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New England TB Case Series January 18, 2006

New England TB Case Series January 18, 2006. Ford von Reyn MD Dartmouth Medical School. Case - 1. 33 yo Thai woman working living in northern New Hampshire, unemployed February 2004: sore throat, followed by dysphagia, R neck swelling, 5 pound weight loss and fever

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New England TB Case Series January 18, 2006

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  1. New England TB Case Series January 18, 2006 Ford von Reyn MD Dartmouth Medical School

  2. Case - 1 33 yo Thai woman working living in northern New Hampshire, unemployed February 2004: sore throat, followed by dysphagia, R neck swelling, 5 pound weight loss and fever March 10, 2004 (Boston): cervical node Bx under CT and US guidance showed AFB and necrotizing granulomatous inflammation, no Hx TB exposure, no PPD done Chest x-ray: next slide

  3. Questions • Differential diagnosis? • Isolation? • Next steps?

  4. Differential Diagnosis • Mycobacterial adenitis: TB or non-tuberculous mycobacteria (NTM) • Other bacterial: cat scratch, S. aureus or Streptococcal spp, tularemia • Parasitic: Toxoplasmosis • Viral • Fungal • Sarcoidosis • Malignancy: lymphoma, sarcoma, carcinoma

  5. MDR tuberculosis Defined as resistance to at least INH and rifampin Website: http://www.who.int/tb/publications/who_htm_tb_2004_343/en/index.html Thailand: approximately 1-2%

  6. Case - 2 March 17, 2004: Started on 4 drug Rx for TB INH, Rifampin, Pyrazinamide, Ethambutol April 9, 2004: Positive culture for TB, later reported as sensitive to all first line drugs

  7. Case - 3 April 19, 2004 (Dartmouth): Referred for evaluation of poorly responsive tuberculous lymphadenitis Hx: Neck still painful, no decrease in size No fever, last night sweats 2 weeks ago PE: Afebrile Weight 105 lb Lungs clear Tender L supraclavicular area 10 x 10 cm, woody induration, no fluctuance L arm weakness

  8. April 2004 Scrofula

  9. Questions • What is the problem? • Other studies? • Therapy?

  10. Case - 4 April 21: Admitted to Dartmouth-Hitchcock Medical Center for further increase in size of neck mass Daily Rx, PZA reduced from 2.0 to 1.2 gm because of nausea April 23: Neck aspirate AFB positive Next steps?

  11. Case - 5 April 28, 2004: Prednisone 80 mg/d May 4, 2004: Neck still painful and mass enlarging I & D at 3 sites by ENT: brown pus, clots, AFB pos May 11, 2004: Prednisone D/Ced, fever and muscle pain developed Prednisone 20 mg/d resumed, fever cleared May 14, 2004: Discharged home on 2x weekly Rx

  12. Case - 6 May 27, 2004: OPD visit. No fevers, still some leg pain, wounds packed daily, less neck pain, 11 lb weight gain June 25, 2004: L leg swelling, neg US, clinical suspicion of DVT, Rx ASA July 27, 2005: Cont’d decrease in neck swelling, weight up 20 lbs, continue prednisone 20 mg Completed 8 mos total Rx in December 2004

  13. Scrofula • Scrofula = mycobacterial lymphadenitis • King’s Evil: Medieval term, “cured” by touch of the king • Historical: common in Europe in 19th century (24% of children had evidence of current or past infection)

  14. Scrofula • Etiology M. tuberculosis (MTB) M. bovis (MB) Non-tuberculous mycobacteria (NTM) • Developing countries: MTB> MB>>>NTM • Developed countries: NTM>>MTB>MB

  15. Lymphadenitis due to MTB • Age 20-30 most common, F: M ratio is 2:1 • Ethnic: esp Asian (80%), Indian; also African, Af-Am, Hispanic, Native American • 3-5% of US TB cases • Clinical settings Primary TB (children) Reactivation TB (adults) HIV IRIS (HIV)

  16. Lymphadenitis due to MTB • Nodes: usu multiple nodes, jugular, posterior triangle, supraclavicular • Pathophysiology: systemic dissemination • Symptoms: weeks to months, fever, wt loss, fatigue, nt sweats in 20-50% • Chest x-ray: 30% have findings • Tuberculin skin test: 70-90% positive

  17. Subclinical TB in HIV: Tanzania HIV positive ambulatory patients with CD4>200 screened for a TB vaccine trial in Tanzania Among first 93 patients 14 (15%) met clinical criteria for active tuberculosis “Subclinical TB”: 10 patients with no signs, symptoms or x-ray abnormalities but positive sputum cultures (DNA typing showed not contaminants); 3/10 pos AFB smears, 60% adenopathy Implications Need for better diagnostics Inappropriate INH for latent TB that is really early active TB -Mtei, von Reyn 2003

  18. Immune reconstitution syndrome (IRIS) in HIV/TB • Fever, lymphadenitis, +/- pulmonary infiltrate, expansion of CNS lesions, in HIV pos patients on Rx for TB who are then started on HAART and experience immune reconstitution • Also called “paradoxical reactions” • Occurred in 6 (35%) patients started on HAART (for HIV) while on TB therapy • All occurred with HAART start <2 mos after TB Rx start (median 22 days), 5/6 had initial CD4<100, more likely if >2 log drop in HIV viral load • Smears pos in 4/6, culture pos in 2/6 • Management: distinguish treatment failure, continue TB Rx, NSIADs for mild Sx, steroids for severe Sx • Most cases resolve within a few weeks -Navas, 2002

  19. Lymphadenitis due to MTB - Dx • Fine needle aspiration (FNA) for cytology and AFB smear sensitivity 80% specificity 90% • Excisional Bx: second choice for Dx because of possibility for fistula, sinus tracts • Culture: positive in 35%

  20. Lymphadenitis due to MTB - Rx • Standard 4 drug chemotherapy • Slow response: common for enlargement of nodes or new nodes on Rx, cultures usu negative • Surgical drainage: for painful lesions or very slow response on chemoRx

  21. Lymphadenitis due to NTM • Clinical: indolent lymphadenitis in healthy children age 1-5 usu due to M. avium complex • Nodes: upper cervical, salivary area nodes • Risk factors: unknown (?soil/water exposure with erupting teeth), BCG protects (Sweden, Finland) • Rx: surgical excision; two drug Rx (from macrolide, ethambutol, rifamycin) may benefit those who are not surgical candidates • Incidence: rising in the United States, increased in Sweden with decreased BCG use

  22. Childhood adenitis: Cleveland, US -Wolinsky. Clin Infect Dis 1995;20:954-63.

  23. Summary - Scrofula • Case presentation: slowly resolving drug sensitive MTB lymphadenitis in a Thai woman, Rx required 8 mos chemo and surgical drainage • Usu demographics: F>M, esp Asian, age 20-30 • Other clinical settings: HIV, IRIS, primary infection • Most adult cases in US due to MTB, childhood cases due to NTM • Rx for childhood NTM is usually surgery

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