Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
To present a case of a patient with persistent fever. To discuss the approach and management in patient with persistence of fever. R.B, 58-year-old male, married, Filipino Farmer from Tuguegarao, admitted 5,2009 on July 3 WEEKS PTA › fever, undocumented › right upper quadrant pain › No change in bowel movement › local Institution in Tuguegarao. › A> enteric fever › Cotrimoxazole and Metronidazole. › A> Malaria › Chloroquine started as an empiric treatment. › opted to go home , and was lost to follow up 2 WEEKS PTA › Fever and Right upper quadrant pain › Dyspnea › No cough, chest pain local institution Tuguegarao. Abdominal Ultrasound: Cholesterolosis Chest xray and Chest Ultrasound : pleural effusion on the right. Thoracentesis 1 liter Empirically treated with Ceftriaxone, Ciprofloxacin and eventually Anti koch’s medication Opted to go home Pleural fluid Culture and histopath results unknown to patient consult in MMC for further management generalized weakness weight loss Loss of appetite no headache no palpitations No signs of bleeding no dysuria/ frequency/ hematuria no joint stiffness/ weakness No Diabetes Mellitus No hypertension No Asthma No Pulmonary Tuberculosis No history of accidents or injuries No history of blood transfusion No history of hepatitis No previous surgeries Non smoker Non alcoholic beverage drinker No illicit drug use Denies exposure to a PTB patient No Hypertension No Cancer No Diabetes Mellitus No asthma No PTB Conscious, coherent, ambulatory, Not in cardio respiratory distress › weight: 61 Kg Height: 165 .4 cm BMI 22.5 › 100/70 HR : 92/min RR 20 cycles/min Temp 38.0 C Skin: no jaundice, good turgor, no lesions. Pink palpebral conjunctivae, anicteric sclerae, no neck mass, no cervical lymphadenopathy, no oral mass or ulcers Adynamic precordium, no heaves, no thrills, Normal rate, regular rhythm, no murmurs Asymmetrical chest expansion (Right chest lag), no rib retractions, decreased tactile fremitus, dull on percussion and decreased breath sounds - mid to lower right lung field, no crackles, no wheezes Left lung field: resonant, clear breath sounds Flat abdomen, normoactive bowel sound, soft, direct tenderness, RUQ, no masses Full & equal peripheral pulses. No cyanosis. no edema 58 year old male FEVER x 3 weeks right lower quadrant pain Dyspnea UTZ: Cholesterolosis CXR & Chest UTZ: Pleural Effusion Febrile ( 38C), RR- 20 R chest lag decreased tactile fremitus, dull on percussion,mid-lower right lung field decreased breath sounds- mid to lower right lung field no crackles, no wheezes Flat abdomen, normoactive bowel sound, soft, direct tenderness, RUQ Fever secondary to Pulmonary Tuberculosis vs. Pneumonia r/o malignancy Pleural effusion, right Cholesterolosis CBC Chest radiograph Serum electrolytes sputum smear for acid fast bacilli Paracetamol 500mg Tramadol 50mg febrile Tmax 39.3 ; abdominal pain Patient referred to IDS Impression: Hepatic abcess. Parapneumonic Effusion, right. CT scan of the chest and abdomen Chest tube thoracostomy, right (300ml of serous fluid) repeat Chest radiograph Acid fast bacilli sputum smear Ampicillin-Sulbactam 1.5g, q6 • • Pleural fluid gram staining Ampicillin-Sulbactam was shifted to Cefepime 1g, every 12 hrs. 4th Hospital day D1 CEFEPIME Febrile Tmax 39.1 CBC Blood culture Acid fast bacilli smear of pleural fluid Acid fast bacilli culture HRZE (Myrin P forte) 4 tablets, once a day. 6th hospital day D1 ANTI KOCH’S › febrile Tmax 39C › loss of appetite › Dizziness › loose bowel movement › Pleural fluid cytology › Myrin P Forte discontinued INH 300mg,1 tab, before breakfast Rifampicin 600mg,1 tab, before breakfast; Ethambutol 400mg,3 tabs, after breakfast PZA 500mg,4 tablets, after lunch Febrile Tmax 38.9 Headache, vomiting, dizziness and tinnitus Impresssion: Drug induced vs central cause R/O Connective tissue disease • Lupus Panel • Plan: Cranial CT scan & Lumbar Tap • Anti Koch’s, Tramadol were discontinued • Betahistine was started 4th Hospital day D1 CEFEPIME 10th hospital day ANTI KOCH’S Fever secondary to Infection vs. Malignancy Naproxen 375mg, BID and later decreased to 275mg, BID Cefepime discontinued 12th hospital day CEFEPIME 12th hospital day NAPROXEN Fever Pleural fluid cytology CYTOSPIN Chest tube thoracostomy drainage (24ml for 24 hrs) Contrast chest CT scan done. Chest tube removed. Video- assisted Thoracoscopic surgery. 18th hospital day 24ml x 24hrs Post MINI thoracostomy, Decortication with pleural and lung biopsy Isoniazid 300mg,1 tab, after dinner (Aug 1) Rifampicin 600mg,1 tab,before dinner (Aug 2) Ethambutol,400mg,3 tabs,after dinner (Aug 4 25th hospital day S/P VATS Afebrile Chest x-ray no recurrence of fever noted DAY 28-30 RE CHALLENGE ANTI KOCH’S PLEURAL EFFUSION, RIGHT SECONDARY TO PULMONARY TUBERCULOSIS S/P CHEST TUBE INSERTION, RIGHT S/P MINI THORACOSTOMY, DECORTICATION WITH PLEURAL AND LUNG BIOPSY Temp of >38.3 on several occasions >3 weeks Failure to reach a diagnosis despite 1 week of inpatient investigation Approach to the adult with fever of Unknown Origin UpToDate®www.uptodate.com AuthorDavid H Bor, MDSection EditorPeter F Weller, MD, FACPDeputy EditorAnna R Thorner, MD Last literature review version 17.2: May 2009 T| his topic last updated: September 22, 200(8M ore) CLASSIC NOSOCOMIAL FEVER OF UNKOWN ORIGIN (FUO) NEUTROPENIC HIV 58 year old male FEVER x 3 wks RUQ pain Dyspnea Decreased tactile fremitus dull on percussion decreased breath soundsmid to lower right lung field no crackles no wheezes INFECTIONS NEOPLASMS COLLAGEN VASCULAR DISEASES MISCELLANEOUS CONDITION Temp of >38.3 on several occasions X >3 weeks; Failure to reach a diagnosis despite 1 week of inpatient investigation PHYSICAL EXAM & HISTORY CBC, DIFF SMEAR, ESR,CRP, URINALYSIS, LFT, MUSCLE ENZYMES,VDRL,HIV,CMV,EBV,ANA,RF,SPEP,PPD,CONTROL SKIN TESTS, CREATININE,ELECTROLYTES, Ca, Fe, TRANSFERRIN, TIBC, VIT B12, BLOOD CULTURE, URINE, SPUTUM,FLUIDS CBC, DIFF SMEAR, ESR,CRP, URINALYSIS, LFT, MUSCLE ENZYMES, VDRL, HIV, CMV, EBV, ANA, RF, SPEP, PPD, CONTROL SKIN TESTS, CREATININE,ELECTROLYTES, Ca, Fe, TRANSFERRIN, TIBC, VIT B12, BLOOD CULTURE, URINE, SPUTUM,FLUIDS Diagnostic clues Directed exam Positive Negative No diagnostic clues Chest CT, abdomen, pelvis. Colonoscopy Negative Positive leading diagnosable cause of FUO 6th leading cause of morbidity and mortality Diagnosis, Treatment, Prevention and Control of Tuberculosis: 2006 Update CLINICAL PRACTICE GUIDELINES When should one suspect that patient may have PTB? › Cough of two weeks or more › Cough with or without the ff: night sweats, weight loss, anorexia, unexplained fever and chills, chest pain, fatigue and body malaise › Cough x 2 weeks or more with or without accompanying symptoms TB SYMPTOMATIC CATEGORIES NEW RELAPSE RETURN TO TREATMENT AFTER DEFAULT DEFINITION A patient who has never had treatment for TB or, if with previous anti TB medications, taken for less than 4 weeks. Declared cured of any form of TB in the past by a physician after one full course of anti TB medications, & now has become sputum smear (+) Stops medications for 2 months or more and comes back to the clinic smear (+) CATEGORIES FAILURE TRANSFER –IN CHRONIC CASE DEFINITION While on treatment, remained or become smear (+) again at the fifth month of anti TB treatment or later; or a patient who was smear (-) at the start of treatment and becomes smear (+) at the 2nd month Management was started from another area and now transferred to a new clinic Became or remained smear (+) after completing fully a supervised retreatment regimen What is the initial work up for a TB symptomatic? › Sputum microscopy (preferably 3 should be sent) › Collected first thing in the morning for 3 consecutive days INTERPRETATION OF RESULTS: › SMEAR POSITIVE: If at least two sputum specimens are AFB (+) › SMEAR NEGATIVE: If none of the specimens are AFB (+) DOUBTFUL: When only one of the 3 sputum specimens is (+) › When results are doubtful, a second set of the three must be collected › One of the second three is (+): SMEAR POSITIVE › All of the second three are (-): SMEAR NEGATIVE What additional tests should be done after a TB symptomatic has been found to be SMEAR POSITIVE? › No further tests are required Chest radiographs are not routinely necessary in the management of a TB symptomatic patient who is smear positive PPD (Purified Protein derivative) testing will not add additional information Blood/serum tests maybe taken when specific risks for possible adverse events during treatment are present All adults suspected to have PTB should have TB culture Drug susceptibility testing is recommended: › Retreatment › Treatment failure › Smear positive patients suspected to have one or multi-drug resistant TB (MDR-TB) What tests are recommended symtomatics who are smear negative? › TB culture with Drug susceptibilty › Chest Radiograph for TB RECOMMENDED TREATMENT DIAGNOSED SMEAR POSITIVE FOR NEWLY › Short course chemotherapy (SCC) regimen 2 months isonoazid, rifampicin, pyrazinamide and ethambutol 4 moths isoniazid and rifampicin Given daily as initial phase followed by daily or thrice weekly administration of isoniazid and rifampicin during the continuation phase The recommended dosages for daily and thrice – weekly administration in mg/kg body weight are as follows: DRUGS DAILY (RANGE) ISONIAZID RIFAMPICIN PYRAZINAMIDE ETHAMBUTOL STREPTOMYCIN 10 10 25 15 15 THRICE-WEEKLY (RANGE) 10 35 30 15 RECOMMENDED TREATMENT FOR NEWLY DIAGNOSED SMEAR NEGATIVE 2HRZE/4HR (WITHOUT HIV OR WITH AN UNKNOWN HIV) How can one reliably diagnose extrapulmonary tuberculosis (EPTB)? › High degree of suspicion in a patient at risk › Appropriate specimen should be processed for microbiologic, both microscopy, culture and histopathologic examinations What is the effective treatment regimen for EXTRAPULMONARY TUBERCULOSIS? › 6-9 month regimen consisting of 2 months Isoniazid, Rifampicin, Pyrazinamide and Ethambutol (Initial Phase) › 4-7 months Isoniazid and Rifampicin (Continuation Phase) TUBERCULOUS PLEURAL EFFUSION Microscopic examination detecs acid fast bacilli in about 5-10% of cases TREATMENT ADMINISTRATION › FIXED DOSE COMBINATION Recommended for newly diagnosed TB patients: Minimize the risk of monotherapy Minimize drug resistance Improve adherence with lesser number of pills to swallow Reduce prescription errors ADVERSE REACTIONS DRUG MANAGEMENT MINOR Gastro intestinal intolerance Rifampicin/INH Meds at bedtime/ small meals Mild skin reaction Any kind of drugs Anti histamine Orange/ red colored urine Pain at the Injection site Rifampicin Reassure patients streptomycin Warm compress ADVERSE REACTIONS DRUG MANAGEMENT Peripheral neuropathy Isoniazid Pyridoxine 100-200ng, daily (Treatment) 100mg prevention Arthralgia due to Hyperurecemia Flu-like symptoms Pyrazinamide NSAID Rifampicin Anti pyretics ADVERSE REACTIONS DRUGS MANAGEMENT Severe skin rash Any kinds of drugs (Streptomycin) Discontinue anti TB drugs, refer to DOTS Jaundice (Isoniazid, Rifampicin, Pyrazinamide) Discontinue anti TB drugs, refer to DOTS; If symptoms subside, resume treatment & monitor clinically Impaired visual acuity Ethambutol Discontinue anti TB drugs, refer to DOTS MAJOR ADVERSE REACTIONS DRUGS MANAGEMENT Psychosis Isoniazid Discontinue anti TB drugs, refer to DOTS Hearing impairment Streptomycin Discontinue anti TB drugs, refer to DOTS Thrombocytopenia, anemia, shock Rifampicin Discontinue anti TB drugs, refer to DOTS Oliguria Streptomycin/Rifam Discontinue anti TB drugs, refer picin to DOTS SINGLE DOSE PREPARATION › Adverse reactions › Co morbid conditions requiring dose adjustments › Disease conditions where treatment is expected to have significant drug interactions with Anti TB drugs › At risk for adverse reactions The 2000 Philippine TB Consensus found no studies correlating the resolution of clinical signs and symptoms with bacterial response to treatment Teo SK. Four month chemotherapy in the treatment of smear negative PTB: results at 30-60 months. Ann Acad Med Singapore 2002;31: 175-81 (CLINICAL PRACTICE GUIDELINES) MONITORING OF OUTCOMES AND RESPONSE DURING TREATMENT › Defervesence occurred within 2 weeks in 78% of patients with drug susceptible organisms while only 9% of patients with multi drug resistance became afebrile › Teo SK. Four month chemotherapy in the treatment of smear negative PTB: results at 30-60 months. Ann Acad Med Singapore 2002;31: 175-81 “Possible causes of persistent fever in pulmonary tuberculosis (once non-compliance and supraadded infections have been excluded) include cytokine release, drug induced fever, drug resistance, and drug malabsorption.” BMJ 1996;313:1543-1545 (14 December) Education and debate Grand Rounds--Hammersmith Hospital: Persistent fever in pulmonary tuberculosis Hammersmith Hospital, London W12 0HS Case presented by: Maha T Barakat, senior house officer in respiratory medicine Chairman: J Scott, director of medicine. Patients with cancer in a study conducted at the Oncology Unit of the Good Samaritan Hospital in Dayton, Ohio. Patients with FUO and suspected or diagnosed malignancy Naproxen 250 mg twice a day orally at 12-hourly intervals for at least 3 days Validity was not established because of the lack of an independent, blind comparison with a reference standard Correlation of the final diagnoses of FUO in all patients with their response to antibiotics and naproxen Recommendation: More appropriate reference standard would be the absence of infection after extensive and thorough laboratory work-up coupled with the absence of any clinical deterioration without administration of any antibiotics on continued follow-up for at least a period of 2 weeks. Utility of Naproxen in the Differential Diagnosis of Fever of Undetermined Origin in Patients with Cancer: A Commentary Marissa M. Alejandria, M.D.* (*Infectious Disease Fellow, UP-PGH, Taft Avenue, Manila) (Phil J Microbiol Infect Dis 1999; 28(2):73-74) Restart each anti koch’s one by one. To determine which the drug that the patient had allergic reaction CBC JULY 5 JULY 10 JULY 27 HEMOGLOBIN 11.6 12.0 12 HEMATOCRIT 33 34.4 36 WBC 3.94 6.79 11.7 SEGMENTER 69 66 76 LYMPHOCYTE 18 17 13 MONOCYTE 9 11 9 PLATELETS 493,00 401,000 349,000 Sodium Potassium Creatinine BUN Glucose Calcium albumin Alkaline phosphatase AST ALT 7/5 139 7/6 137 3.8 0.90 4.3 1.0 75.9 7/15 137 8.3 2.7 152 28 21 42 34 7/23 7/30 0.9 1.0 8/4 Pleural fluid analysis: › MICROSCOPY: RBC 1219 U/L WBC 115 U/L SEGMENTER 0.05 LYMPHOCYTE 0.95 › Fungal elements: negative › AFB smear: negative › Gram stain: pus cell 0-2 Pleural Fluid culture (July 8): no growth Pleural Fluid Cytology: negative for malignant cells Cytospin: Chronic Inflammatory process Pleural Tissue and Lung Biopsy › CHRONIC GRANULOMATOUS INFLAMMATION, CONSISTENT WITH TUBERCULOSIS, RIGHT PLEURAL BIOPSY › Congestion and atelectasis, adjacent lung tissue Lupus panel : negative AFB Sputum x 3 days (July 5-7, 2009): Negative AFB sputum culture July 8,2009: no growth Blood Culture July 6,09: No growth after 5 days Chest x-ray July 6, 2009 Decreased in the pleural density at the right mid-lower outer lung with blunting of the costophrenic sulcus. No layering seen in the right lateral decubitus view. Loculated pleural effusion and /or thickening considered. Underlying parenchymal pathology not ruled out. The heart is not enlarged. JUNE 27,09 JULY 6,09 JULY 6,09 JULY 6,09 July 8. 2009 There is decreased in the pleural fluid seen in the right Hemithorax. Right Chest tube is noted July 29, 2009 There is partial evacuation of the pleural effusion in the right. The visualized lung appear clear JULY 8.09 July 8. 2009 There is decreased in the pleural fluid seen in the right Hemithorax. Right Chest tube is noted July 29, 2009 There is partial evacuation of the pleural effusion in the right. The visualized lung appear clear JULY29,09 CT SCAN OF THE CHEST July 7,2009: › Consider Pneumonia vs PTB, right upper lobe. › Moderate pleural effusion, right › passive atelectasis of the posterior basal segment of the right lower lobe prominent paratracheal lymph nodes, not enlarged by CT criteria › Subcentimeter cyst, right kidney, Bosniak I Category › Normal contrast enhanced CT scan of the rest of the abdominal organs CT SCAN OF THE CHEST July 23,2009: › Interval placement of the right thoracostomy tube with residual pleural effusion › Possibilty of loculation is entertained › No interval change in the right pulmonary infiltrates since the previous examination › Present note of focal atelectasis in the right lower lobe seen › Prominent pretracheal and precarinal lymph node, relatively unchanged. POSITIVE DIRECTED EXAM Needle biopsy, invasive testing NO DIAGNOSIS EMPIRICAL THERAPY Anti TB therapy WATCHFUL WAITING Colchicine/ NSAID Steroids DIAGNOSIS Specific therapy NEGATIVE DIRECTED EXAM GA Scan, PMN scan, PET scan NEGATIVE POSITIVE Needle biopsy, invasive testing NO DIAGNOSIS EMPIRICAL THERAPY Anti TB therapy WATCHFUL WAITING Colchicine/ NSAID Steroids NEGATIVE CT chest, abdomen, pelvis and colonoscopy GA Scan, PMN scan, PET scan POSITIVE NEGATIVE Needle biopsy, invasive testing No diagnosis Empirical therapy Anti TB therapy Watchful waiting Colchicine/ NSAID Steroids POSITIVE CT chest, abdomen, pelvis and colonoscopy Needle biopsy, invasive testing NO DIAGNOSIS Empirical therapy Anti TB therapy Watchful waiting Colchicine/ NSAID Steroids DIAGNOSIS Specific therapy PTB leading diagnosable cause of FUO Defervesence occurred within 2 weeks in 78% of patients with drug susceptible organisms while only 9% of patients with multi drug resistance became afebrile Validty is not established in Naproxen test Should be treated accordingly Thank you!!!