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Medical Grand Rounds

To be or not TB
by

J.c. Villasboas

on 13 February 2013

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Transcript of Medical Grand Rounds

Case Presentation hemoptysis and night sweats Physical Exam Vitals:

Gen:

HEENT:

CV:

Lungs:

Abd:

Neuro: Medicine Grand Rounds "To be or not TB" ...just the tip of the iceberg... J. C. Villasboas, MD
Vitor Pastorini, MD Conflicts of interest: none to disclose Miami VA Healthcare System Chief Complaint:

HPI:





PMHx:

PSHx: 63yo Haitian man with 60-pack-year smoking Hx presents with
2W of progressive cough productive of white, blood-tinged sputum. There was associated drenching night sweats, subjective fevers, chills, SOB, R-sided pleuritic chest pain. Denies sick contacts, travels, incarceration, weight loss. none none Case Presentation father deceased (MI), mother alive. No cancer. 60 pack-year Hx, quit 2w ago
Social ETOH, no drugs
Born in Haiti, moved to US in 1967. Exposed to TB as child, negative PPD.
Manager for USPS
Married, 4 children FHx:

SocHx:






Rx:

Allergies: none aspirin T 98.7, HR 85, BP 124/70, RR 17, POx 98% (RA) NAD PERRL, EOMI, clear oropharynx (no thrush), no LAD RRR, S1S2, no MRG decreased breath sounds R apex and R mid lung. + fremitus and rales.
No ronchi or wheezing flat, benign, no HSM, +BS AAOx3, non-focal Labs 140 3.9 101 26 9 0.9 93 11.5 13.9 42.1 364 21.8 HIV:
PT:
PTT: neg.
11.1
29.9 Imaging Imaging Imaging Imaging Imaging Imaging Imaging Cavitary Lung Disease Infectious Non-Infectious Infectious Causes Mycobacterial Disease
TB
Non-tuberculous mycobacterium (MAI, kansasii)

Necrotizing PNA/lung abscess

Others
Blastomycosis
Cryptococcosis
Actinomycosis Nocardiosis
Mucormycosis
Rhodococcus Non-Infectious Causes Malignancies
Squamous
Adenocarcinoma
Lymphoma
Metastasis (RCC, Sarcomas...)

Septic Embolism

Pulmonary infarct Pulmonary Vasculitides
(e.g. Behcet's)

Autoimmune
RA
GPA

Massive Pulmonary Fibrosis (pneumoconiosis) What's on your mind? What is the best
next step? Clinical Course Microbiology HD#2 HD#4 Bronchoscopy RUL biopsy HD#3 Discharge Plan D/C ID Clinic F/U Oncology Clinic F/U Blood cultures:

Sputum cultures:

Sputum AFB: no growth normal flora positive (Cx pending) Started on 4-drug Tx (INH + RIF + PZA + EMB) Inspection BAL (from RUL and RLL sup. seg.) FNA (subcarinal LAD) / TBB Trachea is unremarkable, carina is sharp and moves freely. The RUL and RML are edematous and tight. No endobronchial lesions are seen. All orifices are patent. Gram stain:
Mycology:
AFB: positive x2 negative negative Pending Pathology FNA (subcarinal LAD) Lung tissue with hemorrhage
No tumor identified on sample Cellular evidence of poorly differentiated malignant epithelioid cells. Tuberculosis Lung Cancer Continue 4-drug treatment
Follow-up AFB culture
Follow-up PCR for TB on BAL
Avoid children and public places
Follow-up in ID clinic Staging scans ordered
Follow-up in Oncology clinic [10/20/12] Clarithromycin added for atypical mycobacterial
PCR/AFB culture pending [10/26/12] ID Clinic [11/02/12] TB PCR:
AFB culture (sputum and BAL): D/C PZA and clarithromycin
Continue INH + EMB + RIF + pyridoxine
Repeat AFB in sputum in 4-6 weeks
May start chemo in 1mo of Tx initiation negative m. kansasii [10/20/12] Dr. Susanne Doblecki-Lewis Infectious Diseases Dr. Michael Campos Pulmonary [11/26/12] Continue NTM Tx
Staging scans ordered
Rad-Onc consult New Admission [12/11/12] Night sweats, chills, progressive dyspnea x 3d Clinical Course Chief Complaint ADM Tx
Plan Radiation Oncology Scans Pleural fluid analysis HD#7 Afluttler with RVR HD#8 New Admission F/U Night sweats + chills + hemoptysis + progressive dyspnea x 3d Initial labs WBC 16.8 (80% PMN, 13% Lymph, no bands) Plan Empyric Tx for HCAP/post-obstructive PNA (Vancomycin + Zosyn)
BCx, SCx, UCx, AFBs
CT chest/abdomen/pelvis Dr. Khaled Tolba Medical Oncology XRT not indicated due to extensive mediastinal involvement Medical Oncology Started palliative ChemoTx
(docetaxel + cisplatin) Cytology: negative
Gram stain and Cx: negative
AFB: negative TEE Cardioversion
Returned to NSR Discharge Plan B-blockers and lovenox (x4w)
F/U with Oncology in 2w for cycle #2 [1/4/13] CC: acute SOB + chest pain
Aflutter + minor ST depressions
WBC 33K, no bands
CT chest: complete R bronchus obstruction + R lung collapse + worsening pleural effusion New Admission ACS ruled out
Morphine started
Broad spectrum ABX started
Progressive deterioration Hospice Expiration
[1/12/13] M. kansasii and Lung Cancer Acknowledgments Dr. Michael Campos
Dr. Susanne Doblecki-Lewis
Dr. Khaled Tolba

All Attendings, Housestaff, Consultants involved in the care of this patient Take Home Points Mycobacterium avium Complex

Mycobacterium kansasii

Rapid Growers
Mycobacterium abscessus
Mycobacerium chelonae
Mycobacterium fortuitum

M. leprae, M. ulcerans, other environmental mycobacteria
Diagnosis requires BOTH culture and radiographic / histopathology findings consistent with disease

At least 2 sputum specimens OR 1 BAL specimen Treatment of M. kansasii Lung Disease Intrinsic resistance to pyrazinamide

INH, RIF, EMB x 12 mo from sputum conversion

Resistance to RIF can develop with therapy

Future Treatments
Clarithromycin 3x/week + RIF, EMB
Role of quinolones American Thoracic Society Guidelines, 2007Griffith DE, et al. Clin Infect Dis 37(9), 2003. Treatment of M. kansasii Lung Disease Other Therapies
Bronchial hygiene
Treatment of underlying disease
Immunotherapy (IFN-gamma) Cavitary lung lesions Nontuberculous Mycobacterium NTM + Lung cancer Keep differential broad
Lower resp. tract or tissue sampling if possible Ubiquitous
Protean manifestations
May mimic TB Occam's razor is not always that sharp... What are NTM? Mycobacterium kansasii
- Similar to Tuberculosis - Described in 1953, the “yellow acid-fast bacillus” causing TB-like disease

Clinical presentation much like Tuberculosis

Sputum conversion 95% with 12 months rifamycin-based therapy

Interferon-gamma Release Assays will be positive
(contains ESAT-6 domain)
Evans, et al. Thorax 51(12), 1996.; Arend, et al. J Infect Dis 191, 2005. Symptoms at Presentation in Patients Infected with M. kansasii or M. tuberculosis Evans, et al. Thorax 51(12), 1996.; Mycobacterium kansasii
- Different from Tuberculosis - Present in municipal tap water

Geographic differences (Mid-West, SE USA)

No person-person spread

Disseminated disease is much less common with M. kansasii (<2% vs. 18%)
Evans, et al. Thorax 51(12), 1996.; Arend, et al. J Infect Dis 191, 2005. M. kansasii
- Summary - M. kansasii has similar clinical presentation to M. tuberculosis

Microbiology and treatment are distinct

Treatment is long and co-morbid diseases must be considered
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