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• High suspicion of TB - Weight loss, fever and cough - Abnormal CXR miliary pattern - Large spleen/liver - Night sweats - Anaemia • Findings that suggest a non-TB - Rigors - Very breathless (respiratory rate >30/min) - Severe diarrhoea - Blood in stool - Positive cryptococcal Ag - malaria smear or likely pathogen - isolated from blood C/S
• High suspicion of TB - Unilateral effusion - Pleural fluid is clear and straw coloured - Clots on standing in a tube without anticoagulants - Weight loss, night sweats, fever - Evidence for TB elsewhere • Findings that suggest a Non-TB - Bilateral effusion - Clinical malignancy - Pleural fluid is cloudy/pus (probable empyema) - Fails to clot (does not exclude TB)
ไอ เหนอย น าหนกลด : คนไหนนาจะเปน TB มากกวากน ?
นาย ก. 40 ป ADA = 40
นาย ข. 40 ป ADA = 50
Approach to the diagnosis of (presumed) pleural TB (IUATLD)
• Lymphocytic exudative pleural effusion in : age < 40 years - low- and middle-income countries - or if the presence of ADA has been determined. “ antituberculous therapy may well be indicated “ : age > 40 years - risk factors for CA - negative pleural fluid or biopsy “ a pleuroscopy before starting empirical Rx is indicated “
• Clinical 1. +symptoms, nodular or cavitary opacities on CXR, or an HRCT scan that shows multifocal bronchiectasis with multiple small nodules. 2. exclusion of other diagnoses • Microbiologic : one of the followings 1. positive C/S > 2 samples of separate sputum 2. positive C/S > 1 sample of bronchial washing or lavage 3. lung biopsy with mycobacterial histopathologic features and positive C/S of 1 sample of any sputum or BAL (washing)
• Pitfall : เลอกใชสตรยา CAT II (2HRZES/1HRZE/5HRE) ในผปวย ทเปน treatment failure • Clue : “ กรณทพบวามการลมเหลวจากการรกษาดวยระบบยา CAT I
และแนใจวาผปวยรบประทานยาสม าเสมอไมควรเปลยนมาใช
CAT II เนองจากผลการรกษาหายขาดต า ” • ประเทศทมอบตการณ MDR-TB สง ถามผปวยท เปน treatment failure ใหพจารณาการรกษาดวย CAT IV (WHO)
Case : หายไปไหนมา ?!
MDR-TB in New and Re-treatment from Drug Resistance Surveys, 1994-2007
MDR in Retreatment TB cases from 10 countries 1997-2007
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Treatment after interruption : CDC
< 14 วน > 14 วน
กนตอ + missed dose
ถาคาดวาไมจบใน 3 เดอน ใหเรมรกษาใหม
เรมการรกษาใหม
< 80% > 80%
< 3 เดอน
> 3 เดอน
Intensive phase Continuous phase
พจารณาหยดยาได แตถา initial
smear + ใหกนยาตอ
กนตอ + missed
dose ถาคาดวาไมจบใน 6 เดอน ใหเรมรกษาใหม
เรมการรกษาใหม
Action in interruption of TB Rx : WHO
Pitfalls : Inappropriate regimen
• No conversion at 2nd month
• Addition of a single drug to a failing regimen
• Failure to identify preexisting or acquired drug resistance
• Initiation of an inadequate primary regimen
• Failure to identify and address noncompliance
Interaction ระหวาง Rifampicin กบยาอน
ตวอยางยา
• Protease inhibitors (PI)
• ยาคมก าเนด
แกไข
• ไมใช PI รวมกบ rifampicin
ใหใช rifampicin + 2NRTIs
• เปลยนวธคมก าเนดเปน
nonhormonal Rx หรอ
เพม estrogen > 50 ไมโครกรม
Worsening of lesions “Paradoxical reaction”
• Fever, enlargement of LN, worsening of chest infiltrates, and an increase of pre-existing TB lesions
• Prevalence : HIV + anti TB + HAART 36%
: HIV + anti TB 7%
: non-HIV + anti TB 2-15%
• Due to : restores an effective Th1 immune response to tuberculous Ag
• self-limited and generally last for 10–40 days
Paradoxical reaction in non-HIV
• Prevalence : up to 20% • EPTB : PTB = 4:1 • median time to onset of CNS manifestation > other sites : 63 d. VS 56 d. • Very common in TB lymph node : prevalence 23 % : onset = median 46 days after Rx (21-139 d) : persisting = median of 67.5 days (34-111 d) • Development of new lesions in anatomical sites other than those observed at initial presentation was observed in 25%
Hawkey CR, et al. Clin Infect Dis 2005;40 Cheng VC, et al. Eur J Clin Microbiol Infect Dis 2002;21
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1 major or 2 minor criteria : paradoxical reaction
Major 1) New/enlarging lymph nodes, cold abscesses or other focal tissue involvement 2) New or worsening radiological features of TB 3) New or worsening CNS TB 4) New or worsening serositis (ascites, pleural or pericardial effusion) Minor 1) New or worsening constitutional symptoms 2) New or worsening respiratory symptoms 3) New or worsening abdominal pain with hepatosplenomegaly, abdominal LN (on U/S) 4) Resolution of clinical +/ radiological findings without change in TB Rx
Paradoxical reaction
Exclusion of alternative explanation
• Failure of TB Rx or ART due to drug resistance
• Poor adherence to Rx
• Another opportunistic infection or neoplasm
• Drug toxicity or reaction
Treatment of paradoxical reaction
• Immunomodulation
- Corticosteroids (Useful? Duration? Dose?)
- NSAIDs
- Other
• ART interruption and reART re-introduction under steroid cover (especially neurological TB)
• Drainage procedures
Lymph node TB : common problems
• Diagnosis
: non diagnostic cytology ???
• During treatment
: increase in size of LN ???
• At the end of Rx
: persistent enlargement of LN ???
Clinical suspicion of lymph node TB
• High suspicion of TB
- > 2 cm
- asymmetrical/ localized
- painless
- cervical
- weight loss, night sweat, fever (in HIV)
• Findings that suggest non-TB
- symmetrical (lymphoma or HIV)
- tender, inflammed, purulent (bacteria or fungus)
- sites other than cervical
Increase in size !
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Enlarging or persisting of LN = Non response ??
• During Rx
- Size of LN decreases very slowly (over wks. or mo.)