Extra Pulmonary Tuberculosis Extrapulmonary TB Robert N. Longfield, MD,

TB Intensive
Tyler, Texas
June 2-4,
2 4 2010
Extrapulmonary TB
Robert N. Longfield, MD,
FACP
June 2, 2010
Extra Pulmonary
Tuberculosis
TB Intensive Course
J
June
22, 2010
Robert N. Longfield, MD, FACP
June 2010
Spectrum of EPTB:
• CNS
• Pleural
– Meningitis
– Tuberculoma
• Skeletal
–
–
–
–
Spinal
Joint
Osteomyelitis
Myositis
• Lymphadenitis
– Effusion
– Empyema
•
•
•
•
•
Genitourinary
Gastrointestinal
Pericardial
Cutaneous
Other
June 2010
Schematic representation of central role of TNF-Alpha in cellular
immune response to M.Tb infection
The Lancet Infectious Diseases 2003;3(3):148-155
June 2010
Model of Granuloma formation. In presence of TNF-Alpha.
The Lancet Infectious Diseases 2003;3(3):148-155
June 2010
Model of Granuloma formation. In absence of TNF-Alpha.
The Lancet Infectious Diseases 2003;3(3):148-155
June 2010
Distribution of EPTB by site, USA, 2005
PTB:
80%
EPTB + PTB:
5%
EPTB Alone:
15%
Co-infection
Co
infection
with HIV has
been seen in
20% of patients
with EPTB in
the US.
June 2010
CNS Tuberculosis:
• CNS TB includes:
– meningitis,
– and tuberculoma.
• CNS infection reported frequently from high
incidence countries.
June 2010
INTRODUCTION
• Approximately 300 to 400 cases of TB
meningitis occur each year in the US.
– 1% of all TB disease.
• Despite effective treatment regimens, case
g - 15% to 40%.
fatalityy remains high
June 2010
INTRODUCTION
• Early recognition of TB meningitis is critical.
critical
• Empiric Rx should be started with:
– a meningitis syndrome and
– low CSF glucose, elevated protein, and lymphocytic
pleocytosis and
– evidence
id
off TB elsewhere
l
h in
i the
th body
b d or
– if prompt evaluation fails to establish another
diagnosis.
June 2010
Pathogenesis:
• Post
Post-primary
primary infection:
– infants and young children
– advanced HIV infection.
• Reactivation bacillemia:
–
–
–
–
–
–
immune deficiency of aging,
TNF inhibitor Rx,
alcoholism,
Malnutrition
Malnutrition,
Diabetes,
malignancy.
June 2010
Pathogenesis:
• Tuberculin spillage into the subarachnoid space
produces:
–
–
–
–
–
intense inflammation,
most marked at the base of the brain.
proliferative arachnoiditis,
p
vasculitis, and
communicating hydrocephalus.
June 2010
Basilar Meningitis:
Thick grey shaggy
exudate encasing
cranial nerves &
blood vessels:
Necrotizing granulomatous
inflammation of arachnoid and
meningeal vessels.
June 2010
CLINICAL FEATURES:
1 Prodromal phase,
1.
phase 2 to 3 weeks,
weeks with
a)
b)
c)
d))
insidious malaise, lassitude,
headache,
low-grade fever, and
personalityy changes.
p
g
2. Meningitic phase
3. Paralytic phase
June 2010
CLINICAL FEATURES:
2 Meningitic phase with
2.
a)
b)
c)
d))
e)
meningismus,
protracted headache,
vomiting,
confusion,, and
varying cranial nerve and long-tract signs.
June 2010
CLINICAL FEATURES:
3 Paralytic phase is the stage during which the
3.
pace of illness may accelerate rapidly;
confusion gives way to
a) stupor and coma,
b) seizures, and
c) hemiparesis.
June 2010
Atypical presentations:
• Acute
Acute, rapidly progressive,
progressive syndrome suggesting
acute bacterial meningitis.
• Slowly progressive dementia over months or
even years characterized by
–
–
–
–
personality change,
social
i l withdrawal,
i hd
l
loss of libido, and
memory deficits.
June 2010
Atypical presentations:
• Encephalitis picture characterized by
– stupor,
– coma, and
– convulsions without overt neck stiffness.
June 2010
Clinical stages:
• Stage I patients are lucid with no focal
neurologic signs or evidence of hydrocephalus.
• Stage II patients are confused or have focal
signs, such as cranial nerve palsies or
hemiparesis.
p
• Stage III represents advanced illness with
delirium, stupor, coma, or dense hemiplegia.
June 2010
HIV infection:
• In one study
study, cerebral tuberculomas were seen
to be more common in the HIV-infected group
(60% versus 14%).
• Otherwise, HIV co-infection did not alter the
clinical manifestations,, CSF findings,
g , or
response to therapy.
June 2010
DIAGNOSIS:
• Serial examination of the CSF by AFB stain and
culture is the best diagnostic approach.
• Smears and cultures may yield positive results
days to weeks after therapy has been initiated.
June 2010
DIAGNOSIS CSF Examination :
•
•
•
•
Diagnosis (Dx) can be difficult
difficult.
Proper CSF specimens are critical for early Dx.
Maintain a high degree of suspicion.
Initiate empiric therapy promptly.
June 2010
DIAGNOSIS CSF Examination :
• Typical CSF formula shows
– elevated protein
– lowered glucose and
– a mononuclear pleocytosis.
• CSF protein ranges from 100 to 500 mg/dL.
• Hydrocephalus with subarachnoid block may have
protein levels of 2 to 6 g/dL, xanthochromia and a poor
prognosis.
June 2010
DIAGNOSIS CSF Examination :
• Early in the course of illness
illness, the cellular
reaction may be atypical with
– only a few cells or
– with a PMN predominance.
• Usually changes rapidly to a lymphocytic
predominance.
June 2010
DIAGNOSIS AFB smears:
• Repeated,
d careful
f l CSF examination
i i andd culture
l
for M. tuberculosis cannot be overemphasized.
• In one series, only 37% of cases were diagnosed
on the basis of an initial positive AFB smear.
• The
Th yield
i ld increased
i
d to
t 87% when,
h ddespite
it
therapy, up to 4 serial specimens were examined.
June 2010
DIAGNOSIS AFB smears:
• A minimum of 3 lumbar punctures should be
performed at daily intervals.
• Empiric therapy should not be delayed.
June 2010
DIAGNOSIS AFB smears:
• The sensitivity of the AFB smear may be
enhanced by:
– Using the last fluid removed at lumbar puncture.
– Removing a large volume (10 to 15 mL) of CSF.
– Examining
g a smear of the clot or centrifuged
g
sediment (cyto-centrifuge).
June 2010
DIAGNOSIS AFB smears:
• 200 to 500 HPF should be examined
methodically (approximately 30 minutes),
preferably by more than one observer.
June 2010
NOT!
June 2010
Molecular Diagnosis of TB Meningitis
Thwaites, J Clin Micro, 2004; 42: 996
73 patients with TM vs. 79 without TM
AFB (Z/N) Staining C/W Gen-Probe
Amplified Mycobacterium Direct Test (MTD)
Z/N
MTD
C bi d
Combined
Sensitivity
Specificity
52% (2% after Rx)
100%
38% (28% after Rx)
99%
68% (83% with
ith repeated
t d samples)
l )
Before Treatment: Careful bacteriology is as good as, or better
than, the commercial NAA assays.
June 2010
PCR
• Nevertheless
Nevertheless, submit CSF specimens for PCR
testing whenever clinical suspicion is high and
initial AFB stains are negative!
• A negative test result does not exclude the
diagnosis
g
or remove the need for continued
empiric treatment!
June 2010
Neuroradiology
• Contrast CT defines the presence and extent of
– basilar meningitis,
– cerebral edema and infarction, and
– hydrocephalus.
June 2010
Multiple
p
tuberculomas
along enhanced
dural
reflections:
June 2010
Basilar Enhancement &
Hydrocephalus:
June 2010
Tuberculoma &
Hydrocephalus:
June 2010
Neuroradiology
• Compatible clinical features,
features CT evidence of
basilar meningeal enhancement AND any degree
of hydrocephalus is strongly suggestive of TB
meningitis.
• Hydrocephalus
y
p
combined with marked basilar
enhancement is indicative of advanced disease
and carries a poor prognosis.
June 2010
Neuroradiology
• Marked basilar enhancement correlates well with
vasculitis and, therefore, with a risk for basal
ganglia infarction.
• MRI is superior to CT in defining lesions of the
basal gganglia,
g , midbrain,, and brain stem and for
evaluating all forms of suspected spinal TB.
June 2010
Other Conditions Mimicking TB
Meningitis Radiographically:
•
•
•
•
•
•
Cryptococcal Meningitis
Coccidioides Meningitis
Viral Encephalitis
Sarcoidosis
Meningeal Metastases
Lymphoma
June 2010
THERAPY Recommended regimens:
• Drug resistance should be considered in
individuals
– from areas of the world where TB is prevalent,
– in those with a history of prior TB treatment, and
– in those with exposure
p
to drug-resistant
g
source.
June 2010
Duration of therapy
• There are no randomized trials to establish the
optimal duration of therapy.
• It is recommended that therapy be administered
for 12 months in the usual case of drug-sensitive
infection.
June 2010
Duration of therapy
• If PZA is omitted or cannot be tolerated,
tolerated
treatment should be extended to 18 months.
• There are no guidelines for the duration of
therapy in patients with MDR-TB.
• The duration of therapy may be extended to 18
to 24 months, based on severity of illness,
clinical response, and the pt’s immune status.
June 2010
CSF Penetration of TB Drugs
GOOD
FAIR
POOR
Isoniazid *
Rifampin *
Streptomycin *
Pyrizimamide
Ethambutol
Capreomycin *
Ethionamide
Quinolones *
Amikacin *
y
Cycloserine
Linezolid *
* Can Be Given IV
June 2010
Adjunctive Corticosteroids:
• There is substantial data that adjunctive
corticosteroid therapy is beneficial.
• A randomized, double-blind trial in Vietnam
compared 6 to 8 weeks of dexamethasone with
pplacebo in 545 patients
p
over 14 years
y
of age.
g
June 2010
Adjunctive Corticosteroids:
Mortality
(%)
Stage I: Stage II: Stage III:
Total:
Steroid
Group:
17
31
55
32
NonSteroid:
20
40
60
41
NS
June 2010
Adjunctive Corticosteroids:
• There was no reduction in residual neurologic
deficits and disability among surviving patients
at nine months.
• I.e., Morbidity not improved by steroids.
June 2010
Adjunctive Corticosteroids:
• The survival benefit associated with steroid
therapy may have been in part due to a reduction
in severe adverse events (9.5 versus 16.6%),
particularly hepatitis that necessitated changes in
TB drug regimens.
• No mortality benefit from dexamethasone was
seen in 98 HIV-infected patients included in
the study.
June 2010
Adjunctive Corticosteroids:
• Adjunctive corticosteroid therapy is
recommended for all children and adults treated
for TB meningitis.
June 2010
Adjunctive Corticosteroids:
• Specific clinical indications include:
– Acute "encephalitis" with high CSF pressure or
cerebral edema.
– Worsening signs after start of therapy.
– Spinal block or incipient block (CSF protein >500
mg/dL and rising).
– CT evidence of marked basilar enhancement.
– Patients with symptomatic tuberculoma(s).
June 2010
Adjunctive Corticosteroids:
• Be aware that concurrent treatment with
Rifampin may reduce effective levels of
corticosteroids by induction of the hepatic
cytochrome P-450 system.
June 2010
Recommended Corticosteroid
regimens:
• Children — Prednisone 2 to 4 mg/kg per day
tapered over 4wks.
• Adults either:
– Prednisone 60 mg per day tapered gradually over six
weeks, or
– Dexamethasone
De amethasone IV ffor th
the fi
firstt 3 weeks
k (i
(initially
iti ll
0.4 mg/kg per day, tapering to 0.1 mg/kg per day)
followed by oral 4 mg per day, tapered over 3 - 4
weeks.
June 2010
Surgery
• Hydrocephalus may require urgent shunting.
shunting
• Serial LP and steroid therapy may suffice for
Stage I pts awaiting response to antibiotics.
• Shunting should not be delayed in patients with
stupor coma or progressive neurologic signs.
stupor,
signs
June 2010
Skeletal Tuberculosis:
•
•
•
•
Vertebral Osteomyelitis – Pott
Pott’ss Disease
Arthritis
Myositis
Osteomyelitis
June 2010
History:
• 39 yy.o.
o undocumented Hispanic male presented
with F, wt. loss & upper back pain which was
worse with cough.
• No prior TB Hx or treatment.
• Pt found to have far advanced TB on CXR
CXR.
• Sputum AFB heavily positive, PCR – MTb.
June 2010
History 2:
• CT spine and MRI spine revealed discitis
discitis,
vertebral osteo. and epidural abscess at T2 – 4.
• Sterile pyuria, anemia and hyponatremia also
noted.
• Patient treated with RIPE
RIPE.
June 2010
Exam:
• T 102.0
102 0oF,
F HR 88
88, BP 84/42
84/42, 55’3”
3 , 111 lbs
lbs.
• Lungs – occ. faint upper lobe crackles.
• Neurologic:
–
–
–
–
Strength 4/5 BLE, weak ankle dorsiflexors.
Sensory numbness below T8
T8.
DTR’s 3/4.
Plantar flexor reflex on Left, equivocal on Right.
BUL, F
Far Advanced, Cavvitary TB.
June 2010
June 2010
June 2010
June 2010
June 2010
Hospital Course:
• Pt continued with daily fevers
fevers.
• He had decreased LE strength and was
transferred for neurosurgical assessment.
• Neuro exam revealed anti-gravity strength Rt >
Lt weak right ankle dorsiflexor,
Lt,
dorsiflexor numbness
below nipples, and intact toe position sense.
June 2010
Laminectomy T2 – T5:
•
•
•
•
Posterior laminectomy.
laminectomy
No discrete epidural mass encountered.
The surgeon decompressed the thecal sac.
Corticosteroids were given during the early post
operative phase then later tapered & stopped.
stopped
June 2010
Further Management:
• Pt returned to TCID on P
P.O.D.
O D 10
10, afebrile with
improved cough.
• He was able to do transfers with improved L.E.
strength.
• Pt completed a 1 year course with prolonged
continuation phase (INH & RIF).
• He was able to walk at discharge.
June 2010
Potts Disease:
June 2010
Potts T10 & T11:
Potts Paravertebral Abscess:
June 2010
24 yo Nigerian Female
with 1 yr history of
b k pain:
back
i
June 2010
Psoas Abscess:
June 2010
Needle Biopsy
of Vertebral
Osteomyelitis
under CT
guidance:
June 2010
TB Osteomyelitis Distal Femur:
June 2010
June 2010
TB Arthritis of the wrist:
June 2010
TREATMENT
• Duration of therapy —
• Traditionally, 12 to 18 months of therapy has
been advocated.
• At issue: drug penetration into necrotic bone.
• Several studies recommended shorter treatment.
treatment
June 2010
TREATMENT
• Many specialists,
specialists continue to advise at least nine
months Rx for skeletal TB.
• Longer treatment regimens (at least 12 months)
are recommended for patients
– with advanced or extensive disease,,
– concern for vital adjacent structures (spinal cord) or
– if the response to therapy is uncertain.
June 2010
Role of surgery
• When available
available, surgery is useful for:
– abscess drainage,
– debridement of infected material,
– decompression and stabilization of vital structures
such as the spinal cord, and
– reconstruction or replacement of joints (usually after
extensive antibiotic treatment).
June 2010
Lymphadenitis:
• Cervical – Scrofula
• Peripheral
• Visceral
June 2010
June 2010
June 2010
Peripheral Tuberculous Lymphadenitis
Polesky, Medicine, 2005; 84:350
106 Patients with TB lymphadenitis
(Santa Clara Co., CA, 1994-1999)
Female
Mean Age
Foreign Born
Years in US
HIV Seropositive
66%
34 years
92% (Vietnam 60%)
5.2 (mean)
5%
June 2010
Necrotic Lymph Node by CT:
June 2010
Immune Reconstitution TB LAD:
 43 y.o. HIV+ (CD4=46)
 Pulmonary TB
 Started on RIPE
 Started on HAART
– AZT/3TC/efavirenz
 17 Days later….
June 2010
TB LAD:
June 2010
Role of Surgery:
• Diagnostic aspiration or biopsy enlarged LN.
LN
– Exclude co-existing malignancy.
• Drain fluctuant lymph nodes.
• Resect chronic draining fistulae.
June 2010
Pleural Tuberculosis:
•
•
•
•
•
Exudate
Empyema
Empyema necessitans
Broncho-pleural Fistula
P
Pneumothorax
h
June 2010
PLEURAL TUBERCULOSIS
• TB is the most common cause of pleural effusion
in most areas of the world.
• In the US, 1/30 patients with PTB have effusion.
• True incidence unknown.
• Higher incidence in HIV (+) patients
patients.
• Frequent manifestation of primary TB.
June 2010
June 2010
June 2010
Therapy of Pleural TB:
• Standard RIPE therapy advised for PTB(S).
• AVOID CHEST TUBE – for
f simple
i l exudates.
d t
• NO DECORTICATION FOR 3-4 MONTHS
– Pleural thickening often decreases with time.
– Entrapped lung occasionally requires surgery.
June 2010
Tb Empyema:
June 2010
Empyema Necessitans:
June 2010
June 2010
June 2010
Therapy of Pleural TB:
• BP FISTULA (air-fluid level in pleural space):
– Does not heal spontaneously.
– 90-120 days therapy before decortication.
June 2010
Role of Surgery:
• Tube thoracostomy management of
pneumothorax or empyema.
• Decortication of thickened pleura.
• Release of entrapped lung.
• Closure of BP fistulae with persistent air leak.
leak
• Resection of necrotic pulmonary tissue.
• Muscle flap placement to fill voids.
June 2010
Pericardial Tuberculosis:
• Effusive
• Constrictive
• Calcific
June 2010
Effusive:
June 2010
Pericardial Calcification:
June 2010
Chronic Pericarditis:
Constrictive Pericarditis:
Fibrinous Pericarditis:
June 2010
June 2010
TB Pericarditis:
• Large pericardial effusion
and inversion of the right
atrium, caused by elevated
pericardial pressure, in late
diastole and early systole.
• A parasternal short-axis view
shows that the right
ventricular
t i l outflow
tfl tract
t t is
i
compressed in diastole
because of the elevated
pericardial pressure.
June 2010
Nardell E. N Engl J Med 2004; 351:1804-1805
NORMAL HEMODYNAMICS:
TAMPONADE:
June 2010
Role of corticosteroids
• In a series reported in 1948,
1948 constrictive pericarditis
occurred in 16 of 18 untreated patients.
• Constriction now occurs in only 10 to 20% of treated
cases.
• A trial from South Africa found that corticosteroids
gi en for the first 11 weeks
given
eeks of Tb therap
therapy red
reduced
ced
mortality and the need for subsequent
pericardiocentesis.
June 2010
Role of corticosteroids
• The following benefits were noted in the
prednisolone group:
–
–
–
–
More rapid reduction in pulse rate and JVP
Improved functional status
Lower mortalityy duringg follow-up
p (4%
(
versus 11%))
Lower need for pericardiectomy (21% versus 30%)
June 2010
Role of corticosteroids
• Mortality with effusion drainage,
drainage TB therapy
and prednisolone was 3%.
• Mortality with drainage and TB therapy was
14%.
June 2010
Role of corticosteroids
• The ATS,
ATS CDC,
CDC and IDSA joint guidelines
recommend corticosteroids as an adjunct
during the first 11 weeks of therapy for TB
pericarditis.
June 2010
Role of corticosteroids
• The recommended regimens are as follows:
– For adults, prednisone 60 mg/day for 4 weeks,
• 30 mg/day for 4 weeks,
• 15 mg/day for 2 weeks, then
• 5 mg/day for week 11.
– For children, prednisone 1 mg/kg daily as the initial
dose for 4 weeks, with a decreasing dose over time as
described for adults.
June 2010
Surgical Pericardiectomy:
• Reserved for recurrent effusions or elevated
CVP after 4 to 6 weeks of combination therapy.
• “Early” surgery - more easily accomplished with
lower mortality.
• The procedure less beneficial with end
end-stage
stage
constriction.
June 2010
Pericardiectomy
Preferred technique
via a left anterior
thoracotomy
thoracotomy.
Pericardium is
removed from the
level of the left
pulmonary veins to
the right side of the
mediastinum.
The left phrenic
nerve is preserved.
June 2010
Genitourinary Tuberculosis:
• Renal
• Ureters & Bladder
• Genital
June 2010
June 2010
June 2010
Ureteral
U
t l TB
with
stenosis.
June 2010
Blunting of the calyces
(caliectasis) and two long
ureteral strictures (arrows)
are seen.
seen Although the
caliceal changes can be seen
in other disorders (such as
reflux nephropathy), the
concurrent ureteral
abnormalities
b
li i are virtually
i
ll
diagnostic of tuberculosis.
June 2010
GU & Male Genital TB
June 2010
TB Prostate:
A 46-year-old man presented with
features of prostatism, lower urinary
tract symptoms, and painless
intermittent hematuria. TRUS showed
a markedly enlarged prostate
containing a large hypoechoic mass
protruding from the base and
d f
deforming
i the
h capsule.
l Urine
U i culture
l
was positive for Mycobacterium
tuberculosis. The patient had no
evidence of pulmonary TB.
June 2010
TB Testis:
June 2010
Laparoscopic views in genitourinary tuberculosis. (a) Free and loculated
ascites and fine fibrous adhesions.
June 2010
Laparoscopic views in genitourinary tuberculosis.. (b) Miliary
nodular exudate in the anterior wall.
June 2010
Diagnosis of Renal Tb:
• Supported by the presence of AFB in the urine.
urine
• Dysuria, sterile pyuria, hematuria, and characteristic
imaging findings support the diagnosis.
• Urine TB culture is the gold standard
– Three to six first morning midstream specimens.
– Bacilli are shed into the urine intermittentlyy
– Only 30% to 40% of single specimens are positive.
June 2010
Role of Surgery:
• Relief of urinary obstruction.
obstruction
• Urinary diversion.
– Temporary.
– Permanent.
• Nephrectomy on rare occasions.
occasions
• Drainage of prostatic abscesses.
June 2010
Gastrointestinal Tuberculosis:
• Peritoneal
• Hollow Viscus
• Hepatosplenic
June 2010
June 2010
Tuberculosis Peritonitis:
• Sx: Acute or chronic pain
pain, swelling,
swelling constitutional
symptoms, intestinal obstruction.
• Doughy abdomen – rare.
• Ascitic fluid: Exudate, 150-400 WBC, lymphocytic
(can be neutrophilic).
• (+)
( ) MTB culture
l
<20%.
• Elevated ascitic fluid adenosine deaminase (ADA).
• Laparoscopy and biopsy offer best approach to Dx.
June 2010
Peritoneal Tb:
Laparoscopic view
ie
of multiple
peritoneal tubercles.
June 2010
Peritoneal Tb.
Laparoscopic
L
i
view of
peritoneal
‘‘spider web’’
adhesions Note
adhesions.
the ascitic fluid
at the right
bottom corner.
June 2010
Hollow Viscus Tuberculosis:
• Chronic pain (R L Q)
Q), weight loss,
loss anorexia fever
• Colitis (ulcerative, hypertrophic) with predilection for
ileocecum.
• Strictures.
• Perforation.
• Endoscopic findings are not definitive,
– full thickness biopsy with AFB smear and culture.
June 2010
Esophageal Tuberculosis:
A 25
25-y.o woman, India
I di
immigrant, presented with
substernal chest pain and
dysphagia for 4 days. She
reported 2.5-kg weight loss in
the past 3 months. Esophagoscopy showed a deep linear
ulcer in the esophagus.
Biopsy showed necrotizing
granulomas and cultures grew
M. tuberculosis complex.
The American Journal of Medicine (2007) 120, e1-e2
June 2010
Duodenal TB (Miliary Case):
June 2010
June 2010
June 2010
June 2010
June 2010
June 2010
•TB Splenic Flexure
at onset of
treatment.
June 2010
•TB Splenic
Flexure after 10
weeks of Rx.
June 2010
84 y.o. WM with change
in bowel habits and an
normal CXR.
June 2010
Anatomic distribution of GI TB:
Site:
Autopsy %:
Clinical %
Esophageal
0.14
0.3
Stomach
0.69
2
Duodenum
2.5
0.3
Ileocecal
66.1
42
Colon
53.8
12
Anorectum
11.9
7
June 2010
Hepatic or Splenic TB:
June 2010
Surgical Considerations:
• Laparascopic biopsy to Dx peritonitis
peritonitis.
• Management of strictures, fistulae and
perforation which do not respond to medical
therapy.
June 2010
ENT Tuberculosis:
• Laryngitis
• Otitis
• Mastoiditis
June 2010
June 2010
TB Otitis Media:
June 2010
Extensive Mastoiditis on L
June 2010
Surgery:
•
•
•
•
•
•
Tracheostomy for respiratory compromise.
compromise
Correction of tracheal stenosis.
Biopsy to exclude malignancy.
Abscess drainage (i.e., mastoid Tb).
D
Decompression
i off the
h facial
f i l nerve.
Treatment of Tb extension into the CNS.
June 2010
Other EPTB:
•
•
•
•
•
Adrenal
Thyroid
Myocardium
Retina – choroidal tubercles
Ski – Lupus
Skin
L
vulgaris
l i
June 2010
Adrenal Calcifications from Tb:
June 2010
Adrenal tuberculosis in 49-year-old man of 2 months duration.
Contrast-enhanced CT shows the bilateral mass-like enlargement
with peripheral enhancement.
June 2010
Choroidal Tubercles:
June 2010
Lupus vulgaris Reddish-brown plaque. Note nodular infiltration,
scaling of the helix, and atrophic scarring in the center of the plaque.
June 2010
16 y.o. male with PTB & Skin TB x 5yrs:
June 2010
June 2010
Miliary TB:
• Wide dissemination throughout the body.
body
• Tiny size of the lesions.
• Distinctive pattern seen on chest X-ray.
– With or without other types of infiltrates.
• Appearance similar to millet seeds,
seeds thus the term
"miliary" tb.
June 2010
Miliary TB:
June 2010
June 2010
June 2010
Guidelines for EPTB Treatment:
• In general,
general EPTB can be treated with the same
regimens as pulmonary disease.
• Evidence suggests that 6- to 9-month regimens
that include INH and RIF are effective.
• If PZA cannot be used in the initial phase,
phase
continuation phase must be increased to 7
months.
June 2010
Guidelines for EPTB Treatment:
• For disseminated TB and TB meningitis,
meningitis 9--12
months of treatment is recommended.
• Prolongation of therapy also should be
considered for TB in any site that is slow to
respond.
• The
Th adjunctive
dj
i corticosteroids
ti t id are
recommended for TB pericarditis and TB
meningitis.
June 2010
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