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

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

3. 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

4. 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

5. 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

6. 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

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

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

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

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

11. 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 ( mmol/L)
PO ( mmol/L)
CRP (<10mg) 

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

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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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?