1 / 28

Mycobacterium and Lung Disease

Mycobacterium and Lung Disease. Tze-Ming Benson Chen, M.D., F.C.C.P. San Francisco Critical Care Medical Grp California Pacific Medical Center. Disclosures. none. Case Presentation.

kiley
Download Presentation

Mycobacterium and Lung Disease

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. MycobacteriumandLung Disease • Tze-Ming Benson Chen, M.D., F.C.C.P. • San Francisco Critical Care Medical Grp • California Pacific Medical Center

  2. Disclosures • none

  3. Case Presentation • 84 year old woman presents with chronic cough. No hemoptysis, fevers, chills, night sweats, and or weight loss. Has noticed progressive fatigue. • No tobacco abuse history • Born and raised in China, immigrated to U.S. in 2010

  4. Chest CT • tree-in-bud opacities • respiratory bronchioles & alveoli obstruction • differential diagnoses: • Mycobacterial • fungal • Viral • Non-infectious inflammatory Diseases

  5. Mycobacterium

  6. Differential Diagnosis • Mycobacterium Tuberculosis • Atypical mycobacterium • Rapid Growers • Chelonei, Fortuitum, Abscessus • Slow growers • Avium Complex

  7. Tuberculosis • Three forms of pulmonary tuberculosis • Latent tuberculosis • Active pulmonary parenchymal tuberculosis • Pleural disease • Tuberculosis Empyema • Tuberculous Pleuritis

  8. Latent Tuberculosis • Tuberculosis present but not causing an active infection • Diagnosis • PPD • Quantiferon Gold • High risk individuals should be tested • HIV • immigrants from endemic countries • homeless • health care professionals • persons living or working in long-term care facilities

  9. PPD Interpretation * Prior BCG vaccination is not considered when determining PPD reaction size

  10. BCG Effectiveness *Alaskan natives and American Indians vaccinated between 1935 and 1938 as part of a clinical trial *52% (95% CI: 27%, 69%) reduction in TB incidence JAMA 2004;291:2086-91

  11. Quantiferon Gold • First approved by the FDA in 2005 as aid in diagnosing both latent and active TB • Enzyme-linked immunosorbant assay to detect the release of interferon-gamma • Requires fresh heparinized whole bood • incubated with 2 antigens found on TB but not in BCG vaccine • False positives with mycobacterium Kansasii, marinum, and szulgai • reproducibility decreased if result is close to cut-off value

  12. QFT-G Studies • 216 Japanese nursing students at low risk for TB • Spec 98.1% • 118 patients with culture confirmed TB • Sens 89.0% • Compare QFT-G to TST • 99 Korean healthy BCG-vaccinated medical students • Spec QFT-G: 96% vs. TST: 49% • 54 patients with pulmonary TB • Sens QFT-G: 81% vs. TST: 78% AJRCCM 2004;170:59-64 JAMA 2005;293:2756-61

  13. QFT-G Studies • In 318 unselected hospitalized patients • sens for TB disease • QFT-G: 67% vs TST: 33% • Indeterminate results in patients with negative TST • QFT-G: 21% AJRCCM 2005;172:631-5

  14. Reactivation Risk • Reactivation of tuberculosis • Risk dependent upon patient’s underlying health and time since initial TB infection AJRCCM 2000;161:S221-47

  15. Latent TB Treatment • Determine that patient does not have active TB • History and physical exam • Chest x-ray http://www.cdc.gov/tb/publications/factsheets/treatment/LTBItreatmentoptions.pdf

  16. INH Hepatotoxicity • Risk Factors • Regular alcohol use • Hepatotoxic Tx • CYP P450 inducers • Liver disease • Pregnancy / immediate postpartum • IVDA • Female Am Rev Respir Dis 1978;117:991

  17. INH Treatment • Administer recommended regimen • Provide pyridoxine if on INH • Evaluate patient monthly in clinic and repeat blood work if suspicious of hepatotoxicity • Discontinue therapy if: • AST > 5x upper nml if Asx • AST > 3x upper nml if Sx • Obtain baseline Tbil, AST, ALT, Alk Phos • baseline liver disease • HIV • pregnant and postpartum (< 3months) • Alcohol use • medications with potential interactions • otherwise at your discretion

  18. Pulmonary TB • Classic Symptoms • Cough, Fatigue, Weight loss, Sweats, Hemoptysis • Classic Radiographic FIndings • Upper lobe opacities • Tree-in-bud opacities to cavitary consolidation

  19. Pleural TB • TB Pleuritis • Immunologic reaction to pulmonary TB infection • Often culture negative • Often self-limited • High risk for active pulmonary TB • TB Empyema • Presence of TB organism in pleural space causing active infection • AFB smear • Culture positive

  20. TB Treatment • Initial: 4 drug therapy for 2 months • Continuation: 2 drug therapy for additional 4 months if TB is sensitive to INH and Rifampin • Today, Directly Observed Therapy via Dept of Public Health is standard of care

  21. TB Tx: Pleural Disease • TB Pleuritis • If suspected, pursuit of diagnosis is essential because of high risk of developing active pulmonary disease within the next 12 months • TB Empyema • Chest tube drainage • Will likely require VATS • initiate 4-drug therapy and contact Dept of Public Health

  22. Atypical Mycobacterium • Symptoms: • chronic cough • fatigue • Occasionally: • hemoptysis • dyspnea • weight loss • Radiographic findings: • Tree-in-bud to consolidation • bronchiectasis

  23. Lady Windermere • Thin caucasian woman with chronic cough • Bronchiectasis involving middle lobe and lingula • Chronic atypical mycobacterial infection • Possible link to cystic fibrosis

  24. Diagnosis • Symptoms • Radiographic findings • Microbiology • 2 of 3 expectorated sputums positive for same organism • 1 bronchoscopic specimen that is culture positive for atypical mycobacterium

  25. Treatment • Decision to treat • Not straightforward • Consider: • Severity of symptoms • Severity of radiographic abnormalities • Patient preference • “Rapid” grower vs “slow” grower

  26. MAC Treatment • Clarithromycin / azithromycin • Rifampin / rifabutin • Ethambutol • Treatment is usually between 12 and 18 months • 12 months of treatment following initial negative respiratory culture

  27. Back to the Case • Sputum culture positive for MAC • Decision made to not treat with antibiotics • Recommended either acapella valve therapy or theravest for airway clearance • Reimage in 6 to 12 months

  28. Questions?

More Related