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

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Presentation on theme: "New England TB Case Series January 18, 2006 Ford von Reyn MD Dartmouth Medical School."— Presentation transcript:

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

2 Case 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

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5 Questions 1.Differential diagnosis? 2.Isolation? 3.Next steps?

6 Differential Diagnosis 1.Mycobacterial adenitis: TB or non-tuberculous mycobacteria (NTM) 2.Other bacterial: cat scratch, S. aureus or Streptococcal spp, tularemia 3.Parasitic: Toxoplasmosis 4.Viral 5.Fungal 6.Sarcoidosis 7.Malignancy: lymphoma, sarcoma, carcinoma

7 MDR tuberculosis Defined as resistance to at least INH and rifampin Website: o_htm_tb_2004_343/en/index.html Thailand: approximately 1-2%

8 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

9 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 Tender L supraclavicular area 10 x 10 cm, woody induration, no fluctuance L arm weakness

10 April 2004 Scrofula

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12 Questions 1.What is the problem? 2.Other studies? 3.Therapy?

13 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?

14 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

15 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: Contd decrease in neck swelling, weight up 20 lbs, continue prednisone 20 mg Completed 8 mos total Rx in December 2004

16 Scrofula Scrofula = mycobacterial lymphadenitisScrofula = mycobacterial lymphadenitis Kings Evil: Medieval term, cured by touch of the kingKings Evil: Medieval term, cured by touch of the king Historical: common in Europe in 19 th century (24% of children had evidence of current or past infection)Historical: common in Europe in 19 th century (24% of children had evidence of current or past infection)

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18 Scrofula EtiologyEtiology M. tuberculosis (MTB) M. tuberculosis (MTB) M. bovis (MB) M. bovis (MB) Non-tuberculous mycobacteria (NTM) Non-tuberculous mycobacteria (NTM) Developing countries: MTB> MB>>>NTMDeveloping countries: MTB> MB>>>NTM Developed countries: NTM>>MTB>MBDeveloped countries: NTM>>MTB>MB

19 Lymphadenitis due to MTB Age most common, F: M ratio is 2:1Age most common, F: M ratio is 2:1 Ethnic: esp Asian (80%), Indian; also African, Af-Am, Hispanic, Native AmericanEthnic: esp Asian (80%), Indian; also African, Af-Am, Hispanic, Native American 3-5% of US TB cases3-5% of US TB cases Clinical settingsClinical settings Primary TB (children) Reactivation TB (adults) HIV IRIS (HIV)

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

21 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

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23 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 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 reactionsAlso called paradoxical reactions Occurred in 6 (35%) patients started on HAART (for HIV) while on TB therapyOccurred in 6 (35%) patients started on HAART (for HIV) while on TB therapy All occurred with HAART start 2 log drop in HIV viral load All occurred with HAART start 2 log drop in HIV viral load Smears pos in 4/6, culture pos in 2/6Smears pos in 4/6, culture pos in 2/6 Management: distinguish treatment failure, continue TB Rx, NSIADs for mild Sx, steroids for severe SxManagement: distinguish treatment failure, continue TB Rx, NSIADs for mild Sx, steroids for severe Sx Most cases resolve within a few weeksMost cases resolve within a few weeks -Navas, 2002

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

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

26 Lymphadenitis due to NTM Clinical: indolent lymphadenitis in healthy children age 1-5 usu due to M. avium complexClinical: indolent lymphadenitis in healthy children age 1-5 usu due to M. avium complex Nodes: upper cervical, salivary area nodesNodes: upper cervical, salivary area nodes Risk factors: unknown (?soil/water exposure with erupting teeth), BCG protects (Sweden, Finland)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 candidatesRx: 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 useIncidence: rising in the United States, increased in Sweden with decreased BCG use

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28 Childhood adenitis: Cleveland, US -Wolinsky. Clin Infect Dis 1995;20:

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


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