Tuberculosis Evaluation in the Underserved Community,John W. Wilson, MD Division of Infectious Diseases Mayo Clinic, Rochester,Estimated TB incidence rate, 2006,Estimated new TB cases (all forms) per 100 000 population,The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2006. All rights reserved,No estimate,0-24,50-99,300 or more,25-49,100-299,Estimated HIV prevalence in new TB cases, 2006,No estimate,04,2049,50 or more,519,HIV prevalence in TB cases, (%),The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2006. All rights reserved,Approx. 50 Countries,Common Lack of Medical Resources in 3rd World Setting,Typically unavailable or not done: Mycobacterial cultures Drug susceptibility/resistance testing Tuberculin skin testing High % positive from TB infection and / or prior BCG vaccination Limited availability CXR if hospital / clinic accessible 2nd-line TB drugs Directly Observed Therapy (DOT),Standard Components of TB/TLBI Evaluation in USA / UK,Patient History Symptoms PMHx, comorbidities FHx and patient demographics Physical examination Radiologic evaluation CXR, CT Laboratory testing TST, QFN If available: CBC, LFTs, Tissue histology, cultures,A New Approach to TB Investigation in Underserved Location: 4 Steps to Success:,The Host The Syndrome The Microbiology The Treatment,Defining / characterizing:,1st - Define the Host,Defining the Host,Immunocompetent vs. Immunosuppressed *Especially HIV status Higher rates of primary TB disease More atypical pulmonary findings Higher rates of extrapulmonary disease & dissemination Other medical comorbidities: Diabetes Adult vs. Child Living status: community vs., hospital, jail, shelter etc. Other cases of TB reported, pattern of spread?,Adult: Reactivation Pulmonary TB,More common presentation in immunocompetent, HIV-neg. adults Typical Symptoms - nonspecific:Dry, NP cough Chest pain, pleurisyHemoptysis DyspneaHoarseness Constitutional symptoms:(malaise, feverish, sweats, weight loss) Predilection for upper lung zones,CXR of Pulmonary TB Disease Reactivation Typically in Immunocompetent Adult,Location: apical and/or posterior segment of RUL; apicoposterior segment of LUL or superior segment of either lower lobe Infiltrate: fibronodular, irregular with variable coalescence and cavitation Cavities: thick, moderately irregular walls Volume loss: progressive, can be rapidPLEASE NOTE: *“Atypical” lung findings in approx. 1/3 patients *Infiltrates can appear anywhere!,Presentation of TB Commonly Different in HIV / Immunosuppressed Pts,TB in an immunosuppressed patient Can be more of a “Systemic” illness More extrapulmonary involvement - up to 60% cases in HIV (+) pts: More atypical presentations: Diarrhea Hepatosplenomegaly Lymphadenopathy,Pulmonary TB with immunosuppression,CXR findings - advanced HIV/AIDS (variable): Confluent pneumonia Lower zone infiltrates Hilar / paratracheal adenopathy Risk for Miliary spread / pattern “Primary Complex pattern” common with HIV/AIDS Hilar adenopathy Lower / mid lung infiltrates, unilateral Pleural effusions,Tuberculin skin testing & HIV infection,Reactivity of TST decreases as CD4 count decreases: 15-25% false-neg. (-) in normal host (HIV neg.) with pulmonary TB (disease) 50-90% false-neg. (-) in pts. with early HIV (no other OIs) 80-100% false-neg. (-) in pts. with advanced HIVIn USA/UK, consider preventative INH therapy for HIV & immunosupp. pts regardless of TST for: Close contacts to “infectious” cases,Clinical Presentations of Pediatric TB is NOT the same as with Adult TB,Distinction between TB infection and disease more clear in adult than in children / infants Adult: disease usually follows reactivation of previously dormant organisms and almost always have Significant symptoms and CXR abnormalities. Infants AFB smear commonly negative,Manifestations of Primary Pulmonary TB in children,Hilar or mediastinal adenopathy Paucity of SSx relative to CXR Usually no cavities,2nd - Define the Syndrome the “-itis”,Define the Syndrome the “itis”,Pneumonitis clinical sxs or via CXR? Lymphadenitis, meningitis / cerebritis, pericarditis, hepatitis, peritonitis, pyelonephritis, etc.Is the syndrome consistent with TB? Is this new vs. recurrent TB? Is drug-resistant TB possible? Prev trx? Treatment approaches based the syndrome not all the same,