Extra Pulmonary Tuberculosis Case Reports

Dr. Nilgün Kalaç Atatürk Chest Disease

and Surgery Centre, Ankara

DE, age 16, Ağrı-Patnos 13.7.2010 hospitalisation Neck pain for 6 months Swelling on the left side of neck for 2

months On 12.7.2010 suddenly she could not move

his arms and legs Applied to emergency

Neurologic Examination Open conscious, cooperative Cervical movements are sensitive and

restricted On upper left extremity the DTRs are

normoactive On upper right extremity and on lower

extremities the DTRs are hyperactive Bilateral Babinski (+) Tetraparesis Anal tonus is intact There are no urine incontinance and

retension

Question 1 Which test would you apply?A. Thorax CTB. Neck CTC. Cranial CTD. All

Neck CT

LEFT: On the left half of the neck, there is a destruction at the LEFT: On the left half of the neck, there is a destruction at the atlantooccipital joint-C1 vertebra level. atlantooccipital joint-C1 vertebra level.

RIGHT: There is an abcess laying towards the spinal canal RIGHT: There is an abcess laying towards the spinal canal and retrofaringeal area. and retrofaringeal area.

Thorax CT

There is a paravertebral abcess which causes litic-There is a paravertebral abcess which causes litic-destructive images that becomes clear at the right destructive images that becomes clear at the right side on the lower thoracal vertebrates.side on the lower thoracal vertebrates.

Thorax CT - 2

There is a subplevral nodular lesion at the anterior upper There is a subplevral nodular lesion at the anterior upper lob of the right lung. lob of the right lung.

Question 2: What is your pre-diagnosis?A. Cervical pyogenic osteomyelitisB. Cervical malignancyC. Cervical vertebral fractureD. An abcess on the vertebral colon

Question 3: What should we do for the exact

diagnosis?A. Operation on cervical vertebra and

abcess examinationB. Fiberoptic broncoscopyC. Sputum test for Acid Fast Bacille(AFB)D. Excision of the cervical LAP

Tests done Post-cervical LAP ponction on the left

neck AFB (+) on abcess material AFB (-) on sputum

Treatment The date she is hospitalised is 13.7.2010

Multiple Pott abcess TB lenfadenite With lung TB pre-diagnosis, HRZE

treatment was started.

The diagnosis was confirmed later.

On the 1st week of treatment She became able to move her arms with

help in her bed. On the 20th day

She become mobilized On the 85th day

She is discharged from the hospital by walking

In Turkey, Extra Pulmonary TB makes the 30% of the all TB cases

Bone-joint TB makes the 1-2% of the all TB cases Mostly the vertebra and the bones that carry weight (knee,

femur, ankle) The TB that affects vertebra is called the Pott disease

Frequent at the lower thoracal, lomber and lombosacral areas

It can diffuse to the soft tissue and make cold abcess The Psoas abcess may diffuse through the muscles via

gravity It may cause paralysis and/or gibbosity

The treatment is standard anti-TB regime for 9 months For stability, surgery may be required

GE, age 24, Ağrı, Patnos – elder sister of the previous patient

her sister’s treatment was started on 13.7.2010

Her hospitalisation on 22.2.2011 Chest pain for 6

months Night sweating,

weight loss Chest X-ray: Pleurisy

Question 4: Which tests should be done?A. Sputum AFBB. ThorasynthesisC. Thorax CTD. Neck USG

Sputum AFB microscopy (-), (-), (-) Plevra fluid

Exuda ADA: 92 U/dl

Thorax CT, 24.2.2011

Pleural fluid on the left hemithorax

Pleural fluid with partly dense areas on the right hemithorax

Sister of the patient is TB Her complaints and symptoms are

coherent with TB Pleural fluid ADA: 92U/dl

hospitalisation on 22.2.201123.2.2011 HRZE was started

Control Thorax CT, 26.7.2011 (23.2.2011 HRZE was started)

Dense pleural fluid with partly dense areas with air values and cistic areas on the right hemithorax

Collapse consolidation on the other side of that lung. .

Question 5: What shall we do with these CT ?A. Extend the duration of the treatmentB. Pleural biopsy C. FOB D. Decortication

(23.2.2011 HRZE was started)

4.8.2011 Right thoracotomy + decortication

Pathology: Caseified granulomatous infection

After operation, she used HR for 3 more months

23.11.2011

23.11.20113,5 months after operation

1.8.2011Before operation

Pleural TB Pleural TB is at the 1st place among the extra-

pulmonary cases It makes the 30% of the all TB cases Pathogenesis:

It is most frequently the complication of the primary infection

It occurs 6-12 weeks after the primary infection Radiology,

Is usually unilateral If it is bilateral, disseminated TB should be

considered

Pleural TB - 2 Pleural fluid is exuda If ADA level is over 40 U/dl :

Sensitivity: 92%, specifity: 93%. High ADA values are seen in parapneumonic fluid

Standard 6 months treatment Steroids are not necessary

With the anti TB treatment, visceral pleura may thicken in some patients. It makes pressure on lungs. Breathing is restricted.

After 3 months of treatmenti if there is thickening on more than ¼ of hemithorax, decortication is applied (opinion of the surgeons).

Lung and pleura curing may continue up to 6-9 months.

Pleural TB - 3

TB Treatment Follow up

(case)

HK, female, age 46, İskenderun Lung TB 20 years ago 3.3.2010 AFB (++++)

Relapse treatment(1HRZES / 2HRZE/ 5HRE)

The treatment is completed at VSD, AFB (-)

6.4.2011 AFB (+++) 12.4.2011 Hospitalization

Audiology: slight conductive hearing loss Psychiatric consultation

12.4.2011 hospitalisation 12.4.2011 a sample sputum is sent to RSH-TB

laboratories 20.4.2011 CYC, OFL, PTH, PAS are started 29.4.2011

M. tuberculosis complexis noticed R resistant. H (inhA sensitive, katG resistant) Florokinolon resistant; Aminoglikozit, EMB sensitive

10.5.2011 SZ sensitive

20.4.2011 CYC, OFL, PTH, PAS 5.7.2011 Amik, E, Z, PAS, CYC, PTH 1.8.2011 ALT: 292, AST 495 IU/L

Treatment is ceased. Hepatitis tests: negative 1, 2, 3 / 8/ 2011 Spread and TB cultures are

negative 9.8.2011

The patient is discharged after she signed.

20.4.2011 minor treatment 1.8.2011 hepatotoxicity, treatment is ceased

Applied to the doctor with complaints. 10.10.2011 ARB (++) 13.11.2011 Hospitalisation

AFB (++) ALT: 526, AST: 390 IU/L Hepatitis tests: negative Amik, E, CYC, Oflo. KCFT increase is normalized on 14.12.2011

9.1.2012 AFB: (-), (+), (-)

13.11.2011: Amik, E, CYC, Oflo 6.2.2012: ARB (++)

New treatment, planned with a new team. H, E, Z, Amikasin, Moksif, CYC, PAS, CLF.

17.3.2012 Hearing loss: Amikasin is ceased.

19.3.2012 Sputum AFB (-), (-), (-) Discharged. Notified about her situation to

İskenderun VSD.

Consultations during the treatment Psychiatry (2 times) Eye Dermatology (3 times) General Surgery Audiology (3 times)

Follow up problems of this resistant TB patient

Specification of the medicine resistance Bacteriologic follow up (spread and culture) Hepatotoxicity Hearing loss Depression DOT application at the hospital DOT application after discharge Problems of control visits of the patient Social and economic support

Thank You

Dr. Nilgün Kalaç Atatürk Chest Disease

and Surgery Centre, Ankara