1 / 21

Another Surprise? Dr M Wansbrough-Jones

Another Surprise? Dr M Wansbrough-Jones. Matthew Drake Mark Rooney Andrew Ladwiniec. History 1. 38 year, Somali refugee (UK: 1989) Unemployed 4/52 Hx Cough Sputum & 1 episode haemoptysis Night sweats Weight loss. History 2. Cough Slowly increasing Wakes at night Sputum Green

ashtyn
Download Presentation

Another Surprise? Dr M Wansbrough-Jones

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

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

  3. History 2 • Cough • Slowly increasing • Wakes at night • Sputum • Green • 1 episode of haemoptysis (fresh blood) • No chest pain or SOB

  4. History 3 • Weight loss • 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. Hb 9.8 (13.5-18g/dL)  WCC 8.7 (4-11x1012/L) Platelets 384 (150-400x109/L) MCV 81 (76-96fl) Normocytic anaemia (?anaemia of chronic disease) Full Blood Count

  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 (2.5-6.7mmol/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++ 2.49 (2.12-2.65mmol/L) • PO4--- 1.06 (0.8-1.45mmol/L) • CRP 249.4 (<10mg) 

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

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

  14. 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

  15. TB Pathology 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. Vaccination • BCG ‘Bacille Calmette-Guerin’ -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?

More Related