Sumatran Surprise An Intriguing Indonesian Infectious Diseases Dr. M. Wansborough-Jones firm Kathryn Brain Norzehan Hj Md Saini Jeremy Rampling Nikunj Shah

MR. A z26 years old, Indonesian, male z8 years in the U.K zSpeaks little English zDelivery man at a takeaway in Battersea

PC zProductive cough zLymphadenopathy zWeight loss zSwollen left knee

HPC z1 month Hx of productive cough, grey sputum, worse in last 2 weeks, associated SOB zAn episode of haemoptysis, last Easter, more than a spoonful of blood mixed with mucus z2 weeks ago - fever, shivering, night sweat, took paracetamol, resolved spontaneously

HPC cont. zPost-prandial nausea, vomited food eaten 2 weeks ago but has good appetite zWeight loss (how much, since when?) z1 month Hx of general malaise zOccasional headache with vertigo after walking a certain distance, last incident a week ago, had to keep his head up to prevent from fainting, passed out once few months before developed cough

HPC cont. zSOB on exertion zLumps in neck for a year, submandibular and on both sides,  in size, went to see his GP in Jan 2003 & was referred to CIU but failed to turn up for appointments few times zSwelling of left knee with lesion & sinus discharging occasionally below the left knee for 3 months, tender and painful to move, lost balance as a result, pain has been there for a year

SE zNo palpitations, central chest pain, oedema zNo neck stiffness, photophobia zNo fits, numbness, pins and needles, muscle pain zNo genitourinary symptoms zNo other GI symptoms

PMH zNo significant illnesses zVaccinated for BCG but no scar found

DRUG Hx zNil zNo known allergies

FAMILY Hx zNil

SOCIAL Hx zCame to the U.K IN 1994 zWent to Saudi Arabia for a month in 97’ zWent back to Indonesia for 2 months in 98’ zBoth parents and two younger sisters in Indonesia - fit and well zLives in 4 bedrooms detached house in Tooting with 3 other people, all fit and well zWorks as delivery man in an Indian takeaway

Social Hx cont. zOccasional smoker and drinker zSingle zNever been in any sexual relationship zDenies any i.v drug use

Physical examination zCachectic, looking unwell zNo pallor, jaundice, clubbing, cyanosis, koilonychia zTemp °C zSat. - 98% on air zLymph nodes enlargement - submandibular and submental, several in anterior cervical chain and a single LN in left axilla

Physical examination cont. CVS zPulse bpm zBP - 106/80 mm Hg zHS - I + II + 0 Respiratory zRight lower zone - dull on percussion, harsh bronchial breathing zCrackles on the left base

Physical examination cont. Bowel zSoft, non-tender, normal bowel sound, zNo organomegaly CNS zGrossly intact

Physical examination cont. zLeft knee - fluctuant swelling + sinus below the knee (dry)

Differential diagnosis zTB (Post-primary > Primary) zLymphoma zCarcinoma of the lung zAtypical pneumonia

Ix at admission 13/5 zFBC (including CRP) zU&E zLFT zBlood culture zSputum microscopy (AFB) zSwab from leg zCXR

Blood results zHb 11.8Na + 133*  Bilirubin 9 zWBC 7.9K + 4.9ALT 42 zNeut 6.7Urea 5.9ALP 92 zPlatelets 240Creatinine 90Albumin 25*  zMCV 77*  Glucose 5.3Gamma GT 34 z CRP 144.5*  Adj Ca z PO zCXR- R lobar consolidation

Admitted 13/5 zIv hydration zErythromycin po 500g qds zCefotaxime iv 1g bds

CXRCXR - closeup

The following day... zIx zX ray left knee zFNA submental + submandibular lymph nodes zTB blood cultures z Management z Ibuprofen po 400mg tds

KneeKnee - closeup

15/5BINGO!!! zMicroscopy- AFB positive zLegionella/ pneumococcal antigen not detected zDIAGNOSIS- Tuberculosis - pneumonia and osteomyelitis

Ziehl-Nielsen Stain Bannister, Begg & Gillespie (2000)

Anti-TB therapy begins15/5 z12 months course zRifater 4 tablets daily y(Rifampicin; Isoniazid; Pyrazinamide) zEthambutol 700 mg po od zParacetamol 1g po (QDS max) as required

15/5Contact tracing zClose family members and work colleagues zIf unwell => rigorous TB Ix zIf well, CXR and tuberculin test zAdult=>CXR; children=> tuberculin zIsoniazid prophylaxis if suggestive, or if <1 y.o.

Epidemiology zLeading infectious cause of death world wide. zIncreasing in the far east and Africa especially in association with AIDS. zIncreasing in London and the UK z40x more likely to have in lifetime if of Asian origin.

Pathology zInfection with Mycobacterium tuberculosis. Mainly in upper of lobe of lungs. zInitial infection in childhood, primary infection. This heals and becomes calcified. zReactivation when host becomes immunosuppressed.

Manifestations zMiliary TB acute diffuse dissemination of tubercle bacilli via the blood stream. zPresents very non specifically, weight loss ill health fever. zMantoux test is normally +ve though can be -ve in severe disease.

Adult post primary pulmonary TB zGeneral onset of non specific symptoms. zMain features fever, cough, weight loss. zSputum mucoid, purulent or blood stained. zPleural effusion or pneumonia. zFinger clubbing is present with advanced disease.

Investigations zChest X-Ray patchy nodular shadows in upper zone. zStaining Ziehl-Nielson culture takes 4-8 weeks. zBronchoscopy if no sputum. zBiopsy of lymph nodes. zDirect testing for rapid result using PCR.

Management zSensitive organisms use. zRifampicin, S/E inducer of liver enzymes, should be stopped if bilirubin is elevated. zIsoniazid, can cause a polyneuropathy at high doses. Can cause nausea and vomiting. zPyrazinamide reduces renal excretion of urate and an precipitate hyperuraemic gout. Can cause hepatotoxicity. zIf resistant use ethambutol or myambutol. These can cause optic retro bulbar neuritis. All patients must be seen by an ophthalmologist prior to treatment.

Control and prevention zTB is a notifiable disease. zAll close contacts are screened with a mantoux test and a chest X-Ray. zPrevention is with immunisation with BCG vaccination administered at in the UK zAdministered at birth to groups at high risk