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Sumatran Surprise
An Intriguing Indonesian
Infectious Diseases
Dr. M. Wansborough-Jones firm
Kathryn Brain
Norzehan Hj Md Saini
Jeremy Rampling
Nikunj Shah
MR. A
26 years old, Indonesian, male
8 years in the U.K
Speaks little English
Delivery man at a takeaway in Battersea
PC
Productive cough
Lymphadenopathy
Weight loss
Swollen left knee
HPC
1 month Hx of productive cough, grey
sputum, worse in last 2 weeks,
associated SOB
An episode of haemoptysis, last Easter,
more than a spoonful of blood mixed with
mucus
2 weeks ago - fever, shivering, night
sweat, took paracetamol, resolved
spontaneously
HPC cont.
Post-prandial nausea, vomited food eaten
2 weeks ago but has good appetite
Weight loss (how much, since when?)
1 month Hx of general malaise
Occasional 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.
SOB on exertion
Lumps 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
Swelling 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
No palpitations, central chest pain,
oedema
No neck stiffness, photophobia
No fits, numbness, pins and needles,
muscle pain
No genitourinary symptoms
No other GI symptoms
PMH
No significant illnesses
Vaccinated for BCG but no scar found
DRUG Hx
Nil
No known allergies
FAMILY Hx
Nil
SOCIAL Hx
Came to the U.K IN 1994
Went to Saudi Arabia for a month in 97’
Went back to Indonesia for 2 months in 98’
Both parents and two younger sisters in
Indonesia - fit and well
Lives in 4 bedrooms detached house in Tooting
with 3 other people, all fit and well
Works as delivery man in an Indian takeaway
Social Hx cont.
Occasional smoker and drinker
Single
Never been in any sexual relationship
Denies any i.v drug use
Physical examination
Cachectic, looking unwell
No pallor, jaundice, clubbing, cyanosis,
koilonychia
Temp. - 37.1 °C
Sat. - 98% on air
Lymph nodes enlargement submandibular and submental, several in
anterior cervical chain and a single LN in
left axilla
Physical examination cont.
CVS
Pulse - 130 bpm
BP - 106/80 mm Hg
HS - I + II + 0
Respiratory
Right lower zone - dull on percussion,
harsh bronchial breathing
Crackles on the left base
Physical examination cont.
Bowel
Soft, non-tender, normal bowel sound,
No organomegaly
CNS
Grossly intact
Physical examination cont.
Left knee - fluctuant swelling + sinus
below the knee (dry)
Differential diagnosis
TB (Post-primary > Primary)
Lymphoma
Carcinoma of the lung
Atypical pneumonia
Ix at admission 13/5
FBC (including CRP)
U&E
LFT
Blood culture
Sputum microscopy (AFB)
Swab from leg
CXR
Blood results
 Hb 11.8
 WBC 7.9
 Neut 6.7
 Platelets 240
 MCV 77* 


Na+ 133*
K+ 4.9
Urea 5.9
Creatinine 90
Glucose 5.3
CRP 144.5*
 CXR- R lobar consolidation
Bilirubin 9
ALT 42
ALP 92
Albumin 25*
Gamma GT 34
Adj Ca2+ 2.25
PO4 1.24
Admitted 13/5
Iv hydration
Erythromycin po 500g qds
Cefotaxime iv 1g bds
CXR
CXR - closeup
The following day...
Ix
X ray left knee
FNA submental +
submandibular lymph
nodes
TB blood cultures
Management
Ibuprofen
po 400mg tds
Knee
Knee - closeup
15/5
BINGO!!!
Microscopy- AFB positive
Legionella/ pneumococcal antigen not
detected
DIAGNOSIS- Tuberculosis - pneumonia
and osteomyelitis
Ziehl-Nielsen Stain
Bannister, Begg & Gillespie (2000)
Anti-TB therapy begins15/5
12 months course
Rifater 4 tablets daily
(Rifampicin; Isoniazid; Pyrazinamide)
Ethambutol 700 mg po od
Paracetamol 1g po (QDS max) as required
15/5
Contact tracing
Close family members and work
colleagues
If unwell => rigorous TB Ix
If well, CXR and tuberculin test
Adult=>CXR; children=> tuberculin
Isoniazid prophylaxis if suggestive, or if
<1 y.o.
Epidemiology
Leading infectious cause of death world
wide.
Increasing in the far east and Africa
especially in association with AIDS.
Increasing in London and the UK
40x more likely to have in lifetime if of
Asian origin.
Pathology
Infection with Mycobacterium
tuberculosis. Mainly in upper of lobe of
lungs.
Initial infection in childhood, primary
infection. This heals and becomes
calcified.
Reactivation when host becomes
immunosuppressed.
Manifestations
Miliary TB acute diffuse dissemination of
tubercle bacilli via the blood stream.
Presents very non specifically, weight loss
ill health fever.
Mantoux test is normally +ve though can
be -ve in severe disease.
Adult post primary
pulmonary TB
General onset of non specific symptoms.
Main features fever, cough, weight loss.
Sputum mucoid, purulent or blood
stained.
Pleural effusion or pneumonia.
Finger clubbing is present with advanced
disease.
Investigations
Chest X-Ray patchy nodular shadows in upper
zone.
Staining Ziehl-Nielson culture takes 4-8 weeks.
Bronchoscopy if no sputum.
Biopsy of lymph nodes.
Direct testing for rapid result using PCR.
Management
 Sensitive organisms use.
 Rifampicin, S/E inducer of liver enzymes, should be
stopped if bilirubin is elevated.
 Isoniazid, can cause a polyneuropathy at high doses.
Can cause nausea and vomiting.
 Pyrazinamide reduces renal excretion of urate and an
precipitate hyperuraemic gout. Can cause hepatotoxicity.
 If 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
TB is a notifiable disease.
All close contacts are screened with a
mantoux test and a chest X-Ray.
Prevention is with immunisation with BCG
vaccination administered at 12-13 in the
UK
Administered at birth to groups at high
risk