
HKCEM_JCM_NDH
2 Jan 2008
23
HKCEM_JCM_NDH
2 Jan 2008
Wh t other
What
th iinvestigation?
ti ti ?
|
Lumbar puncture on D4
z
z
z
z
z
z
z
|
24
Opening pressure ( 10cm)
CSF color ( clear CSF)
C ll count,
Cell
t gram stain
t i
Protein. Glucose
C/St ZN stain,
C/St,
t i AFB culture,
lt
Cryptococcus
H
Herpes
simplex/
i l / varicella
i ll zoster
t
Blood glucose
HKCEM_JCM_NDH
2 Jan 2008
M i iti
Meningitis
|
|
|
|
|
|
|
25
Any empirical
A
i i l ttreatment?
t
t?
COC guideline on Antibiotic use in A&E
( July 2007)
Cefotaxime ( Claforan) 2g OR
Ceftriaxone ( Rocephin) 2g
HAHO CPG o Antibiotics use
Penicillin G 4MU q4h IV and
Cefotaxime 1.5-2g
1 5 2g q4h IV OR
Ceftriaxone 2g q12h IV
HKCEM_JCM_NDH
2 Jan 2008
E ii lT
Empirical
Treatment
t
t
|
Started on IV Rocephin
T cover for
To
f suspected
t d meningitis
i iti and
d
persistent fever
26
HKCEM_JCM_NDH
|
2 Jan 2008
CSF results
lt
27
HKCEM_JCM_NDH
2 Jan 2008
•Glucose (spot) 6.1
28
HKCEM_JCM_NDH
2 Jan 2008
S what
So
h t is
i your opinion
i i
? Bacterial
| ? Viral
| ? TB
| ? Fungal
|
29
HKCEM_JCM_NDH
2 Jan 2008
CSF results
lt
30
HKCEM_JCM_NDH
2 Jan 2008
P
Progress(D6)
(D6)
CSF reviewed ÆZN –ve
| Started
St t d Pen
P G/ Claforan
Cl f
& IV acyclovir
l i
|
SR : compatible with TBM
| Acyclovir off
| Started anti-TB treatment
| Notification to DH
| Transferred to IT ward
|
31
HKCEM_JCM_NDH
2 Jan 2008
St d d treatment
Standard
t t
t for
f TB
Which drugs would you start?
z Duration
D ti off anti-TB
ti TB medication
di ti
z
32
HKCEM_JCM_NDH
2 Jan 2008
Extrapulmonary
TB
TBM
Treatment
3HRZE+/-S Æ 9HR+/-E
Miliary
3HRZ + (E or S)Æ 9HR+/-E
9HR+/ E
B
Bone
& jjoints
i
2HRZ + (E or S)Æ10HR
Lymphendenitis
(cervical)
2HRZ + (E or S)
Æ4HR
Pericarditis,
Pericarditis
Same as uncomplicated PTB
peritonitis,
GU tract Total 9 months
33
HKCEM_JCM_NDH
2 Jan 2008
Progress
Fever downward trend
| Complicated with deranged LFT due
to anti-TB medication
| Titration of medication
| CSF broth culture showed AF bacilli
(D19)
|
34
HKCEM_JCM_NDH
2 Jan 2008
TB drug
d
related
l t dH
Hepatoxicity
t i it
|
Isoniazid, rifampicin, pyrazinamide,
|
Prar-aminosalicylic
y acid,,
prothionamide & ethionamide
35
HKCEM_JCM_NDH
2 Jan 2008
Progress
Found increased vomiting after antiTB med
d
| GCS 15/15
| Managed conservatively
| Treated as S/E of anti-TB
anti TB med
| Vomiting gradually subsided
|
36
HKCEM_JCM_NDH
2 Jan 2008
Progress
Developed vomiting again D 25 of
antiTB
tiTB med
d
| 2-3 times per day
| CT brain repeated 3 days later
|
37
HKCEM_JCM_NDH
2 Jan 2008
CT brain
b i
38
HKCEM_JCM_NDH
2 Jan 2008
CT brain
b i
39
HKCEM_JCM_NDH
2 Jan 2008
H d
Hydrocephalus
h l
Headache, neck pain
| Nausea, vomiting
| Blur vision,, diplopia
p p ((6th nerve p
palsy)
y)
| Gait disturbance
| Drowsiness
D
i
| Cognitive
g
disturbance
| Papilloedema
|
40
HKCEM_JCM_NDH
2 Jan 2008
H d
Hydrocephalus
h l
|
Pathophysiology
Communicating
z Non-communicating
z
|
41
Causes for hydrocephalus?
HKCEM_JCM_NDH
2 Jan 2008
H d
Hydrocephalus
h l iin TBM
Bacteraemia seeding in meninges
| Ruptured into subarachonoid space
| Reactive thick exudates formed
| Adhesion in basal cistern Æ
hydrocephalus
| Or obstruction of arachnoid
granulation
|
42
HKCEM_JCM_NDH
2 Jan 2008
Progress
Transferred to Neurosurgical unit
| Dexamethazone IV started
| Repeat
p
CT brain Æ no interval change
g
| Transferred back to NDH 1 week later
| Sputum
S t
C/St & EMU – mycobacterium
b t i
tuberculosis
|
43
HKCEM_JCM_NDH
2 Jan 2008
L t t Progress
Latest
P
Transfer to WTS hospital for TB bed
| Continued on anti-TB medication
titration
| LFT improved
| Patient discharged and returned back
to Indonesia
|
44
HKCEM_JCM_NDH
2 Jan 2008
Tuberculosis
45
HKCEM_JCM_NDH
2 Jan 2008
TB in
i H
Hong K
Kong
Important infectious disease in HK
| Notification
N tifi ti rate
t ~6000
6000 tto 7000 per
year
| 10 ti
times hi
higher
h th
than western
t
developed countries
| Listed by WHO as intermediate
burden of TB
| Lifetime risk 1 in every 13 persons
|
46
HKCEM_JCM_NDH
2 Jan 2008
Total no. in 2006 :
5856
47
HKCEM_JCM_NDH
2 Jan 2008
T
Transmission
i i
Air-borne transmission
| Through
Th
h cough,
h sneeze, speaks
k
| Chance of infection
|
z
|
Only 1 in 10 patients Æ full blown TB
z
|
48
Immunity, virulence, duration of
exposure
50% of them develop
p disease within
first 2 years
Death rate ~ 4-5 %
HKCEM_JCM_NDH
2 Jan 2008
Cli i l ffeatures
Clinical
t
In Hong Kong
| 90% involve lungs
| 1/3 of them smear positive
p
|
z
|
2/3 smear negative
~ 25% extrapulmonary TB
Commonest site: LN & pleural
z Other common sites: meninges. brain
z
49
HKCEM_JCM_NDH
2 Jan 2008
Cli i l ffeatures
Clinical
t
|
Constitutional symptoms
z
non-specific
Fever,, weight
g loss,, night
g sweat,,
malaise
| Cough,
Cough haemoptysis
| Symptoms according to site of
i f ti
infection
|
50
HKCEM_JCM_NDH
2 Jan 2008
Di
Diagnostic
ti ttests
t
|
Tuberculin skin test
Detection of TB infection
z Delayed hypersensitivity reaction to
tubercle bacillus
z
|
Laboratory test
Sputum, urine for smear & culture
z Tissue
Ti
for
f histology
hi t l
z Tissue fluid e.g. CSF
z
51
HKCEM_JCM_NDH
2 Jan 2008
NTEC Pharmacy Bulletin Issue
16 Apr 2004
M t
Mantoux
Test
T t
|
PPD
Tuberculin purified protein derivative
z Sterile preparation from precipitate of
heat treated M Tuberculosis or bovis
z
|
52
Previous
P
i
iinfection
f ti with
ith mycobacterium
b t i
Æ
delayed hypersensitivity reaction Æ
reexposure to antigen ( ii.e
e PPD) Æ mount
host immune system Æ skin induration
HKCEM_JCM_NDH
2 Jan 2008
NTEC Pharmacy Bulletin Issue
16 Apr 2004
M t
Mantoux
test
t t
|
|
|
|
|
Intradermal injection of
0.1 ml PPD
To volar side of forearm
Look for a round wheal
8-10mm diameter
Read at 48 to 72 hours
( 96hrs for elderly)
Positive reactionÆ
induration 10mm
53
HKCEM_JCM_NDH
2 Jan 2008
R
Results
lt
|
Interpret as Positive if patient has:
Large TST reaction
z BCG long time ago
z From area with high prevalence of TB
z Known TB contact
z
54
HKCEM_JCM_NDH
2 Jan 2008
TST reaction
ti
Size of
>=5mm
induration
Consider
|HIV
positive for |Close
contacts
|Hx of TB
55
>=10mm
>=15mm
|Foreigner
|People
income with no risk
f t
factors
for
f
|Residential
TB
facilities
|Immunocompromised
|< 4 years old
|Low
HKCEM_JCM_NDH
2 Jan 2008
I t
Interpretation
t ti
False Positive
| Infection with non-tuberculous
mycobacteria
| Vaccination with BCG
|
56
HKCEM_JCM_NDH
2 Jan 2008
I t
Interpretation
t ti
|
False negative
15-20%
z Test error/anergy
z Old age, high fever, steroid,
immunosuppressant, hematological
disease, HIV, recent viral infection,
immature immune system ( < 6mths)
z
57
HKCEM_JCM_NDH
2 Jan 2008
T t
Treatment
t
Pulmonary
tuberculosis
Treatment
Uncomplicated
2HRZ + (E or S)
Æ4HR
Retreatment
3(4)HRZES
Æ 6(5)HR +/-E
H isoniazid; R
H,
R, rifampicin; S
S, streptomycin
streptomycin, E
E, ethambutol; Z
Z, pyrazinamide
58
HKCEM_JCM_NDH
2 Jan 2008
Extrapulmonary
TB
TBM
Treatment
3HRZE+/-S Æ 9HR+/-E
Miliary
3HRZ + (E or S)Æ 9HR+/-E
9HR+/ E
B
Bone
& jjoints
i
2HRZ + (E or S)Æ10HR
Lymphendenitis
(cervical)
2HRZ + (E or S)
Æ4HR
Pericarditis,
Pericarditis
Same as uncomplicated PTB
peritonitis,
GU tract Total 9 months
59
HKCEM_JCM_NDH
2 Jan 2008
P d i l reaction
Paradoxical
ti
Temporary exacerbation of TB
symptoms and lesions after treatment
| At least 2 weeks after treatment
| Initially
I iti ll shown
h
iimprovementt tto
treatment
| More common in
|
Extrapulmonary
p
y TB
z Disseminated TB
z
60
HKCEM_JCM_NDH
2 Jan 2008
M ltid
Multidrug
resistant
i t t TB
MDR-TB
| Resistance to at least both isoniazid &
rifampicin in vitro
| 3.2% of world new TB cases
| 1% in HK
| Inadequate drug prescribed
| Poor drug compliance
|
61
HKCEM_JCM_NDH
2 Jan 2008
Ri k ffactor
Risk
t
High index of suspicions
| Hx of incomplete treatment
| Close contact with MDR-TB patients
p
| Endemic area
|
62
HKCEM_JCM_NDH
2 Jan 2008
T t
Treatment
t
According to drug sensitivity
| 5-6 drugs for 6 months
| Followed by
y 3-4 drugs
g
| Total duration 18 months
|
|
63
Quinolones/ aminoglycosides
HKCEM_JCM_NDH
2 Jan 2008
E t
Extensively
i l drug
d
resistance
i t
TB
XDR-TB
| Resistance to 1st line & some 2nd line
drug
|
1st line : at least isoniazid & rifampicin
z 2nd line: any fluroquinolones and any 1
of the 3 injectable (capreomycin,
kanamycin and amikacin)
kanamycin,
amikacin),
z
64
HKCEM_JCM_NDH
2 Jan 2008
XDR TB
XDR-TB
Speed of transmission probably no
diff
difference
tto allll fforms off TB
| Incidence is rare at this stage
| Variable treatment outcome
|
Depends on drug resistance
z Disease severity
z Own immune system
z
65
HKCEM_JCM_NDH
2 Jan 2008
I f ti
Infectious
Control
C t l Measures
M
NTEC guidelines, June 2007
| HA task force in Infection Control
| TB in HCW : 29-57 cases p
per yyear
( DH figure)
|
66
HKCEM_JCM_NDH
2 Jan 2008
S
Suspected
t d TB case
Airborne infection isolation room
| Continue airborne isolation ( CDC 2006)
|
Till 3 consecutive negative
g
AFB
sputum smears collected
z Or another diagnosis is made
z
67
HKCEM_JCM_NDH
2 Jan 2008
C fi
Confirmed
d TB di
disease
Smear positive PTB
| Airborne isolation until
|
Received anti-TB drug
g for minimum 2
weeks AND
z Demonstrated clinical improvement
z
|
MDR-TB
z
68
Till sputum
t
smear show
h
seroconversion
i
HKCEM_JCM_NDH
2 Jan 2008
N i f ti
Non-infectiousness
|
Smear –ve/ extrapulmonary TB
z
|
Smear +ve
z
|
Non-infectious
Complete 2 weeks of chemotherapy +
clinical improvement
MDR-TB
z
S t
Sputum
smear conversion
i
Tuberculosis Manual,
69
Tuberculosis and Chest2 JanService
2008
HKCEM_JCM_NDH
Public Health Services Branch
St ff Precautions
Staff
P
ti
|
|
|
|
70
High risk procedure Æ N95 mask
O chemotherapy
On
h
th
and
d improving
i
i -->
Surgical mask
Wear gloves when handling infectious
material e.g. sputum
Patients utilizing investigation facilities
e.g.
g to x-rayy should wear surgical
g
mask
HKCEM_JCM_NDH
2 Jan 2008
C t t tracing
Contact
t i
|
|
71
Patients
z Required
R
i d off HIV positive
iti
z < 1 year old with contact with infectious
case > 8 hours in same ward
z Expose
p
to p
patient with strong
g smear +ve
Staff
z FU needed if carried out high risk
procedure without airborne precautions
HKCEM_JCM_NDH
2 Jan 2008
HCW with
ith Si
Significant
ifi
tC
Contact
t t
Monitor symptoms
| FU CXR annually for 2 yrs
| Limited role in Terbeculin skin test Æ
high background positive rate
|
72
HKCEM_JCM_NDH
2 Jan 2008
Thank You
73
HKCEM_JCM_NDH
2 Jan 2008