「Tuberculosis」の版間の差分

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==Various presentations==
 
==Various presentations==
*pulmonary
+
===pulmonary===
 
**80-85% of TB diagnosis are pulmonary
 
**80-85% of TB diagnosis are pulmonary
*extra-pulmonary
+
 
**lymphadenitis - hilar/other
+
===extra-pulmonary===
***cold abscess
+
*lymphadenitis - hilar/other
***more common in cervical and hilar
+
**cold abscess
***possibly in axillar, inguinal and abdominal
+
**more common in cervical and hilar
***hilar adenitis DDx - sarcoidosis, lymphoma, histoplasmosis
+
**possibly in axillar, inguinal and abdominal
**pleural
+
**hilar adenitis DDx - sarcoidosis, lymphoma, histoplasmosis
***usually uni-lateral
+
*pleural
***effusion high LDH, high protein, high lymphocyte
+
**usually uni-lateral
**intestinal
+
**effusion high LDH, high protein, high lymphocyte
***can mimic Crohn's disease
+
*pericardial
***most common in ileocecal
+
**cardiac tamponade
**meningitis
+
**sequele - carcified pericardium
***often involves 3rd and 6th cranial nerves
+
*intestinal
***meningeal irritation signs often unaccompanied
+
**can mimic Crohn's disease
**cerebral tuberculoma
+
**most common in ileocecal
***DDx primary CNS lymphoma
+
*meningitis
**Pott's disease (vertebral destruction due to TB)
+
**often involves 3rd and 6th cranial nerves
***kyphosis, gibbus formation
+
**meningeal irritation signs often unaccompanied
***sometimes extends to psoas muscle abscess;  
+
*cerebral tuberculoma
**arthritis
+
**DDx primary CNS lymphoma
***synovial fluid does not necessarily contains enough TB bacteria; fluid culture may miss diagnosis
+
*Pott's disease (vertebral destruction due to TB)
***IGRA could be clue
+
**kyphosis, gibbus formation
**......
+
**sometimes extends to psoas muscle abscess;  
 +
*arthritis
 +
**synovial fluid does not necessarily contains enough TB bacteria; fluid culture may miss diagnosis
 +
**IGRA could be clue
 +
*skin
 +
**erythema nodosum
 +
***DDx - TB, cryptococcal, sarcoidosis, UC, oral contraceptive, ≈50% idiopathic
 +
**lupus vulgaris
 +
*......
  
  

2021年4月15日 (木) 15:41時点における版

History

  • Died from or infected by Tb
    • John Keats (poet)
    • George O'well
    • Nelson Mandella
  • Hippocrates description
    • Phthisis (to waste away, consumption)
  • Robert Koch found the bacteria 1882

Epidemiology

est. case est. death all form 10mil 1.4mil HIV-ass 0.9 mil 208,000 MDR-Tb ≈558,000 ≈190,000

  • 8 countries account for 2/3 of all worldwide Tb
  1. India
  2. China
  3. Indonesia
  4. the Phillippines
  5. Pakistan
  6. Nigeria
  7. Bangladesh
  8. South Africa

Transmission

  • transmission-influencing factors
    • sputum status of index case
    • proximity - distance between each other
    • time
  • susceptibility of person
  • [math]\displaystyle{ R_0 \approx r \times c \times d }[/math]
    • [math]\displaystyle{ r }[/math] = transmissibility
      • to reduce [math]\displaystyle{ r }[/math]
        • ealier detection
        • rapid commencing of treatment
        • reduce aerolization (surgical masks on patients)
          • surgical masks on patients reduce infectivity by 56%
    • [math]\displaystyle{ c }[/math] = susceptibility of contacts
      • to reduce [math]\displaystyle{ c }[/math]
        • open windows
          • Tb airborne transmission risk: windows closed 97%, negative pressure room (ACH12) 39%, windows and doors fully open 33%
        • N95 respirator
        • ARTs for HIV patients
    • [math]\displaystyle{ d }[/math] = duration of infectivity
      • to reduce [math]\displaystyle{ d }[/math]
        • treat patients appropriately

Risk factors

  • HIV
  • malnutrition
    • Tb risk inversely correlates with BMI
  • diabetes
    • diabetes and Tb are syndemic
    • diabetes and Tb pathophysiologically exacerbate each other even under treatment condition in terms of hepatotoxicity
  • overcrowding
    • people per room vs Tb rate per 100,000 (in Canada)
      • 0.4-0.6 vs 18.9
      • 1.0-1.2 vs 113
  • ....

Natural history

  1. inhalation of M.tb containing droplets
  2. macrophages phagocytosis
  3. granuloma + lymphadenopathy
  4. Ghon complex - primary infection
    1. 5% local progression/disseminated Tb
    2. 95% latent Tb
      1. 10% of latent Tb reactivates in lifetime - secondary Tb

Latent Tb

  • 1/3 of the world's population have latent Tb
    • modelling approx. 1.7 bil. people
  • 10% of those latent Tb people get reactivation in their lifetime

Symptoms

  • cough ± sputum ± hemoptysis > 2weeks
  • fever
  • malaise
  • weight loss

Various presentations

pulmonary

    • 80-85% of TB diagnosis are pulmonary

extra-pulmonary

  • lymphadenitis - hilar/other
    • cold abscess
    • more common in cervical and hilar
    • possibly in axillar, inguinal and abdominal
    • hilar adenitis DDx - sarcoidosis, lymphoma, histoplasmosis
  • pleural
    • usually uni-lateral
    • effusion high LDH, high protein, high lymphocyte
  • pericardial
    • cardiac tamponade
    • sequele - carcified pericardium
  • intestinal
    • can mimic Crohn's disease
    • most common in ileocecal
  • meningitis
    • often involves 3rd and 6th cranial nerves
    • meningeal irritation signs often unaccompanied
  • cerebral tuberculoma
    • DDx primary CNS lymphoma
  • Pott's disease (vertebral destruction due to TB)
    • kyphosis, gibbus formation
    • sometimes extends to psoas muscle abscess;
  • arthritis
    • synovial fluid does not necessarily contains enough TB bacteria; fluid culture may miss diagnosis
    • IGRA could be clue
  • skin
    • erythema nodosum
      • DDx - TB, cryptococcal, sarcoidosis, UC, oral contraceptive, ≈50% idiopathic
    • lupus vulgaris
  • ......


  • miliary TB
    • massive lymphohematogenous dissemination
      • nodules diameter <10mm
    • liver
    • spleen
    • bone marrow
    • lungs
      • pulmonary miliary TB easily missed by chest X-ray
    • meninges

Diagnosis

Treatment&Management

Drug-resistant