Clinical Diagnosis Nov2009 [Autosaved]

7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]

http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 1/51

Clinical Presentationand Diagnosis of

TuberculosisMakiyatul M

BBKPM Surakarta

International Standards 1-5



ISTC TB Training Modules 2009

Clinical Presentation and Diagnosis of TB

Objectives: At the end of this presentation,participants will be able to

Describe the signs!sy"pto"s and risk factors thatshould raise suspicion for the diagnosis of TB

#nderstand the i"portance of sputu" s"ear"icroscopy, as well as the need to obtainspeci"ens for "icrobiologic e$a"ination fro"e$trapul"onary sites

%ecogni&e that C'% alone is not sufficient for thediagnosis of TB

(ist criteria used for the diagnosis of s"ear)negati*e TB





International Standards 1 2 ! " and 5

Overvie#: +eneral considerations

Signs and sy"pto"s

%ole of AB s"ear %adiographic

presentation

AB s"ear)negati*ediagnosis




Standards for Diagnosis




%apid, accuratediagnosis is essential

for indi*idual and

public health

Despite technical

ad*ances, clinical

acu"en with a high

inde$ of suspicion

re"ains *ital to the

diagnosis of TB T$in% TB

unda"ental Principles




-Classic. TB Clinical Presentation

/nsidious onset and chronic course Chest sy"pto"s

• Cough 0usually producti*e1

•

2e"optysis• Chest pain 0usually pleuritic1

3onspecific constitutional sy"pto"s

0"ore co""on in children and 2/41

5$trapul"onary sy"pto"s 0if in*ol*ed1


http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 7/51 ISTC TB Training Modules 2009

3onspecific Syste"ic Sy"pto"s

e*er in 67)89: of cases Chills!night sweats

atigue!"alaise Anore$ia!weight loss

However , ;9)<9: of TB cases ha*e no

sy"pto"s at the ti"e of diagnosis



Diagnosis of TB in 2/4

Cannot rel& on 't&(ical) indicators o* TB

e*er and weight loss are i"portant

sy"pto"s

Cough is less co""on

Chest radiographic pattern "ore *ariable

More e$trapul"onary and disse"inated TB Differential diagnosis is broader



Standard ; Prolonged Cough

All persons withotherwise

une$plained

producti*e coughlasting two)three

weeks or "ore

should bee*aluated for

tuberculosis



Prolonged Cough

T$in% TB: Prolonged Cough 0<)= weeks1 Cough "ay not be specific for TB,

howe*er, long duration raises likelihood ofTB diagnosis

Criterion for suspecting TB in "ostnational and international guidelines

Percentage of AB s"ear)positi*e sputu"increases with increasing duration ofcough

>ill not identify all TB cases? use bestclinical @udg"ent



Clinical Presentation %isk actors

+is% *or +ecent In*ection Contact with acti*e TB case

ccupational risk eg healthcare worker

Crowded conditions eg @ails, institutionalresidences

%ecent stay in a healthcare facility



Clinical Presentation %isk actors

+is% o* ,rogression to ctive TB 2/4 infection

Abnor"al C'% suggesti*e of prior TB 0withinadeuate treat"ent1

Children 0less than 7 years of age1

#nderlying "edical conditions

• /""unosuppressi*e therapy

• Malnutrition

• Diabetes, renal failure, and other conditions

• Tobacco use, in@ection drug use 0E1



Clinical Presentation Physical 5$a"ination

May be nor"al in "ild"oderate disease Chest rales, rhonchi? absent breath sounds

and dullness to percussion if pleural fluid ispresent

5$trapul"onary 0site specific1 adenopathy,skin lesions, bone tenderness, neck stiffness,etc

The physical e$a"ination is nonspecific, butit is helpful to identify e$trapul"onary sites of

in*ol*e"ent



Standard < Sputu" Microscopy

All patients 0adults,adolescents, and

children who are

capable of producing

sputu"1 suspectedof ha*ing pul"onary

TB should ha*e at

least two sputu"

speci"ens obtained

for "icroscopic

e$a"ination in a uality)assured laboratory

>hen possible, at least one early "ornings eci"en should be obtained



Sputu" Microscopy

To pro*e a diagnosis of TB, e*ery effort "ustbe "ade to identify the causati*e agent

The .B s/ear in high)pre*alence areas is

• 2ighly specific for TB• Most rapid "ethod for deter"ining TB diagnosis

• /dentifies those at greatest risk of dying fro" TB

• /dentifies those "ost likely to trans"it disease



Mase S%, Int J tuberc Lung Dis <99F?;;071 G87)H7

A*erage yield of single early "orning speci"en 86G:

A*erage yield of single spot speci"en F=H:

S(eci/enu/ber

Incre/ental ield o*s/ear s(eci/ens

0of all s"ear positi*e1

Incre/ental Sensitivit&o* s/ear s(eci/ens

0co"pared with culture1

; 878: 7=8:

< ;;H: ;;;:

= <G: =;:

Total 100 340

Perfor"ance of Sputu" Microscopy



5"-&ear-old /an #it$

t$ree /ont$s o* *ocal

lo#-bac% (ain

Can this be TBE



5"-&ear-old /an #it$

t$ree /ont$s o* *ocal

lo#-bac% (ain

Can this be TBE 5$trapul"onary

'PottIs disease.

Signs and sy"pto"s of e$trapul"onary TB are sitespecific

Sa"pling of e$trapul"onary sites for s"ear, culture, andhistopathology "ay confir" diagnosis



Standard = 5$trapul"onary Speci"ens

or all patients0adults, adolescents,

and children1

suspected of ha*inge$trapul"onary TB,

appropriate

speci"ens fro" the suspected sites ofin*ol*e"ent should be obtained for

"icroscopy, culture, and

histopathological e$a"ination



Pul"onary, F;:

5$trapul"onary, <9:

Both, H:

Pleural, ;8:

(y"phatic, G<:

Bone!@oint, ;;: +enitourinary, 7:

Meningeal, 7:

ther, ;=:

TB Cases b& .or/ o* 6isease

7nited States C6C 2004 Peritoneal, 6:

5$a"ple of 5$trapul"onary Sites

Incidence8site /a& var& TB can involve an& organ

More co//on in I8TB



5$trapul"onary Tuberculosis



%adiographicPresentation

of TB



Standard G 5*aluation of Abnor"al C'%

All persons withchest radiographic

findings suggesti*e

of tuberculosisshould ha*e sputu"

speci"ens

sub"itted for"icrobiological

e$a"ination

ISTC Training Modules 2004



Can this be TBE




6istribution Apical ! posterior

seg"ents of upper lobes

Superior seg"ents oflower lobes

/solated anterior seg"entin*ol*e"ent is unusual

Can this be TBE

T&(ical ,attern:+eactivation,ost-(ri/ar& TB




%eacti*ation!Post)pri"ary TB

,atterns o* disease Air)space consolidation

Ca*itation, ca*itary

nodule Miliary

ibro)nodular densities

3odule 0Tuberculo"a1 Pleural effusions




Can this be TBE




Can this be TBE

Distribution Any lobe in*ol*ed 0slight lowerlobe predo"inance1

Air)space consolidation

Ca*itation is unco""on0J ;9:1

Adenopathy is co""on0esp in children and 2/41

Miliary pattern

t&(ical (attern:,ri/ar& TB




Can this be TBE




Can this be TBE Miliary TB




Can this be TBE




Can this be TBE

.indings suggestive o*

(rior TB

Ca granulo"a +hon

lesionCa granulo"a and hilar

node calcification %ankeco"ple$

Apical pleuralthickening

ibrosis and*olu"e loss




C'% /ssues

%eliance on chest radiograph aloneresults in both o*er)diagnosis and "isseddiagnosis of TB and other diseases

%adiography needs to be held to highstandards of technical uality andinterpretation

%esults of poor i"aging uality "ay be

har"ful to patient care




5*aluation of Abnor"al C'%

Stud& *ro/ India:2229 out(atients evaluated b& C;+8culture

f <<F cases dee"ed TB by C'% alone•

=6: had negati*e sputu" cultures for TB f ;FF culture)positi*e cases of TB

• ;8: would ha*e been "issed based on C'%alone

C'% alone is not enough

3agpaul D%, Proceedings of the Hth 5astern %egion Tuberculosis Conference

and <Hth 3ational Conference on Tuberculosis and Chest Diseases ;HFG Delhi,

as cited in Toman’s tuberculosis. Case detection, treatment and monitoring,

2 nd Edition >orld 2ealth rgani&ation, <99G




The diagnosis of s(utu/ s/ear-negative pul"onarytuberculosis should be based on the following criteria

At least two negati*e sputu" s"ears 0including at

least one early "orning speci"en1

Chest radiography findings consistent with

tuberculosis

(ack of response to a trial of broad)spectru"

anti"icrobial agents03ote Because the fluorouinolones are acti*e against M.

tuberculosis co"ple$, and thus "ay cause transient i"pro*e"ent in

persons with tuberculosis, they should be a*oided1

Standard 7 S"ear)negati*e Diagnosis

0; of <1




0Continued1 or such patients, sputu" cultures should

be obtained

/n persons who are seriously ill or ha*eknown or suspected 2/4 infection, thediagnostic e*aluation should be e$peditedand if clinical e*idence strongly suggests

tuberculosis, a course of antituberculosistreat"ent should be initiated

Standard 7 S"ear)negati*e Diagnosis

ISTC Training Modules 2004

0< of <1




Clinical assess/ent I test;

s(utu/ s/ear /icrosco(&

t least 2 s(utu/ s(eci/ens .B negative

I < and8or severe illness2

I- /ild8/oderate illness2

; %eco""ended in countries or areas with adult 2/4 pre*alence L;: orpre*alence a"ong TB cases L7:

< Se*ere illness respiratory rate L=9 breaths!"in, te"perature L=HNC, pulseL;<9 beats!"in, unable to walk unaided, sy"pto"s!signs progressing rapidly

TB Diagnostic Algorith"S,7T7M SM=+-=>TI= TB




I < and8or severe illness

S,7T7M SM=+-=>TI= TB

Clinical!radiographic findingsOT suggestive of TB

3egati*e culture

Consider ot$er diagnoses

ot TB

• Clinical!radiographic findingssuggestive of TB

• Positi*e or negati*e culture

Treat 0e"piric TB treat"ent before confir"eddiagnosis if se*ere illness1

• I staging ? =valutate *or +s ? C,T (ro($&la@is

%epeat clinical assess"ent Chest radiograph Sputu" culture 0or other test1

Parenteral broad)spectru"anti"icrobials 0e$cludingfluorouinolones1

TB Diagnostic Algorith"

TB




IA /ild8/oderate illness

S,7T7M SM=+-=>TI= TB

Broad-s(ectru/ anti/icrobials0e$cluding anti)TB drugs and fluorouinolones1

Consider ot$er diagnosis

%epeat clinical assess"ent Chest radiograph Sputu" culture 0or other test1

Treat

TB Diagnostic Algorith"

O IM,+O=M=T

ot TB ot TBTB

Clinical!radiographic findings OT suggestive of TB

3egati*e culture

Clinical!radiographicfindings suggestive of TB

Positi*e culture

IM,+O=M=T





dditional (oints: Sy"pto"s!se*erity none to o*erwhel"ing

Te"po of illness ranges fro" indolent to fast

TB can in*ol*e any organ or tissue

Signs!sy"pto"s "ay be both local andsyste"ic

Consider 2/4 testing in the diagnostice*aluation

TB is capable of presenting in "any ways





Su//ar&:

T$in% TB A prolonged duration of cough should raise TB

suspicion and trigger a diagnostic e*aluation

TB risk factors and e$posure increase le*el ofsuspicion

AB s"ear in high)pre*alence areas is highlyspecific and "ost rapid tool for diagnosing TB

%adiographic patterns "ay help in TB diagnosisif suspicion high and AB s"ear is negati*e, buta radiograph alone is not enough to "akediagnosis



ISTC TB Training Modules 2009O Abbre*iated *ersions

Su""ary /STC Standards Co*eredO

Standard 1: #ne$plained producti*e cough lasting<)= weeks or "ore should be e*aluated for

tuberculosis

Standard 2: All TB suspects should ha*e at least

< sputu" speci"ens obtained for "icroscopic

e$a"ination 0at least one early "orning

speci"en if possible1 in a uality)assured

laboratoryStandard !: Speci"ens fro" suspected

e$trapul"onary TB sites should be obtained for

"icroscopy, culture and histopathological e$a"




Su""ary /STC Standards Co*eredO

O Abbre*iated *ersions

Standard ": All persons with chest radiographicfindings suggesti*e of TB should ha*e sputu"

speci"ens sub"itted for "icrobiological

e$a"ination

Standard 5: The diagnosis of s"ear)negati*e

pul"onary TB should be based on the following

at least two negati*e sputu" s"ears 0including at

least one early "orning speci"en1? C'% findingconsistent with TB? lack of response to broad)

spectru" antibiotics 0a*oid fluorouinolones1, and

culture data 5"piric treat"ent if se*ere illness




lternate Slides

Purpose of /STC




Purpose of /STC

/STC K P i t




/STC Key Points

<; Standards 0re*ised!renu"bered in <99H1 Differ fro" e$isting guidelines standards

present what should be done, whereas,

guidelines describe how the action is to be

acco"plished

5*idence)based, li*ing docu"ent

De*eloped in tande" with atients’ C!arter

"or Tuberculosis Care

Handboo# "or using t!e International

$tandards "or Tuberculosis Care

/STC K P i t




udience: all health care practitioners,public and pri*ate

Sco(e: diagnosis, treat"ent, and public

health responsibilities? intended toco"ple"ent local and national guidelines

+ationale: sound tuberculosis control

reuires the effecti*e engage"ent of all

pro*iders in pro*iding high uality care and

in collaborating with TB control progra"s

/STC Key Points




uestions

Cli i l P t ti d Di i f TB





1 A =< year)old "an co"plains of cough and"alaise for the past three weeks 2is wife is

currently being treated for acti*e tuberculosis f

the following choices, your *irst ste( would be

A Begin an e"piric trial of treat"ent with afluorouinolone antibiotic for a possible co""unity)

acuired pneu"onia

B btain a chest fil" to confir" your suspicion for TB

which will "ake sputu" testing unnecessaryC btain two sputu" speci"ens for AB "icroscopy

0including at least one early "orning speci"en1

D Both answers A and C






2 /n high pre*alence areas, the AB sputu""icroscopy s"ear

A /s highly specific for TB

B /dentifies those at greatest risk of dying fro" TB

C /dentifies those "ost likely to trans"it disease

D All of the abo*e





! A 7G year)old wo"an co"plains of cough, fe*er,and une$pected weight loss o*er the past

"onth She ad"its s"oking ;9 cigarettes per

day for o*er <9 years Two sputu" s"ears were

negati*e for AB ou would consider each ofthe following e@ce(t

A An e"piric trial of antibiotics 0non)fluorouinolone1

B btaining a chest fil" for further e*aluation

C A trial of bronchodilator "edication alone and

follow)up in = "onths

D Sending sputu" speci"ens for AB culture

Clinical Diagnosis Nov2009 [Autosaved]

Documents

Transcript of Clinical Diagnosis Nov2009 [Autosaved]