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Another Surprise?
Dr M Wansbrough-Jones
Matthew Drake
Mark Rooney
Andrew Ladwiniec
History 1
 38 year, Somali refugee (UK: 1989)
– Unemployed
 4/52 Hx
– Cough
– Sputum & 1 episode haemoptysis
– Night sweats
– Weight loss
History 2
 Cough
– Slowly increasing
– Wakes at night
 Sputum
– Green
– 1 episode of haemoptysis (fresh blood)
 No chest pain or SOB
History 3
 Weight loss
– Little over 1st couple of weeks then sudden loss
– Approx 10kg in total
 Night sweats
– Every night
– Clothes and bed sheets dripping
History 4
 Moved house 6/52 ago from cold, damp
dirty flat in Streatham. House mate well.
 Non-smoker, teetotal
 Unaware of exposure to TB or other
infections
– Believes some contacts within community may
have TB
 No recent foreign travel
Examination
 Mildly wasted/cachectic
 HR 114 Bpm.
 Lungs
– ® upper zone dull to percussion
– ® upper zone  tactile fremitus
– ® upper zone  vocal resonance
– ® upper zone bronchial breath sounds
– Widespread bilateral inspiratory crackles
Investigations
 FBC, U&E, LFT, Bone Profile, Clotting
 Blood cultures
 Sputum culture & examination for acid fast
bacilli
 Chest X-Ray
Full Blood Count
 Hb 9.8 (13.5-18g/dL) 
 WCC 8.7 (4-11x1012/L)
 Platelets 384 (150-400x109/L)
 MCV 81 (76-96fl)
 Normocytic anaemia (?anaemia of chronic
disease)
Clotting
 INR 1.0 (0.9-1.2)
 APTT 38 (35-45s)
 TT 12 (10-15s)
 D-Dimers 3.44 (<0.5 mg/L) 
Urea & Electrolytes
 Na+ 133 (135-145mmol/L) 
 K+ 4.0 (3.5-5.0mmol/L)
 Cl- 97 (95-105mmol/L)
 Urea 1.8 (2.5-6.7mmol/L) 
 Creatinine 17 (70-150mol/L) 
Liver Function Tests/Bone Profile
 Bilirubin 16 (3-17mol/L)
 ALT 39 (5-35u/L) 
 ALP 107 (30-150u/L)
 Albumin 26 (35-50g/L) 
 Gamma GT 61 (11-51u/L) 
 Corrected Ca++ 2.49 (2.12-2.65mmol/L)
 PO4--- 1.06 (0.8-1.45mmol/L)
 CRP 249.4 (<10mg) 
Sputum examination
 Upper respiratory tract flora (++ growth)
 Coliforms (Scanty growth)
 Acid Fast Bacilli +++
Management
 Admitted + Isolated
 Rifater (Rifampicin, Isoniazid, Pyrazinamide)
-before breakfast
 Ethambutol
 Pyridoxine
TB Epidemiology
 UK incidence = 7000 new cases/year
 Higher in immigrant populations:
-Indian subcontinent:  x 40
-West-Indies:  x 4
• 
frequency in developing world
• Worldwide TB  since mid-80’s due to:
-HIV,  migration
TB Pathology
Mycobacterium tuberculosis (Aerobic, acid-fast bacillus)
1ry TB (usually no symptoms):
 Infection, macrophage ingestion, T-cell response
 Cellular immunity in 3-8 weeks
 Caseating granuloma form, heal, may calcify
 20% calcified 1ry lesions contain tubercle bacilli
TB Pathology 2
Post-1ry TB (often years later)
 Reactivation of remaining M.tb/reinfection
  susceptibility due to:
-Immunosupprssion (e.g. drugs, HIV, lymphoma)
-Malnutrition
-DM
 Typically, cavitation at apex/upper zones
Management
 Hospitalise if smear positive (stop spread)
 Most important factor = good compliance
-If poor, directly observed therapy
 Standard 6 month regimen:
-Rifampicin
-Isoniazid +Pyridoxine (vit. B6)
-Pyrazinamide (first 2 months)
-Ethambutol (first 2 months)*
 Follow-up (check compliance)
 Contact tracing
Drug side-effects + precautions
 Rifampicin
-Warn about orange secretions
-OCP ineffective
-Regular LFTs, stop if: bilirubin/3x transferases
 Isoniazid
-Polyneuropathy: give pyridoxine (vit. B6)
 Pyrazinamide
-  urate excretion, can precipitate gout
 Ethambutol
-Optic retro-bulbar neuritis: see opthalmologist before treatment
Drug Resistance
 1ry -infected with D.R. TB (mainly immigrants)
 2ry -poor compliance (developed in patient)
Medication:
 Use at least 3 drugs to which it is sensitive
 Resistance to 1 of 4 main drugs, use other 3
 Use of second line agents
 Treat for up to 2 years
Vaccination
 BCG ‘Bacille Calmette-Guerin’
-Live attenuated vaccine
-Developed from M.bovis
 Protective efficacy ~50%
 Gives 1ry immunity
 Prior Heaf/Mantoux test (ppd), if 1ry immunity -CXR
 Normally given at 13 years
 ?some areas with high immigrant population given to
infants?