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Extra Pulmonary Tuberculosis Case Reports

Extra Pulmonary Tuberculosis Case Reports. Dr. Nilgün Kalaç Atatürk Chest Disease and Surgery Centre, Ankara. DE, age 16, Ağrı-Patnos. 13.7.2010 hospitalisation Neck pain for 6 months Swelling on the left side of neck for 2 months

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Extra Pulmonary Tuberculosis Case Reports

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  1. ExtraPulmonaryTuberculosisCaseReports Dr. Nilgün Kalaç Atatürk Chest Disease and Surgery Centre, Ankara

  2. DE, age 16, Ağrı-Patnos • 13.7.2010 hospitalisation • Neck pain for 6 months • Swelling on the left side of neck for 2 months • On 12.7.2010 suddenly she could not move his arms and legs • Applied to emergency

  3. Neurologic Examination • Openconscious, cooperative • Cervicalmovementsaresensitiveandrestricted • On upperleftextremitytheDTRsarenormoactive • On upperrightextremityand on lowerextremitiestheDTRsarehyperactive • BilateralBabinski (+) • Tetraparesis • Anal tonus is intact • Thereare no urineincontinanceandretension

  4. Question 1 • Which test would you apply? • Thorax CT • Neck CT • Cranial CT • All

  5. Neck CT LEFT: On thelefthalf of theneck, there is a destruction at theatlantooccipitaljoint-C1 vertebralevel. RIGHT: There is an abcesslayingtowardsthespinalcanalandretrofaringealarea.

  6. Thorax CT There is a paravertebralabcesswhichcauseslitic-destructiveimagesthatbecomesclear at therightside on thelowerthoracalvertebrates.

  7. Thorax CT - 2 There is a subplevralnodularlesion at theanteriorupper lob of therightlung.

  8. Question 2: • What is your pre-diagnosis? • Cervical pyogenic osteomyelitis • Cervical malignancy • Cervical vertebral fracture • An abcess on the vertebral colon

  9. Question 3: • What should we do for the exact diagnosis? • Operation on cervical vertebra and abcess examination • Fiberoptic broncoscopy • Sputum test for Acid Fast Bacille(AFB) • Excision of the cervical LAP

  10. Tests done • Post-cervical LAP ponction on the left neck • AFB (+) on abcess material • AFB (-) on sputum

  11. Treatment • The date she is hospitalised is 13.7.2010 • Multiple Pott abcess • TB lenfadenite • With lung TB pre-diagnosis, HRZE treatment was started. • The diagnosis was confirmed later.

  12. On the 1st week of treatment • She became able to move her arms with help in her bed. • On the 20th day • She become mobilized • On the 85th day • She is discharged from the hospital by walking

  13. In Turkey, Extra Pulmonary TB makes the 30% of the all TB cases • Bone-joint TB makes the 1-2% of the all TB cases • Mostly the vertebra and the bones that carry weight (knee, femur, ankle) • The TB that affects vertebra is called the Pott disease • Frequent at the lower thoracal, lomber and lombosacral areas • It can diffuse to the soft tissue and make cold abcess • The Psoas abcess may diffuse through the muscles via gravity • It may cause paralysis and/or gibbosity • The treatment is standard anti-TB regime for 9 months • For stability, surgery may be required

  14. GE, age 24, Ağrı, Patnos – elder sister of the previous patient • her sister’s treatment was started on 13.7.2010 • Her hospitalisation on 22.2.2011 • Chest pain for 6 months • Night sweating, weight loss • Chest X-ray: Pleurisy

  15. Question 4: • Which tests should be done? • Sputum AFB • Thorasynthesis • Thorax CT • Neck USG

  16. Sputum AFB microscopy (-), (-), (-) • Plevra fluid • Exuda • ADA: 92 U/dl

  17. Thorax CT, 24.2.2011 Pleuralfluid on thelefthemithorax Pleuralfluidwithpartly dense areas on therighthemithorax

  18. Sister of the patient is TB • Her complaints and symptoms are coherent with TB • Pleural fluid ADA: 92U/dl hospitalisation on 22.2.2011 23.2.2011 HRZE was started

  19. Control Thorax CT, 26.7.2011 (23.2.2011 HRZE was started) Dense pleuralfluidwithpartly dense areaswithairvaluesandcisticareas on therighthemithorax Collapseconsolidation on theotherside of thatlung.

  20. Question 5: • What shall we do with these CT ? • Extend the duration of the treatment • Pleural biopsy • FOB • Decortication

  21. (23.2.2011 HRZE was started) • 4.8.2011 Right thoracotomy + decortication • Pathology: Caseified granulomatous infection • After operation, she used HR for 3 more months 23.11.2011

  22. 1.8.2011 Before operation 23.11.2011 3,5 months after operation

  23. Pleural TB • Pleural TB is at the 1st place among the extra-pulmonary cases • It makes the 30% of the all TB cases • Pathogenesis: • It is most frequently the complication of the primary infection • It occurs 6-12 weeks after the primary infection • Radiology, • Is usually unilateral • If it is bilateral, disseminated TB should be considered

  24. Pleural TB - 2 • Pleural fluid is exuda • If ADA level is over 40 U/dl : • Sensitivity: 92%, specifity: 93%. • High ADA values are seen in parapneumonic fluid • Standard 6 months treatment • Steroids are not necessary

  25. Pleural TB - 3 • With the anti TB treatment, visceral pleura may thicken in some patients. It makes pressure on lungs. Breathing is restricted. • After 3 months of treatmenti if there is thickening on more than ¼ of hemithorax, decortication is applied (opinion of the surgeons). • Lung and pleura curing may continue up to 6-9 months.

  26. TB TreatmentFollowup(case)

  27. HK, female, age 46, İskenderun • Lung TB 20 years ago • 3.3.2010 AFB (++++) • Relapse treatment(1HRZES / 2HRZE/ 5HRE) • The treatment is completed at VSD, AFB (-) • 6.4.2011 AFB (+++) • 12.4.2011 Hospitalization • Audiology: slight conductive hearing loss • Psychiatric consultation

  28. 12.4.2011 hospitalisation • 12.4.2011 a sample sputum is sent to RSH-TB laboratories • 20.4.2011 CYC, OFL, PTH, PAS are started • 29.4.2011 • M. tuberculosis complexis noticed • R resistant. H (inhA sensitive, katG resistant) • Florokinolon resistant; Aminoglikozit, EMB sensitive • 10.5.2011 • SZ sensitive

  29. 20.4.2011 CYC, OFL, PTH, PAS • 5.7.2011 Amik, E, Z, PAS, CYC, PTH • 1.8.2011 ALT: 292, AST 495 IU/L • Treatment is ceased. • Hepatitis tests: negative • 1, 2, 3 / 8/ 2011 Spread and TB cultures are negative • 9.8.2011 • The patient is discharged after she signed.

  30. 20.4.2011 minor treatment • 1.8.2011 hepatotoxicity, treatment is ceased • Applied to the doctor with complaints. • 10.10.2011 ARB (++) • 13.11.2011 Hospitalisation • AFB (++) • ALT: 526, AST: 390 IU/L • Hepatitis tests: negative • Amik, E, CYC, Oflo. • KCFT increase is normalized on 14.12.2011 • 9.1.2012 • AFB: (-), (+), (-)

  31. 13.11.2011: Amik, E, CYC, Oflo • 6.2.2012: ARB (++) • New treatment, planned with a new team. • H, E, Z, Amikasin, Moksif, CYC, PAS, CLF. • 17.3.2012 • Hearing loss: Amikasin is ceased. • 19.3.2012 • Sputum AFB (-), (-), (-) • Discharged. Notified about her situation to İskenderun VSD.

  32. Consultations during the treatment • Psychiatry (2 times) • Eye • Dermatology (3 times) • General Surgery • Audiology (3 times)

  33. Follow up problems of this resistant TB patient • Specification of the medicine resistance • Bacteriologic follow up (spread and culture) • Hepatotoxicity • Hearing loss • Depression • DOT application at the hospital • DOT application after discharge • Problems of control visits of the patient • Social and economic support

  34. Thank You Dr. Nilgün Kalaç Atatürk ChestDisease andSurgeryCentre, Ankara

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