1. Unit 6 Diagnosing TB: B Family Case Botswana National Tuberculosis Programme Manual Training for Medical Officers

2. Slide 2 Unit 6: Case Studies B Family Background Recall that: Mrs. B visits a clinic after noticing a cough her husband had for a few weeks and suspecting that he might be engaging in behaviors risky for HIV She tests positive for HIV and is started on IPT Contact tracing is initiated

3. Slide 3 Unit 6: Case Studies Case: B Family Mr. B, a 32 year old man, presents to the clinic with a cough he has had for 1 month He is not severely ill and can be evaluated in an ambulatory setting

4. Slide 4 Unit 6: Case Studies B Family Case: Question 1 What questions do you ask about his history?

5. Slide 5 Unit 6: Case Studies B Family Case: Answer 1 Ask questions regarding his history of smoking and occupational exposures

6. Slide 6 Unit 6: Case Studies B Family Case: Question 2 What signs and symptoms do you look for when examining him?

7. Slide 7 Unit 6: Case Studies B Family Case: Answer 2 Cough for 2-3 weeks Usually sputum productive May be bloodstained Chest pain Dyspnoea Night sweats Loss of appetite Weight Loss Fatigue Evaluate him for tuberculosis symptoms:

8. Slide 8 Unit 6: Case Studies B Family Case: Question 3 (1) During examination, Mr. B: Denies experiencing dyspnoea, chest pain, fever, shortness of breath, loss of appetite, chronic diseases, smoking or taking any medications Reports having no prior history of TB, but reports having had contact with a TB positive uncle Reports coughing for 1 month, weight loss over the past few months, night sweats and fatigue

9. Slide 9 Unit 6: Case Studies B Family Case: Question 3 (2) T 37 Wt 58kg R 18 P 82 Pt looks thin, wasted Crepitations to auscultation Cervical lymphadenopathy Otherwise, exam normal What do you do next for Mr. B? During examination, health worker finds:

10. Slide 10 Unit 6: Case Studies B Family Case: Answer 3 (1) Obtain relevant contact history When was the exposure? Is the patient on treatment? What was the duration of exposure, etc.? Take a spot sputum test today When obtaining the spot sputum, have the patient rinse his mouth with water first Stand outside with him, behind the direction he is facing, and have him cough Counsel Mr. B and test him for HIV today

11. Slide 11 Unit 6: Case Studies B Family Case: Answer 3 (2) Send Mr. B home with another specimen jar for a morning specimen and ask him to return the following day Pending results, prescribe amoxicillin, 500mg TDS x 5 days, for presumptive bacterial pneumonia Provide him with Panado, 1000 TDS x 5 days, for pain NOTE: ESR is a non-specific test and cannot be used to prove or exclude TB

12. Unit 6 Diagnosing TB: Additional Case Botswana National Tuberculosis Programme Manual Training for Nursing Officers

13. Slide 13 Unit 6: Case Studies Additional Case PD, a 27 year old woman, is brought to the hospital by her family She was sleeping much of the time and it became difficult to wake her up She has had 2 weeks of fever, sweats and headache Temperature of 39ºC She appears thin She is sleepy but arousable She has a small cervical, axillary and inguinal lymph nodes and a stiff neck The rest of her exam is normal A malaria smear is negative

14. Slide 14 Unit 6: Case Studies Additional Case: Question 1 She is empirically started on IV antibiotics by the medical officer 1.Why is she started on antibiotics? What is her most likely diagnosis? 2.What organisms could be causing her symptoms? 3.What is the differential diagnosis for PD? 4.What tests do you order and why?

15. Slide 15 Unit 6: Case Studies Additional Case: Answer 1 (1) 1.Meningitis 2.None (aseptic), bacterial, viral, tuberculosis, cryptococcus neoformans, syphilis

16. Slide 16 Unit 6: Case Studies Additional Case: Answer 1 (2) 3.Differential diagnosis for PD Tuberculous meningitis Cryptococcal meningitis When completing a lumbar puncture, measure opening pressure for elevated pressure –AIDS-defining illness in HIV positive patients Bacterial meningitis

17. Slide 17 Unit 6: Case Studies Additional Case: Answer 1 (3) 3. (cont.) Viral meningitis Rarely prolonged Neurosyphilis Subacute or chronic lymphocytic meningitis Other infections such as trypanosomiasis, leptospirosis, Amoebic encephalitis may be considered, but are much less common than those listed above

18. Slide 18 Unit 6: Case Studies Additional Case: Answer 1 (4) 4.Cerebral Spinal Fluid (CSF) evaluation (AFB and routine culture) after lumbar puncture Glucose, protein WBC Gram stain India ink Culture Cryptococcal antigen VDRL Blood tests HIV test FBC Blood cultures RPR Cryptococcal antigen A CXR or biopsy of lymph node (if lymph node is suspiciously large)

19. Slide 19 Unit 6: Case Studies Additional Case: Answer 1 (5) TestNormalBact.ViralCyrptococcalTB Opening Pressure <200mm water IncreasedNormalINCREASEDVariable WBC 0-5 cells/uL >1000<100Low Differential PMN’sLymphs Protein 15-45 mg/dL INCREASE D Increased Glucose Ratio CSF 60- 70% of blood LOWDecreased

20. Slide 20 Unit 6: Case Studies Additional Case: Question 2 1.If TB meningitis is one of the likely diagnoses, when should treatment begin? 2.What is necessary to diagnose TB meningitis?

21. Slide 21 Unit 6: Case Studies Additional Case: Answer 2 1.Treatment should begin right away when TB meningitis is one of the likely diagnoses 2.Diagnosis of TB meningitis can be supported by: CSF showing lymphocytic meningitis AND negative India Ink CSF AFB culture (which may be positive, but may take three to eight weeks for a result) Evidence of TB disease elsewhere in the body