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TB – Presentation, Investigation and Overview

TB – Presentation, Investigation and Overview. Paul McWhinney, Infectious Diseases, BRI. An Old Friend. Well adapted to life with humans Severe Disease in Host is not useful It’s all a terrible mistake….. Most primary cases are asymptomatic. Primary Infection.

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TB – Presentation, Investigation and Overview

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  1. TB – Presentation, Investigation and Overview Paul McWhinney, Infectious Diseases, BRI

  2. An Old Friend • Well adapted to life with humans • Severe Disease in Host is not useful • It’s all a terrible mistake….. • Most primary cases are asymptomatic 2

  3. Primary Infection • Close, extended contact…..(mostly) • Pulmonary • Resolution (for a while) • Primary Complex • Local Spread • Bronchopneumonia • Distant Spread • Milliary • Focal disease • GI – hopefully non-UK or historical 3

  4. Post-Primary • Relapse • Re-Infection • Disease developing in a person with some immunity . 4

  5. Why Bother? • Risk to that person • Acute Inflammatory Illness • Severe sepsis • Meningitis, Osteomyelitis, Pyelonephritis etc • Late Complications • Lung damage • Other organ destruction • Risk to others • So, it is notifiable 5

  6. Problems • An illness that is history • Explainable feature • Diversity of presentation • Chronicity • Misplaced faith in BCG • Dread diagnosis • Poor appreciation of efficacy of treatment • Lack of Public Awareness • Socially Stigmatising 6

  7. Presentation • Patient from Risk Group • (but NOT always) • Fever • Night sweats • Weight Loss • Chronic Chest Infections • Several Months, not responding well to usual antibiotics • Occasionally years (esp abdominal) • Lymphadenopathy (eg cervical) 7

  8. Protean… • Skin • Joints • Spine • Bowel Upset • Recurrent symptoms with very non-specific features • Cold Abscess • Not hot / erythematous • Weeks rather than days • Well for size of lesion 8

  9. Similar Illnesses • Lymphoma • HIV • Bronchiectasis • Cancer • Inflammatory Bowel Disease • Anything • The Unexpected & Serendipity 9

  10. What to do…. • Confirm the diagnosis • Don’t muddy the water… • Quinolones (& linezolid) • Steroids etc • TB team will consider empirical treatment after specimens sent 10

  11. Why Confirm the Diagnosis • Because we should & people want to know…. • Treatment is extended, toxic and awkward • Response may be slow • Patient may be intolerant of drugs • Isolate may be resistant • And become more so • Reason to trace contacts • And stratify risk • (It might not be TB…..) 11

  12. Tests • CXR (etc) • Sputum x3 • EMU if wcc present unless immunocompromised • Biopsy everything & send for AFB culture • No clever tests… • (perhaps a Mantoux test) 12

  13. What else to do • Especially if unwell or pulmonary, TALK to the TB office • Delay can be bad for the patient AND contacts • Weigh them • To calculate doses and Monitor response • LFT, U&E, FBP • Vitamin D? • HIV test (+B&C while ‘there’) 13

  14. Who to talk to • TB office • A good place to start • Respiratory Physicians • Chest disease • ID Physicians • Non-pulmonary disease • HIV related disease • Paediatricians! (Dr Moya) • Neck nodes etc: ENT 14

  15. Treatment • Usually: • 2 months 4 drugs then 4 months of 2 drugs • All dispensed by hospital & whole prescription given at once • Sometimes: • Steroids • Then need bone protection 15

  16. Also…. • Check for immunocompromise • Explain need to comply • (none of this concordance business) • Warn about effects of drugs… • Including baseline eye check • & Check for interactions • Warn may take 2 weeks to start to respond • AND some things may get worse first 16

  17. And Then…. • Patient attends regularly • & TB nurses are able to visit • taking all their tablets • without side effects • and with a good response • while their contacts attend for screening • (well, some peoples patients might…) 17

  18. & when they come back…. • Relapse / Re-Infection • Really important to get the isolate • Consequences of organ damage • Recurrent chest infections • Bowel Obstruction • Aspergillus infection 18

  19. Thank you 19

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