Another Surprise? Dr M Wansbrough-Jones Matthew Drake Mark Rooney Andrew Ladwiniec

History 1 38 year, Somali refugee (UK: 1989) 4/52 Hx Unemployed Cough Sputum & 1 episode haemoptysis Night sweats Weight loss

History 2 Cough Sputum No chest pain or SOB Slowly increasing Wakes at night Sputum Green 1 episode of haemoptysis (fresh blood) No chest pain or SOB

History 3 Weight loss Night sweats Little over 1st couple of weeks then sudden loss Approx 10kg in total Night sweats Every night Clothes and bed sheets dripping

History 4 Moved house 6/52 ago from cold, damp dirty flat in Streatham. House mate well. Non-smoker, teetotal Unaware of exposure to TB or other infections Believes some contacts within community may have TB No recent foreign travel

Examination Mildly wasted/cachectic HR 114 Bpm. Lungs ® upper zone dull to percussion ® upper zone  tactile fremitus ® upper zone  vocal resonance ® upper zone bronchial breath sounds Widespread bilateral inspiratory crackles

Investigations FBC, U&E, LFT, Bone Profile, Clotting Blood cultures Sputum culture & examination for acid fast bacilli Chest X-Ray

Full Blood Count Hb 9.8 (13.5-18g/dL)  WCC 8.7 (4-11x1012/L) Platelets 384 (150-400x109/L) MCV 81 (76-96fl) Normocytic anaemia (?anaemia of chronic disease)

Clotting INR 1.0 (0.9-1.2) APTT 38 (35-45s) TT 12 (10-15s) D-Dimers 3.44 (<0.5 mg/L) 

Urea & Electrolytes Na+ 133 (135-145mmol/L)  K+ 4.0 (3.5-5.0mmol/L) Cl- 97 (95-105mmol/L) Urea 1.8 (2.5-6.7mmol/L)  Creatinine 17 (70-150mol/L) 

Liver Function Tests/Bone Profile Bilirubin 16 (3-17mol/L) ALT 39 (5-35u/L)  ALP 107 (30-150u/L) Albumin 26 (35-50g/L)  Gamma GT 61 (11-51u/L)  Corrected Ca++ 2.49 (2.12-2.65mmol/L) PO4--- 1.06 (0.8-1.45mmol/L) CRP 249.4 (<10mg) 

Sputum examination Upper respiratory tract flora (++ growth) Coliforms (Scanty growth) Acid Fast Bacilli +++

Management Admitted + Isolated Rifater (Rifampicin, Isoniazid, Pyrazinamide) -before breakfast Ethambutol Pyridoxine

TB Epidemiology UK incidence = 7000 new cases/year Higher in immigrant populations: -Indian subcontinent:  x 40 -West-Indies:  x 4  frequency in developing world Worldwide TB  since mid-80’s due to: -HIV,  migration

TB Pathology 1ry TB (usually no symptoms): Mycobacterium tuberculosis (Aerobic, acid-fast bacillus) 1ry TB (usually no symptoms): Infection, macrophage ingestion, T-cell response Cellular immunity in 3-8 weeks Caseating granuloma form, heal, may calcify 20% calcified 1ry lesions contain tubercle bacilli

Post-1ry TB (often years later) TB Pathology 2 Post-1ry TB (often years later) Reactivation of remaining M.tb/reinfection  susceptibility due to: -Immunosupprssion (e.g. drugs, HIV, lymphoma) -Malnutrition -DM Typically, cavitation at apex/upper zones

Management Hospitalise if smear positive (stop spread) Most important factor = good compliance -If poor, directly observed therapy Standard 6 month regimen: -Rifampicin -Isoniazid +Pyridoxine (vit. B6) -Pyrazinamide (first 2 months) -Ethambutol (first 2 months)* Follow-up (check compliance) Contact tracing

Drug side-effects + precautions Rifampicin -Warn about orange secretions -OCP ineffective -Regular LFTs, stop if: bilirubin/3x transferases Isoniazid -Polyneuropathy: give pyridoxine (vit. B6) Pyrazinamide -  urate excretion, can precipitate gout Ethambutol -Optic retro-bulbar neuritis: see opthalmologist before treatment

Drug Resistance 1ry -infected with D.R. TB (mainly immigrants) 2ry -poor compliance (developed in patient) Medication: Use at least 3 drugs to which it is sensitive Resistance to 1 of 4 main drugs, use other 3 Use of second line agents Treat for up to 2 years

Vaccination BCG ‘Bacille Calmette-Guerin’ Protective efficacy ~50% -Live attenuated vaccine -Developed from M.bovis Protective efficacy ~50% Gives 1ry immunity Prior Heaf/Mantoux test (ppd), if 1ry immunity -CXR Normally given at 13 years ?some areas with high immigrant population given to infants?