Morning

Report
Catherine J. Steingraeber DATE: 10/31/12

Tuesday, October 30, 12

HPI
17yo male with a PMHx signicant for limited scleroderma, underlying IgA deciency and chronic ITP, presents with nightly fever x10 days non-producMve cough night sweats unintenMonal weight loss diarrhea x2 days Despite symptoms has been able to play tennis 2 hours per day without issues Scheduled f/u with Rheumatologist today, CXR obtained based on symptoms; showed possible perihilar lymphadenopathy
Tuesday, October 30, 12

AddiMonal History
PMHx: Limited scleroderma Underlying IgA deciency ITP (baseline platelets teens-40s) Leishmaniasis aZer vacaMon to island in the Mediterranean 2 prior hospitalizaMon for PNA Imms: UTD Meds: Nifedipine ER 30mg PO BID, Tadalal 20mg PO qhs Allergies: NKDA
Tuesday, October 30, 12

Physical Exam

VS: T 38.7 P 88 RR 22 BP 118/56 SaO2 97% RA Wt: 59.6 kg GEN: Awake, alert, pleasant male sijng comfortably in bed, working on computer HEEN: nml OROPHARYNX: mmm, tonsils 2+ without exudate, no pharyngeal erythema or lesions. NECK:Palpable, nontender, sholy anterior cervical adenopathy. CV: nml LUNGS: no increased wob, intermilent dry cough, CTAB, adequate air ow in all elds ABDOMEN: s/nt/nd, + bowel sounds, no masses or hepatosplenomegaly EXTREMITIES: nml NEUROLOGIC: nml SKIN: no rashes, no lesions, discoloraMons, or ulceraMons of digits MSK: No joint tenderness, swelling, or erythema, full ROM of upper and lower extremiMes
Tuesday, October 30, 12

DierenMal Diagnosis
17 yo male with hx of limited scleroderma with Raynaud's, chronic ITP, and IgA deciency, who presents with 10 days of intermiLent fevers, occasional night sweats, nonproducNve cough and diarrhea x2 days, with prior chest CT conrmatory for mediasNnal and hilar adenopathy and bilateral nodular parenchymal opaciNes.

Tuesday, October 30, 12

DierenMal Diagnosis
ID
TB EBV Coccidioides Histoplasma Mycoplasma HIV Aspergillus Strep Pneumo Nocardia Bartonella Toxoplasma

Heme/Onc: PULM

Lymphoma Bronchiectasis IntersFFal Fibrosis (Scleroderma)

RHEUM

Sarcoidosis Scleroderma IMMUNE CGD G6PD deciency Myeloperoxidase deciency

Tuesday, October 30, 12

Labs
WBC 7.8 0B 60N 28N 12L Hgb 12.5 Hct 36.2 Plt 23 LDH 474 Uric Acid 4.8 CRP 5.8 ESR 22 CMP and Phos: wnl NEGATIVE/NR HIV abs PPD Mycoplasma PCR EBV Panel Cocci IgG/IgM 1,3 Beta-D glucan ACE Urine Histo VRP

Tuesday, October 30, 12

Micro
AFB stains x4 negaNve Blood cultures negaNve x 2 QuanNferon Gold x2 posiNve

Tuesday, October 30, 12

Imaging: CXR

Tuesday, October 30, 12

Imaging: CT

MediasMnal and hilar adenopathy and bilateral nodular parenchymal opaciMes suggesMng fungal or other atypical infx including TB
Tuesday, October 30, 12

Mycobacterium tuberculosis
Weak Gram + curved bacilli, nonmoNle/spore Lipid rich cell wall (accounts for resistance) Acid fast (all mycobacterium) IsolaNon takes 1-6 weeks (medium dependent) Transmission person-person; airborne mucus droplet nuclei

13 Tuesday, October 30, 12

Mycobacterium Tuberculosis
Lung portal of entry >98% of cases Primary complex (Gohn) = parenchymal pulmonary lesions and assd lymph nodes Disseminated = # circulaNng bacilli large w/ inecient immune
Primary Complex: Sub pleural nodule with mediastinal adenopathy
14 Tuesday, October 30, 12

AcMve Tuberculosis
PresenNng sx/symptoms:
Lung: chronic cough, +/- hemoptysis, night sweats, weight loss, weakness, chest pain Spinal: Back Pain, paralysis Bone Marrow: weakness, anemia CNS: AMS, headache Cardiac: chest pain, fricMon rub Disseminated: ??

Risk factors (of developing acNve TB)

Close contacts/high incidence TB, immunocompromised (HIV, transplant, etc.
Tuesday, October 30, 12

Latent TB
ReacNve TST and absence of clinical/ radiographic ndings Secondary to inhalaNon of infecNve droplet nuclei Greatest risk for progression is in 2 years aeer infecNon WHO esNmates 30% worlds populaNon infected; geographic distribuNon similar to HIV
16 Tuesday, October 30, 12

Tuberculosis: DiagnosMc TesMng

Mantoux TST - interdermal injecMon of PPD - dependent on delayed-type hypersensiMvity

response - previously sensiMzed T-cells recruited, release lymphokines - false-posiMve w/prior infx of NTM - BCG vaccine; results to PPD vary

Tuesday, October 30, 12

Mantoux TST: InterpretaMon

InduraMon 5 mm: Persons with HIV infecMon or immunosuppression Recent close contact to person with known acMve TB Persons with CXR consistent with acMve/prior disease Persons w/clinical evidence of TB (or risk of)
18 Tuesday, October 30, 12

Mantoux TST: InterpretaMon

InduraMon 10 mm: Recent immigrants, I.V. drug users, residents and employees of high-risk sejngs children <4 years of age DM, oncologic process, chronic renal fx, malnutriMon InduraMon 15 mm: Persons who do not meet any of the above criteria (no risk factors for TB)
19 Tuesday, October 30, 12

Tuberculosis: DiagnosMc TesMng

Blood Tests: IFN-gamma detecNon - QuanNFERON measures whole blood [] IFN- gamma - T-SPOT.TB measures number lymphs producing IFN-gamma - no cross-reacNvity with BCG or other mycobacterium - limited data in young children or immunocompromised AFB Stains and Sputum Culture
20 Tuesday, October 30, 12

Tuberculosis: Treatment
Pulmonary Disease (acNve):
6 mos Isoniazid and Rifampin PLUS 1-2 mos of Pyrazinamide and Ethambutol * Isoniazid + Rifampin for 9 mos very eecMve if known suscepMble with good compliance
Directly Observed Therapy is suggested IF Isoniazid resistant: 9 mos Rifampin, Pyrazinamide, Ethambutol

Extrapulmonary
Variable! Surgical v. longer/broader therapy
Tuesday, October 30, 12

Tuberculosis: Treatment
Latent TB:
Isoniazid for 9 mos **
Bi-weekly DOT Daily if self-administered

Rifampin for 6 mos

Consider:
<5 yo means recent infecMon Risk of disease progression is high Untreated infants have 40% to progress to disease Risk for progression decreases through childhood Infants/Children more likely for life-threatening infx
Tuesday, October 30, 12

Tuberculosis: Treatment
Isoniazid hepaMc enzyme elevaMon, hepaMMs peripheral neuriMs Rifampin orange urine/bodily uid staining contact lenses hepaMMs, thrombocytopenia Ethambutol OpMc neuriMs, red-green color diculMes Pyrazinamide hepatotoxic, hyperuricemia
Tuesday, October 30, 12

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