Dr.Sathaporn Kunnathum13 Jun 2010

HemoptysisInfectionTumorBleeding disorderFBMedicineDestructive lung

Hemoptysis or Hematemesis

EpidemiologyTuberculosis (TB) remains the leading cause of

death worldwide from a single infectious disease agent. Indeed up to 1/2 of the world's population is infected with TB.  The registered number of new cases of TB worldwide roughly correlates with economic conditions

the highest incidences are seen in those countries of Africa, Asia, and Latin America .

WHO estimates that eight million people get TB every year, of whom 95% live in developing countries. An estimated 2 million people die from TB every year. 

Clinical featuresFeverHemoptysisLoss of appetiteWeight lossFatiqueNight sweatsChest pain

Cause

Mycobacterium tuberculosis

Tuberculosis is Tuberculosis is transmitted by transmitted by airborne droplet airborne droplet nuclei(containinnuclei(containing tubercle g tubercle bacilli )bacilli )

Many droplet nuclei Many droplet nuclei are capable of floating are capable of floating in the immediate in the immediate environment for environment for several hoursseveral hours

Large particles may Large particles may be inhaled by a be inhaled by a personperson

breathing the breathing the same air and impact same air and impact on theon the

trachea or wall of trachea or wall of the upper airwaythe upper airway

Laboratory and physical examinations

Chest radiography Chest radiography Sputum examinationSputum examinationTuberculin testingTuberculin testingPCR test to detect PCR test to detect

TBTBTB antibody testingTB antibody testingbronchoscopybronchoscopy

DiagnosisUsually Dx from clinical, CXY and Sputum

AFB

Radiology Chest radiography is the most Chest radiography is the most

important method to detect TB important method to detect TB TB’s characteristics of a chest TB’s characteristics of a chest

radiograph favor the diagnosis of radiograph favor the diagnosis of tuberculosis as following :tuberculosis as following :

(1)(1) Involve mainly in the upper zone Involve mainly in the upper zone(2)(2) patchy or nodular infiltration patchy or nodular infiltration(3)(3) cavity lesion. cavity lesion.(4)(4) calcification. calcification. (5)(5) bilateral infiltration, especially if these are in the bilateral infiltration, especially if these are in the upper zonesupper zones(6)(6) the persistence of the abnormal shadows without the persistence of the abnormal shadows without alteration in an x-ray repeated after several weeks alteration in an x-ray repeated after several weeks this helps to exclude a diagnosis of pneumonia this helps to exclude a diagnosis of pneumonia

or or other acute infectionother acute infection

Milliary TuberculosisMilliary Tuberculosis

acute milliary tuberculosis

Upper lung infiltrate

infiltrate

Tuberculoma

Chronic fibro-cavitary pulmonary tuberculosis

cavity

Tuberculous effusion

Sputum examinationSputum examination There are direct smear and There are direct smear and

culture culture

Direct smear examination Direct smear examination is only positive when large is only positive when large numbers of bacilli begin to numbers of bacilli begin to be excreted be excreted

Sputum examinationA negative smear by no means A negative smear by no means

excludes tuberculosisexcludes tuberculosisA negative smear in the presence A negative smear in the presence

of extensive disease and cavitation of extensive disease and cavitation makes the diagnosis less likely.makes the diagnosis less likely.

Particularly if the negatives are Particularly if the negatives are frequently repeated frequently repeated

Tuberculin Tuberculin testingtesting

A positive tuberculin test A positive tuberculin test although it is of great although it is of great use in children, but it use in children, but it has limited diagnostic has limited diagnostic significance in older significance in older age groupsage groups

•• A reaction of less than 5 mm is A reaction of less than 5 mm is

considered considered

negative negative

• • 5-9 mm is considered positive (+)5-9 mm is considered positive (+)

•• 10-19 mm is considered positive (+10-19 mm is considered positive (+

+) +)

•• more than 20 mm is considered more than 20 mm is considered

positive positive

(+++)(+++)

A positive tuberculin skin test A positive tuberculin skin test

indicates indicates

tuberculous infection, with or tuberculous infection, with or

without diseasewithout disease

Differential Diagnosis 1 2 3 4

BronchiectasisBronchiectasis may confused with may confused with chronic fibrocavenous pulmonary chronic fibrocavenous pulmonary tuberculosis. They also have chronic tuberculosis. They also have chronic cough, sputum production and cough, sputum production and hemoptysis. Usually we can use chest x-hemoptysis. Usually we can use chest x-ray examination and CT scan to ray examination and CT scan to distinguish them. distinguish them.

Cavitary lung abscessCavitary lung abscess often involves the often involves the dorsal segments of the lower lobes and posteriordorsal segments of the lower lobes and posteriorsegments of the upper lobes. Typically lungsegments of the upper lobes. Typically lung abscess causes litt1e in the way of physical abscess causes litt1e in the way of physical findings, may have a air-fluid level, and is findings, may have a air-fluid level, and is

notnot associated with patchy bronchogenic infiltrates.associated with patchy bronchogenic infiltrates. In contrast, physical findings are prominentIn contrast, physical findings are prominent over tuberculous cavities, fluid levels are rare.over tuberculous cavities, fluid levels are rare. And patchy infiltrates elsewhere are the rule.And patchy infiltrates elsewhere are the rule.

Differential DiagnosisDifferential Diagnosis 1 2 3 4

Acute bacterial pneumoniasAcute bacterial pneumonias may may resembleresemble

florid tuberculosis in all particulars florid tuberculosis in all particulars except forexcept for

the sputum examination and the sputum examination and response toresponse to

antimicrobial drugs.antimicrobial drugs.

Differential DiagnosisDifferential Diagnosis 1 2 3 4

Neoplasm Neoplasm may resemble tuberculosis. may resemble tuberculosis. As inAs in

an isolated coin lesion. ( An irregular an isolated coin lesion. ( An irregular cavity wallcavity wall

suggests necorotic neoplasm. )suggests necorotic neoplasm. )

Differential DiagnosisDifferential Diagnosis 1 2 3 4

Differential Diagnosis 1 2 3 4 5Fever caused by some other diseases

complicationsPneumothoraxBronchiectasisEmpyemaExtrapulmonary expansionHemoptysisChronic pulmonary heart disease

TreatmentThe critical issue in TB control is The critical issue in TB control is

adopting the DOTS (1995) adopting the DOTS (1995) ( Directly Observed Treatment, ( Directly Observed Treatment,

Short-course therapy; DOTS Strategy Short-course therapy; DOTS Strategy is recommended by the WHO TB is recommended by the WHO TB Program.Program.

TreatmentWHO Category of treatmentI 2IRZE + 4IR in general caseII 2IRZES + IRZE + 5IRE in relapse and

default case

Adverse effectsINH : hepatotoxicity and periphral hepatotoxicity and periphral

neuropathy neuropathy Rifampicin : gastrointestinal upset, gastrointestinal upset,

hepatitishepatitisEthambutol : optic neuritis optic neuritis PZA : hepatotoxityhepatotoxityStreptomycin : Ototoxicity, Renal toxicityOtotoxicity, Renal toxicity

Resources WHO Tuberculosis Resources (Columbia Medical School) 

http://www.cpmc.columbia.edu/tbcpp Tuberculosis, NIAID Fact Sheet

http://www.niaid.nih.gov/factsheets/tb.htm Positive Skin Tests for Tuberculosis (American Family Physician)

http://www.aafp.org/afp/961101ap/pat_1991.html National Tuberculosis Center

http://www.umdnj.edu/~ntbcweb/ntbchome.htm CDC; Division of Tuberculosis Elimination

http://www.cdc.gov/nchstp/tb/structure.htm Treatment of Tuberculosis and Tuberculosis Infection in Adults

and Children American Thoracic Society Medical Section of the American Lung Association American Journal of Respiratory and Critical Care Medicine Vol 149 1994  http://aepo-xdv-www.epo.cdc.gov/wonder/PrevGuid/p0000413/p0000413.htm

Brief History of Tuberculosis http://www.umdnj.edu/~ntbcweb/history.htm

Thank you for your attention