Transcript Dr. Horsburgh - New England TB Consortium

Overview
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Case Presentation
Diagnosis
Treatment – Induction phase
Treatment – Continuation Phase
Treatment Monitoring
Assessment of Transmission
Outcome
References
Case Presentation
18 y.o Hispanic female presents with 2
day hx of postpartum normal vaginal
delivery and abnormal CXR.
No cough, mild fever, no unexpected
weight loss
PPD 25 mm by history.
Case Presentation - 2
• PMH: Pt is G1P1, otherwise unremarkable
• FMH: Mother alive and well living in El
Salvador; father unknown health status. 1 sib
living in El Salvador A/W.
• Social: Lives alone in bedroom room apt in 3family house. Rents apartment.Works as
babysitter. Marital status is single though does
have BF. Medical coverage is Medicaid.
Immigration status undocumented
Case Presentation - 3
• Meds: Tylenol 1gm PRN pain
• Substance Abuse: Denies smoking, ETOH, and
IVDU
• Allergies: none known
Physical Exam
Pt sitting in bed in precaution room. In NAD, breathing
comfortably.
VS: WT 108 lbs, T 99.5 (F)
HR 98-Pulse Reg--Resp18 BP 104/60
Resp: Symmetric chest wall motion. Neg for retractions or
use of accessory muscles. No dullness noted on
percussion. No palpable tenderness on palpation. BS with
normal air movement, neg for rales and wheezes
Labs
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Hematocrit 40.8
MCV 84
WBC 6.0
Platelets 453
AST 22
Alk Phos 180
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Creat 0.6
Serum Ca 9.9
PCO2 36.9
O2 sat 100
Sputum smear – x3
pending
Chest Radiograph and CT
• CXR suggestive of cavity lesion in LUL
and RUL otherwise heart normal size.
Diaphragm slightly elevated secondary to
heightend uteral placement. Film suggestive
of active process of pulmonary tuberculosis.
• CT confirms cavity opacity in RUL
Differential Diagnosis
• Tuberculosis
• Bacterial Pneumonia
• Carcinoma
Diagnosis
• CXR abnormal but not necessarily diagnostic.
• Sputum smears may be – or + depending on the
level of infectiousness
• May need bronchoscopy with bronchial washings
or lavage
• Biopsy may be warranted to confirm
Diagnosis - 2
• Culture is gold standard but takes 3-6 weeks to
grow in solid media, 12-28 days with liquid media
• Smear is strongly suggestive but could be due to
nontuberculous mycobacteria
• Nucleic acid amplification can rule TB in but not
out
• TB skin test not sensitive or specific
• In-vitro interferon gamma-based tests similar to
TB skin test
Case Presentation - 4
• Smears: 2+/1+/neg
• HIV serology - negative
Treatment - Induction Phase
Because of the relatively high proportion of adult
patients with tuberculosis caused by organisms
that are resistant to isoniazid, four drugs are used
in the induction phase for the 6-month regimen to
be maximally effective.
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Isoniazid
Ethambutol
Rifampin
Pyrazinamide
5-10 mg/kg day
15-20 mg/kg day
10 mg/kg day
20-25 mg/kg/day
Case Presentation - 5
Our patient:
Daily therapy with
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Isoniazid
Ethambutol
Rifampin
Pyrazinamide
300 mg p.o. (1 pill)
800 mg p.o. (2 pills)
600 mg p.o. (2 pills)
1000 mg p.o. (2 pills)
Other issues: intermittent regimens, combination
pills
Management
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DOT- directly observed therapy
Self- Administered therapy
Case Management
Mandatory Confinement?
Assessment of Transmission
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How long to isolate the patient?
Source case?
Transmission to household contacts?
Transmission in the workplace?
Case Presentation - 6
Initial sputum culture results from our patient:
“M. tuberculosis”
Isoniazid
Ethambutol
Rifampin
Pyrazinamide
Sensitive
Sensitive
Sensitive
Sensitive
Treatment – Continuation Phase
Because of the relatively small number of
organisms remaining after 2 months of intensive
phase treatment, most patients with tuberculosis
can be placed on continuation phase treatment
after 8 weeks of induction.
Induction Phase usually lasts 4 months (18 weeks)
and can be give daily or twice weekly
– Isoniazid
– Rifampin
5-10 mg/kg day
10 mg/kg day
Treatment Monitoring
• Visit Schedule:
q 2wk during induction
q month during continuation
• Adherence monitoring
• Efficacy monitoring
Weight, temperature
2 month and 6 month films
monthly smear and culture
• Toxicity monitoring
Skin rash, LFTs, Nausea, Color vision
Case Presentation - 7
Sputum culture results from our patient after 2
months of induction phase therapy:
“No Growth”
Outcome
• Patient received induction and continuation
therapy (2+4=6 months) and was cured
• All household members received TST and
chest radiograph if TST+. There we no
active cases, but the 2 persons with TST+
received INH for treatment of LTBI
• Baby received INH until follow-up TST
3months later was negative
References
1. Horsburgh CR, Burman WJ. Tuberculosis Treatment:
Theory and Practice. In: Therapy of Infectious Diseases,
ed Baddour L, Gorbach SL. Philadelphia PA; Saunders,
2003: 529-46.
2. Centers for Disease Control and Prevention. Treatment of
Tuberculosis, American Thoracic Society, CDC, and
Infectious Diseases Society of America. MMWR
2003;52(no. RR-11):1-80.
3. Horsburgh CR, Feldman S, Ridzon R. Quality standards
for the treatment of tuberculosis. Clin Infect Dis
2000;31:633-9.