Tuberculsosis Flashcards
Task 96
A58-year-old patient A. is engaged in rotation-based work in the oil and gas field. For 5 years, he has been followed up by the internal medicine physician for gastric ulcer with frequent exacerba- tions. The patient smokes 1 pack a day and does not abuse alcohol. The last fluorographic examina- tion of the chest took place 1 year ago and did not reveal any pathology. The patient denies tubercu- losis contact. Currently, he complains of cough with mucous sputum, weakness, sweating, fever up to 37.5 °C, shortness of breath, and pain on the right side under the shoulder blade. These symptoms appeared about a month ago after hypothermia.
Objective examination findings: the condition is of moderate severity, height – 176 cm, weight – 61 kg. Peripheral lymph nodes are palpated in the axillary region on the right up to 0.6 cm in diameter; they are dense, mobile, and painless. Respiratory rate is 20 breaths per minute. The percussion sound is shortened on the right under the scapula, where medium moist rales are heard. Heart sounds are muffled. Heart rate is 92 beats per minute, BP is 145 / 90 mm Hg. On the part of the ab- dominal organs, no pathology is detected. Complete blood count: erythrocytes - 3.5 x 1012/ l, hemo- globin – 103 g / l, leukocytes – 12.0 x 109 / l, eosinophils – 2%, band neutrophils – 7%, segmented neutrophils – 69% , lymphocytes – 14%, monocytes – 8%, ESR – 60 mm / h. Urinalysis: straw col-
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ored, acidic reaction, specific gravity – 1020, glucose – negative, protein – 0.033, 1–2 leukocytes / HPF, erythrocytes – negative.
In the internal medicine hospital, where the patient applied for emergency medical care, a chest X- ray was performed which revealed changes in the lungs requiring differential diagnosis.
Task:
1. Describe the chest X-ray pattern. Identify the primary radiographic syndrome. Present a differ- ential diagnosis list of conditions with similar symptoms.
2. List clinical syndromes; interpret the findings of the clinical tests; formulate a preliminary clin- ical diagnosis; identify a plan of actions by a primary medical care facility physician when working with patients with respiratory diseases with suspected tuberculosis; identify risk factors for tubercu- losis in this patient.
3. Identify a physician’s treatment strategy in case acid-fast bacilli are detected.
4. List mandatory tests in a specialized anti-TB facility for verifying pulmonary tuberculosis.
5. Formulate a clinical diagnosis, compile a plan of treatment and follow-up at the dispensary,
given the findings of bacteriological tests with detected MBT sensitivity to HRZE therapy.
***Description of chest x ray=
- we can. See chest of direct projection and lateral projection
-changes in the 2nd segment of the upper lobe of the right lung
-A dimming of medium intensity,inhomogeneous structure
- we can see enlargement area in the dimming
-fuzzy contours is determined
-we can also see inflammation press towards the root of the right lung
-few focal shadows small medium intensity,homogeneous structure ;fuzzy contours we can see this in lateral projection
Conclusions = syndromes ;dimming shadow syndrome , focal shadow syndrome ,root pathology syndrome (pathological changes of the right lung(roots have changes,fuzzy contours
Differential diagnosis
*Pulmonary TB of the upper right lung in the phase of decay and seeding
*Destructive pneumonia in S2 segment of the right upper lung
2- clinical syndromes
*Bronchitis
*intoxication
respiratory failure
Laboratory results =mild anemia,moderate leukocytosis,left shift leukocytes,leucopenia and increased ESR .
** clinical data ,
Anamesis,clinical symptoms,laboratory radiological data help the doctor to diagnose :Community acquired destructive pneumonia. In this regard before microbiology of sputum ,Emprical antibiotics is prescribed before patients go for lab.
In this case penicillin or ceftraone or macrolides is prescribed for 6 days ,symptoms of this disease is cough for more than 2weeks, fever for more 3 weeks,wheezing in the upper lobe , presence risk factors such of ulcer ,patient should be examined for TB
4: mandatory tests
*light microscopic sputum zhiel
*chest x ray
*Recombinant test allergen of TB
*WHO recommended studying by seeding morning sputum preferred,gene expert ,molecular genetic test PcR note one sample for first line Anti-TB drugs and another sample for culture of TB,
3. Identify treatment plan incase bacilli are detected
*one positive test is enough to confirm diagnosis,patient should be isolated,consulted by a pthiologist in a short time ,redirected by ambulance to a specialized ANTItuberculosis institution
4.list mandatory tests
*Study of two sputum samples, 1 test for genetic molecular, 2nd test for sputum culture,one liquid ,two samples a dense nutrient media, determination of drug sensitivity to TB and rest for HIV,Hepatitis
5. Make conclusion and
*Final diagnosis:infiltrative pulmonary TB of the S2 segment of the upper lobe of the right lung in the phase of decay and seeding MBT +
1st group of dispensary:according the result of cultivation and determination of sensitivity MBT the patient has drug sensitive Tuberculosis patient requires
**First regimen:H , R ,Z,E , daily dose are taken based on the patients weight . Intensive phase 4 TB drugs for 2 months , continuous phase 2-3 AntiTB drugs for 4 months H,+R+z total duration of treatment will be 4+2=6months
Before the determination of treatment patient was in the hospital so a sick leave is given for the treatment
Diagnosis: Tuberculosis S2 of the right lung with infiltration in the phase of decay and dissemination,
MTB (+), I group of follow-up at a specialized dispensary
Task 97
A 33-year-old patient M. is unemployed. She was followed up at the anti-TB dispensary with a di- agnosis of infiltrative tuberculosis of the upper lobe of the left lung, MBT (+). The patient has been treated for 6 months. The course of treatment was completed as effective: resorption of the infiltrate was achieved, bacterial excretion was stopped. The patient was examined annually, there were no data on recurrence of tuberculosis. 8 years after the disease, she gave birth to a full-term healthy baby. Labor proceeded without complications. On day 2 after the delivery, the patient felt worse: weakness, loss of appetite, sweating, fever up to 39 ̊ C with chills, dry cough, and severe shortness of breath were noted.
Objective examination findings: the patient’s condition is moderate. Lip cyanosis is noted. Peripher- al lymph nodes are not enlarged. Breathing is weakened, single dry rales are heard. Respiratory rate 110
is 30 breaths per min. Heart sounds are rhythmic, heart rate is 110 beats per minute, blood pressure – 100 / 60 mm Hg. The abdomen is soft and painless.
Complete blood count: erythrocytes – 3.9 × 1012 / l, hemoglobin - 105 g / l, leukocytes - 11.2 × 109 / l, eosinophils - 1%, band neutrophils - 7%, segmented neutrophils - 63%, lymphocytes - 15%, mon- ocytes - 14%; ESR – 38 mm / hour. An emergency chest X-ray was performed
Task:
1.Describe the chest X-ray pattern. Identify the primary radiographic syndrome. Present a differen- tial diagnosis list of conditions with similar symptoms.
2. List clinical syndromes; interpret the findings of the clinical tests; identify risk factors for tuber- culosis; formulate a preliminary clinical diagnosis and justify it.
3. Identify a plan of actions by a perinatal facility physician when working with this patient. Decide on the need for child’s vaccination and a possibility of breastfeeding.
4. Explain the pathogenesis of the disease.
5. List mandatory methods of laboratory diagnosis in a specialized anti-TB facility that will verify pulmonary tuberculosis and identify a treatment strategy
1.Diagnosis: Miliary tuberculosis, focal bilateral pneumonia, miliary carcinomatosis.
Description of chest x ray
*x ray in direct and lateral projection
*we can see single type small ,miliary focal shadows of medium intensity, very small miliary shadows, homogeneous shadows,clear contours in all lung fields
*Roots of the lungs are not changed
*conclusion : only dissemination syndrome
#Differential diagnosis
*miliary pulmonary tuberculosis
* focal bilateral pneumonia
*carcinomatosis
2.list clinical syndromes
*severe intoxication syndrome
*Bronchitis
*respiratory failure
##results of LAb: mild anemia,moderate leukocytosis,left shift , lymphopenia, monocytosis and increased ESR
*Taking into account of risks factors
-previous Tb and pregnancy
-data of chest x ray
Diagnosis of military TB is made of the basis of patient’s symptoms such as dry cough,dyspnoe and symptoms of intoxication fever,weakness
*pathogenesis
-during pregnancy immunity decreases and delivery can be a source of endogenous reactivation of TB
Findings of physical examination:Dry rales ,tachypnoe, blood exam results and chest x ray miliary dissemination
3: plan
*decide need for vaccination
* first mother should be isolated in a separate room consulted by a TB doctor in a short time and referred to a specialized Tuberculosis hospital for proper treatment
*if there is no contact with the mother after birth the child is separated and transferred to anti fusion feeding and given BCG vaccination if there is no contraindications
*final disinfection is carried out by epidemiological services upon request of institution if diagnosis of TB is established
4. Explain pathogenesis
*most likely there was reactivation of Tb during pregnancy and after delivery and decreased immunity in this patient
*physiological ectopic lowering of the diaphragm and abdominal decompression syndrome which lead to development of acute hematogenous dissemination of MBT and all changes of the lung
5:mandatory diagnosis
* in specialized institutions of TB lab diagnosis exam of two samples of reminiscence microscopy:one sample for molecular genetic analysis(gene pert 1liquid media and dense media2 for second for culture for growth and drug sensitivity
*Test for HIV and hepatitis B and C
##Treatment strategies
In the case patient treated TB for 6months which means 4 main AntiTB drugs should be prescribed HRZE intensive phase 2 months and continuous phase 4months 2-3 TB drugs HRZ total duration of treatment is 6month
Final diagnosis: Miliary pulmonary tuberculosis MBT -negative
Task 98
A 37-year-old man applied to the emergency internal medicine hospital on his own. History-taking revealed that he had been experiencing weakness, loss of appetite, productive cough with mucopu- rulent sputum, fatigue, and fever up to 38.2 °C over the past three months. At the onset of the dis- ease, he visited an internal medicine physician at the district hospital on an outpatient basis (X-ray of the chest was not performed) and received nonspecific antibiotic therapy for chronic bronchitis (amoxiclav), which did not provide effect. In addition, he noted that three weeks ago, a tumor-like lump appeared on the lateral surface of the neck on the right, just above the clavicle, which in- creased in size and burst with little yellowish discharge on the day of admission.
The patient’s condition was satisfactory. A patient was undernourished (height – 175 cm, weight – 53 kg). Percussion revealed dullness of the percussion sound projected at the upper lobe of the right lung. Auscultation revealed moist rales of different intensity in this area with bronchial breath
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sounds; on the left, breathing was rough. Heart sounds were rhythmic, heart rate was 102 beats per minute, blood pressure – 125 / 85 mm Hg. The abdomen was without any pathology. Complete blood count: erythrocyte count – 4.8 × 1012/ l, hemoglobin - 132 g / l, leukocytes – 11.4 × 109 / l, band neutrophils – 3%, segmented leukocytes – 78%, lymphocytes – 15%, monocytes – 4%, ESR - 39 mm / h.
Upon examination of the neck, on the right, above the clavicle along the anterior edge of the ster- nocleidomastoid muscle, a tumor-like mass with hyperemia (the size of a walnut) was noted with a yellowish crust from the fistulous tract in the center. Upon palpation, the mass moved and was moderately tender. Other regional lymph nodes were not enlarged. A chest X-ray was performed.
Task:
1.Describe the chest X-ray pattern. Identify the primary radiographic syndrome. Present a differen- tial diagnosis list of conditions with similar symptoms.
2. List clinical syndromes; interpret the findings of the clinical tests; formulate a preliminary clini- cal diagnosis; identify the physician’s actions.
3. List mandatory methods of laboratory diagnosis in a specialized anti-TB facility that will verify pulmonary tuberculosis.
4.Identify the differential diagnosis list for peripheral lymphadenopathy and the physician’s treat- ment strategy.
5. What are the treatment strategy and prognosis for this patient?
1.Diagnosis: Necrotizing pneumonia of the upper lobe of the right lung. Tuberculosis with infiltration S2
on the right in the phase of decay and dissemination.
Description of chest x ray
*in direct projection of the right upper lung ,a dimming of medium intensity of inhomogeous structure, with fuzzy contours is determined
*we can also tell about cavity shadow of 3-5cm in the structure of irregular cavity also tell about changes in upper part of the right lung non structural with fuzzy contours
*on the 3 rd rib of right lung we can see a few or multiple focal shadows small or medium size intensity,fuzzy contours
#Radiological syndromes include
*dimming shadow syndrome
*cavity shadow
*root pathology
*focal shadow syndrome
#differential diagnosis
*infilitrative pulmonary TB of upper lobe of the right lung in the phase of decay and seeding on left lung
*destructive pneumonia of upper lobe of right lung
##list clinical syndromes
*bronchitis
*intoxication
*peripheral lymphoadenopathy
## laboratory results
*leucocytosis
*lymphopenia
*increased ESR
## due to the absence of TB in anamnesis make us conclude diagnosis of Community acquired pneumonia so we can start to treat pneumonia ,chest x ray data showing infiltrative phase of decay,non effective treatment with antibiotics indicates of pneumonia
3.list mandatory tests do be carried out by anti TB specialized institutions
*chest x ray
*sputum exam by light microscopy with zhiel ,staining for the iso resistance of MBT and diagnostic test with TB recombinant allergen in standard dilution is mandatory,if bacteria excretion is detected the patient is redirected by specialized transport to the antiTB hospital,if microscopic test is negative but suspicious of TB patient is further examined in a specialized institution
##list mandatory test in specialized institution
* in specialized institutions of TB lab diagnosis exam of two samples of reminiscence microscopy:one sample for molecular genetic analysis(gene pert 1liquid media and dense media2 for second for culture for growth and drug sensitivity
*Test for HIV and hepatitis B and C
##Identify differential diagnosis
*purulent discharge should be tested in lab by microscopic with pcR in absence of data we can do biopsy of peripheral lymph nodes ,detect material in MBT ,cytological and histological
##Treatment strategies
* complex treatments strategies with the inclusion of chemotherapy regimen according to the spectrum of MBt activity maybe use pathological
And symptomatic treatment too
With progress of TB lymphoadenonitis we can use surgical treatment
*prognosis of TB process in lungs and peripheral lymph node ,patient will have a good prognosis if we treat all chemotherapy
##final diagnosis =infiltrative pulmonary TB on the upper lobe of the right lung in the phase decay in seeding
Task 99
Patient N. was a 19-year-old student. The patient complained of cough with scarce mucous sputum, intermittent pain in the right half of the chest, reddish-purple rash on the shins, and swelling and soreness of the ankle joints. The patient has had these symptoms for two weeks and has not visited a doctor. Pathological changes were detected during chest X-ray upon dormitory check-in. Anamnesis vitae: the patient had measles as a child. The previous chest X-ray conducted a year ago did not reveal any pathology.
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Objective examination findings: the patient had regular build and was overweight. Erythema nodosum was seen on both shins. Peripheral lymph nodes were not enlarged. The heart rate was rhythmic, 72 bpm. The heart sounds were clear. Blood pressure was 130 / 70 mm Hg. The chest was symmetrical. On percussion, the lung sound was clear. On auscultation, the patient had vesicular breath sounds, no abnormal breath sounds were noted. The abdomen was soft, painless; the liver and spleen were not enlarged.
Complete blood count: erythrocytes 4.1х1012 / l, hemoglobin 126 g / l, leukocytes 5.7х109 / l, eosin- ophils 1%, band leukocytes 1%, segmented leukocytes 53%, lymphocytes 37%, monocytes 8%, and ESR 16 mm / h. The patient was referred to a phthisiologist to establish a differential diagnosis of the detected changes in the lungs, where a test with a recombinant tuberculosis allergen (RTA) was conducted. After 72 hours the result was negative.
Task:
1. Describe the chest X-ray pattern. Highlight the primary syndrome that can be detected on the chest X-ray. List diseases with similar syndromes based on the differential diagnosis.
2. Formulate a preliminary clinical diagnosis, justify it, conduct differential diagnosis of tuber- culosis.
3. List the necessary methods of laboratory diagnosis in a specialized anti-TB facility for dif- ferential diagnosis of pulmonary tuberculosis.
4. What are the diagnostic criteria of sarcoidosis?
5. What is the treatment strategy
1.Diagnosis: Syndrome of pathological changes in the roots of the lungs. Bilateral intrathoracic lymphad-
enopathy. Intrathoracic lymph node sarcoidosis, intrathoracic lymph node tuberculosis, lym-
phogranulomatosis, non-Hodgkin lymphoma, central lung cancer
#*** Additional information
Description of chest x ray
*chest x ray on direct projection
*no physiological changes on lung parenchyma
*I see roots of both sides of the lungs are expanded ,non structure ,due to enlarged lymph nodes of the paratracheal of the right part tracheal bronchial and bronchial pulmonary groups
*the surrounding lung tissue around the lymph nodes without inflammatory changes
*conclusion patient has root pathology syndrome of the lungs
### differential diagnosis
*sarcodosis of intrathoracic lymph nodes
*TB of in-thoracic lymph nodes
*lymphogranulomatosis
*central cancer
2## make a diagnosis and justify
Diagnosis:sarcoidosis of intrathoracic lymph nodes active phase
##according to the clinical symptoms and presence of arthritis of ankle joint ,erythema nodosum ,no changes in the hemogram ,chest x ray picture with shows us bilateral root lungs changes with out involvement lung parenchyma ** note Tb of intrathoracic lymph nodes is characterized by signs of intoxication and inflammatory changes in the blood and it’s possible to detect MBT in sputum and it’s has unilateral changes in roots on chest x ray only one root is affected not both roots ,more often on the bronchial pulmonary group with involvement of surrounding lung tissue in inflammatory process and positive test with TB recombinant allergen is positive and in the task it is negative
3.List necessary methods
chest x ray
*sputum exam by light microscopy with zhiel ,staining for the iso resistance of MBT and diagnostic test with TB recombinant allergen in standard dilution is mandatory,if bacteria excretion is detected the patient is redirected by specialized transport to the antiTB hospital,if microscopic test is negative but suspicious of TB patient is further examined in a specialized institution
##list mandatory test in specialized institution
* in specialized institutions of TB lab diagnosis exam of two samples of reminiscence microscopy:one sample for molecular genetic analysis(gene pert 1liquid media and dense media2 for second for culture for growth and drug sensitivity
*Test for HIV and hepatitis B and C
##Identify differential diagnosis
*purulent discharge should be tested in lab by microscopic with pcR in absence of data we can do biopsy of peripheral lymph nodes ,detect material in MBT ,cytological and histological
4.Diagnostic criteria of Sarcoidosis
*Gold standard for sarcoidosis of intrathoracic lymph nodes is Histological examination where epithelial granulomas are determined without caseous necrosis,the biopsy can be done by endobronchial scopy on the ultrasound fine needle puncture, we can use this method for deep tissue for intrathoracic
## treatment strategies
*Not all sarcoidosis require treatment the disease may disappear spontaneously in the case of Acute course just like our case ,follow up and regularly check up is suggested
* in acute sarcoidosis with severe symptoms NSAIDs such as Aspirin and ibuprofen are primarily prescribed which have anti flammatory and analgesic effects
*only with severe symptoms and lesions of the heart,kidney,nervous system, Glucorticoids prednisone are prescribed for a short period of time
Task 100
A 40-year-old patient who worked as a laborer at a food market was admitted to the emergency room of a hospital with complaints of weakness, pain in the right side of the chest, dyspnea, and a rise in the body temperature up to 38 °С.
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His condition deteriorated suddenly after hypothermia. The patient developed dry cough, dyspnea on mild exertion, he had a heavy sensation in the chest during breathing; and the body temperature increased. When the history was taken, it was revealed that about two months ago, the patient began to lose weight and feel tired and considered it to be the result of increased workload. One year ago, the patient had a contact with a relative infected with tuberculosis, MTB (+).
On examination, the patient’s condition was of moderate severity. Skin was pale; the patient had dyspnea, with respiration rate of 30 breaths per minute at rest. The heart rate was 110 bpm, satisfac- tory on palpation. The heart sounds were clear and rhythmic. The right side of the chest showed poor respiratory movements, intercostal space was flat. The percussion sound was short above the lower lobe of the right lung, vocal fremitus was decreased; breath sound in this lobe could not be auscultated. The abdomen was soft and painless; the liver was below the costal margin; the liver edge was sharp and elastic.
Complete blood count: hemoglobin 120 g / l, erythrocytes 4.8×1012 / l , leukocytes 9.0×109 / l, band neutrophils 8%, segmented neutrophils 66%, eosinophils 1%, lymphocytes 18%, monocytes 7%, and ESR 35 mm / h.
Urinalysis was performed with the following results: straw yellow color, transparent, aciduria, spe- cific gravity 1017, protein 0.066 ‰, 2–3 squamous epithelial cells / HPF, 5–6 leukocytes / HPF
Task:
1. Describe the chest X-ray pattern. Highlight the primary syndrome that can be detected on the chest X-ray. List diseases with similar syndromes based on the differential diagnosis.
2. List clinical syndromes. Interpret test results and establish a preliminary diagnosis. Develop a plan of doctor’s actions to differentiate the etiology of pleural effusions.
3. The patient underwent three pleural punctures, 80, 40 and 15 ml of straw yellow transparent fluid was removed respectively. Pleural fluid was analyzed with the following results: protein 50 g / l, cytosis; 96% of lymphocytes, 4% of neutrophils, 4% of acid-fast bacteria, no tumor cells. Was it correct to perform three pleural punctures?
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- List the necessary tests to be carried out at a specialized anti-TB facility to verify tuberculo- sis.
- The cartridge PCR GeneXpert System identified the MTB DNA, without rifampicin re- sistance. Decide on the treatment strategy.
- Diagnosis: Pleurisy with effusion on the right. Focal tuberculosis S1 of the right lung?
Description of chest x ray
*in direct projection we can see on the right side of the chest from the diaphragm to the anterior segment of 1,2,3,4th ribs shows an area of homogeneous darkening…
*real diaphragm sinus is also darkened, the darkening has an oblique upper border of clear contours going downward from the top in wards and outside
*there are are single focal shadows in the first segment of the upper lobe of the right lung ,small sizes,medium intensity,homogeneous structure and fuzzy contours
*conclusion :patient has two radiological syndrome
-pathology of pleurisy
-focal shadow syndrome
###list of differential diagnosis
*exudative pleurisy in the right side maybe TB etiology or non specific bacterial etiology
*focal pulmonary TB on the first second of the upper part of the right lung in infiltrative phase
###list clinical syndromes
*intoxication
*pain syndrome
*respiratory effusion
### laboratory results
*normal leukocytes
*left shift of leukocytes
*lymphopenia
*increased ESR
### clinical symptoms during two months radiology the patient complained of weakness ,weight loss, chest pain, shortness of breath,smoothening of intercostal spaces ,decreased vocal fremitus,dullness of percussion sound,no breathing in lower part of right chest ,blood changes and radiology changes allows the doctor to diagnose =Exudative pleurisy of unclear etiology and prescribe anti microbial therapy taking into account of the severity of concomitant pathology
*in this case doctor can prescribe protective penicillin,cephalosporin 3rd generation or macrolides for 6 days
*taking in to account of Anamesis data of contact with patients with TB as well if clinical picture of the disease we can mostly likely think of Exudative pleurisy of Tuberculosis etiology ,nonspecific pleurisy,mesothelioma metastasis pleurisy,cardiogenic effusion pleurisy
2a:list necessary tests in facilities
*differential diagnosis is carried out mainly of two forms of laboratory examination of pleura usually in a flu laboratory,specific gravity
protein,cytosois ,or also bacteriological maybe microscopy for isoresistance MBT,also culture for nonspecific microflora, cytological cellular composition of inflammatory remnants in exudate, and index primary investigation to establish the causes of fluid in pleura cavity in this case changes in the upper right lung which requires clarification of activity of TB , if TB is suspected a TB recombinant test is carried out
*Also HIV,Hepatitis B and C test are mandatory for TB patients
3:The patient underwent three pleural punctures
Answer:pleural fluid analysis has indirect signs of Type of Tuberculosis inflammation,there are transparent Exudative,protein >50% of serum proteins,lymphocytes in cells and in nonspecific more often neutrophils, fluid in the pleura cavity should be evacuated completely in order to prevent mucopurulent and effusion, and chest radiolography should be repeated after pleura puncture
4:list necessary tests to be carried out in specialized AntiTB facility
*we must use all method of diagnosis in previous tasks but material sample here will be sputum or Exudative
*tests include: * in specialized institutions of TB lab diagnosis exam of two samples of reminiscence microscopy:one sample for molecular genetic analysis(gene pert 1liquid media and dense media2 for second for culture for growth and drug sensitivity
*Test with TB recombinant allergen,, Maybe positive or hyper…ergic
5: The cartridge pcR gene X pert system identified MBT DNA without rifampin resistance decide on the treatment strategy
*we must give 1st regimen of chemotherapy H,R,Z,E, intense phase 2months, continuous phase 4 months with 3 AntiTB drugs such as :H,E,R total duration of is 6months
Task 101
A 46-year-old woman was admitted to the emergency room with complaints of increased body tem- perature up to 38.5 oC, chest pain, and cough with mucopurulent sputum. In the morning of that day, the patient noted streaks of blood in the sputum. The patient was a college teacher, who un- derwent preventive cheat X-ray every year. During the previous four months, the patient felt weak- ness which deteriorated over time, lost appetite and weight. The deterioration of the patient’s condi- tion occurred a week ago after hypothermia. Last year, the patient contacted a relative infected with tuberculosis. On examination, the patient’s condition was of moderate severity. The patient was emaciated. The skin was pale; acrocyanosis was noted. The patient coughed up blood (20–30 ml). Dyspnea, respiration rate of 26 breaths per minute at rest. The right side of the chest showed poor respiratory movements. The percussion sound was short above the lower lobe of the right lung. There was also bronchial respiration, fine and medium bubbling rales. Heart sounds were muffled, heart rate was 102 bpm. The liver was felt 1 cm above the costal margin. No other specific details were revealed. Complete blood count was performed with the following results: hemoglobin 95 g / l, erythrocytes 3.8×1012 / l, leukocytes 15.0×109 / l, band neutrophils 70%, eosinophils 1%, lympho- cytes 8%, monocytes 7%, and ESR 45 mm / h. The patient underwent chest X-ray in the emergency room.
Task:
1. Describe the chest X-ray pattern. Highlight the primary syndrome that can be detected on the chest X-ray.
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- List the clinical syndromes, interpret clinical tests. Decide on a preliminary clinical diagno- sis. Determine the algorithm of action of the primary health care facility physician when working with patients with respiratory diseases with suspected tuberculosis. Identify risk factors for TB in this patient.
- Determine further strategy when a patient is found to have AFB and a positive (10 mm indu- ration) test with a recombinant tuberculosis allergen (a test with RTA, Diaskintest).
- List the necessary tests to be carried out at a specialized anti-TB facility to verify pulmonary tuberculosis.
- Decide on a clinical diagnosis. Make a treatment plan taking into account the complication and the absence of laboratory data on sensitivity to drugs of the TB causative agent at the initial stage. What work should be carried out with the exposed persons?
1:Describing of chest x ray
*chest x ray on the direct and lateral projection
*in the lower part there are changes in the lateral projection of the right lung we can see dimming of medium intensity of inhomogeous structure, we can see small areas of enlightenment with fuzzy contours is determined
*pulmonary field of the left lung is without focal or infiltrative changes
*The root of the left lungs is normal but right lung root is changed no structure and has fuzzy contours near there is dimming
*conclusion# first syndrome is -Dimming syndrome
-pathology of the root
##differential diagnosis
*infiltrative pulmonary TB of the lower lobe of the right lung in phase of decay inhomogeous structure
*pneumonia of the lower lobe of the right lung
## clinical syndromes
*Bronchitis
*intoxication
*respiratory failure
*hemorrhagic syndrome
##laboratory CBC:mild anemia ,leukocytosis, left shift,lymphopenia and increased ESR
In Anamesis data clinical symptoms such as shortness of breath ,acrocyanosis,laboratory and radiological studies at the initial stage allows the doctor to diagnose community acquired lower lobe pneumonia,complicated by Hemoptysis .in this regard at the hospital stage before receiving microbiological analysis of sputum .empirical antibiotics is prescribed
*we also take note of concomitant diseases in this case we can prescribe protective penicillin or cephalosporin or macrolides
*if there is an epidemiological risk factor mainly contact with TB patient, the mandatory algorithm includes
-chest x ray
-light microscope sputum by zhiel nelson 3 types of samples and test with TB recombinant allergen but WHO recommends studying sputum by seeding 2 samples preferably morning sample for molecular genetic test genexpert and one sample for culture for solid or liquid media
-only when a positive molecular genetic test is obtained then microscopic sputum smear be useful in assessing of bacteria involved and degree of conjugation of the patient
3: determine further strategy when a patient
* we found acid resistance MBT and test with recombinant test is 10mm induration is positive our strategy here is
-patient should be isolated and attended by phthilogist in a short time and redirected by sanitary transport or ambulance to a specialized institution of TB
4: list the necessary tests to be carried out at a specialized AntiTB facility
* in specialized institutions of TB lab diagnosis exam of two samples of reminiscence microscopy:one sample for molecular genetic analysis(gene pert 1liquid media and dense media2 for second for culture for growth and drug sensitivity
*Test for HIV and hepatitis B and C
5: decide on clinical diagnosis.make a treatment
*clinical diagnosis is infiltrative pulmonary TB of the lower lobe of the right lung in the phase of decay MBT positive,complications:hemoptysis ,respiratory failure grade 2 and anemia of mild severity
*In the absence of data of drug sensitivity of MBT first chemotherapy is prescribed H,R,Z,E for 2months intensive phase, continuous phase H,E,R for 4 months duration of treatment is 6months
*what work should be carried out :after isolation of patient in TB hospital it’s is necessary to carry out a comprehensive medical assessment of students and teachers of the college and family members in a Anti TB dispensary risks we can prescribe prophylactic drugs and disinfection of the place of residence and work , final disinfection is carried out by the epidemiological service institution when there is an established diagnosis of TB
Task 102
A 27-year-old patient sought medical care at an emergency hospital. During the last two weeks, the patient has had weakness, sweating, drowsiness, extreme irritability, loss of appetite, wet cough, rise of body temperature (37.5–38.0 ̊С), photophobia, and dyspnea at rest. The patient sought med- ical care at the hospital at his place of residence. After the examination by the general practitioner, the patient was diagnosed with acute respiratory viral infection of moderate severity. The patient was prescribed therapy to treat symptoms (antipyretics, antihistamines, and vitamins) with a follow- up in five days. Despite the therapy the patient received, his condition deteriorated. Headache with- out a clear localization became more intense and could not be relieved by analgesics. Headache was accompanied by vomiting which was unrelated to food intake, without previous nausea. The body temperate rose to 39 °С. The patient noted red spots on the face and chest which appeared sponta- neously and disappeared shortly. Complete blood count was performed with the following results: 3.5×1012 / l erythrocytes, 115 g / l hemoglobin, 9.4×109 / l leukocytes, eosinophils 3%, band neutro- phils 7%, segmented neutrophils 61%, lymphocytes 17%, monocytes 12%, and ESR 52 mm / h. Taking into account the above clinical symptoms, changes in the tests and the course of the disease, the on-call internal medicine physician referred the patient to a neurologist. The patient had positive meningeal signs (neck stiffness, a positive Kernig’s sign, and a positive Brudzinski’s sign), dilated pupils, and exotropia. A spinal puncture revealed an increased pressure (the fluid flows out in a stream); cytosis with 200 cells in 1 mcL, with neutrophils 10%, lymphocytes 90%, chlorides 70 mmol / l, glucose 0.6 mmol / l, protein 1.2 g / l. The results of chest X-ray might suggest pulmonary tuberculosis, the patient was referred to a phthisiologist with a further visit to a specialized institu- tion where he was diagnosed with HIV, CD+102 cells / ml
Task:
1. Describe the chest X-ray pattern. Highlight the primary syndrome that can be detected on the chest X-ray. List diseases with similar syndromes based on the differential diagnosis.
2. List clinical syndromes, interpret clinical tests, and justify a preliminary clinical diagnosis. Determine, based on the symptoms, which pair of cranial nerves is affected in the patient, which other cranial nerves can be affected by central nervous system tuberculosis.
3. Determine the indirect signs of cerebrospinal fluid in patients with TB.
4. Make a plan of actions for the doctor of the primary health care facility when working with a
patient with symptoms suggestive of tuberculosis. List the necessary tests to be carried out at a spe- cialized anti-TB facility to verify the disease.
5. Establish a clinical diagnosis, make a treatment plan taking into account the results of bacte- riological tests of sputum and cerebrospinal fluid with established sensitivity of MTB to anti- tuberculosis drugs.
- Diagnosis: Subacute disseminated tuberculosis, focal bilateral pneumonia. Meningism, aseptic
viral meningitis, purulent meningitis, brain tumors, subarachnoid hemorrhages, brain ab-
scesses.
** Additional information - The chest X-ray pattern description
*chest x ray is in direct projection
*Both lungs have multiple focal shadow,medium intensity,fuzzy contours like a snow like pattern
*lung roots are poorly differentiated hardly visible
*conclusion :Dissemination syndrome
###Diagnosis is subacute disseminated pulmonary tuberculosis,focal bilateral pneumonia
*This patient has meningeal signs👉🏿meningitis ,brain abscess
1a:list clinical syndromes
*bronchitis
*meningeal syndrome
*severe intoxication
*respiratory failure
###laboratory test result interpretation:mild anemia,leucocytosis,lymphopenia,monocytosis,increased ESR
##patients which risk factors include
*pronounced immunosuppression
*Hiv diagnosed
##which pair of cranial nerves is affected in this patient
*Abducens never 6
*facial nerve
*ocular motor nerve
*vagus nerve
*vestibocochlear nerve
*glossopharyngeal nerve
3-:determine the indirect signs of csF in patients with Tb
*increased cystosis
*increased glucose
*increased lymphocytes
*decreased proteins
4.make plans for the doctor of the primary health care facility
*with the interpretation of the clinical results and confirmation the patient will be isolated and attended to by a phthiologist then transferred in an ambulance 🚑 to a specialized Tuberculosis facility
# Test to be carried out in a TB
*sputum analysis two samples preferably morning sputum according to wHO, analysis for liquid media and dense medium for Antibiotics sensitivity and recombinant allergen test and also genetic testing gene xpert Elisa or PCR
5:Establish a clinical diagnosis
*Hiv stage 4B, progressive with antiretroviral drug with manifestation of multiple secondary diseases,generalized Tb,subacute disseminated and infiltration phase,TB meningitis basilar form ,MBT -(ve) negative
Sputum and
### treatment in this patient is the 1st regime HRZE 2 months intensive phase,HRE 4 months total period of treatment is 6months
Task 103
A preventive chest X-ray revealed changes in the lungs of a 35-year-old patient. The patient’s living conditions were safe. The patient worked as a sales assistant at a shopping center, where he was not exposed to hazards. The patient has not undergone not undergo preventive chest X-ray for 4 years. The patient had no complaints or intoxication symptoms. Objective examination findings: no pa- thology of chest organs was revealed on percussion and auscultation. Heart sounds were rhythmic. Heart rate was 79 bpm. Blood pressure was 125 / 85 mmHg. The abdomen was soft and painless. Complete blood count: erythrocytes 4.1×1012 / l, hemoglobin 130 g / l, leukocytes 5.4×109 / l, band leukocytes 1%, segmented leukocytes 68%, lymphocytes 25%, monocytes 4%, and ESR 9mm / h. For further examination, she was referred to the phthisiopulmonological medical center. No AFB were detected in the sputum by bacterioscopy; no MTB DNA was detected by Gene-Xpert MTB/RIF. After the test with RTA was carried out, the size of the induration was 21 mm.
Task:
1. Describe the chest X-ray pattern. Highlight the primary syndrome that can be detected on the chest X-ray. List diseases with similar syndromes based on the differential diagnosis.
2. List clinical syndromes, interpret clinical tests, and establish a preliminary clinical diagnosis.
3. List necessary tests to be carried out at a specialized anti-TB facility to verify pulmonary
tuberculosis.
4. Determine the role of immunodiagnostic methods in the differential diagnosis of tuberculo- sis, list the methods and purposes of their application.
5. What are the treatment strategy and prognosis?
1:Description of chest x ray
*chest ray of direct projection we can see on the right lung in the 3rd intercostal space a rounded shadow 2cm in diameter medium intensity,homogeneous structure with clear contours is determined pleural in the 6th segment have this pathology
*conclusion :rounded shadow syndrome
## differential diagnosis
*Tuberculoma of the right lung presumably in the 6th segment of the lower lobe of the right lung
*peripheral cancer
*maybe pneumonia
###clinical syndromes
*Signs of disease is inclined towards tuberculoma of the right lung in the compaction phase , asymptomatic course of the disease,absence of physical changes ,laboratory information data are characterized of tuberculosis of this size but the absence of Fluorographs for years ,patient didn’t understand preventive chest x ray for 4 years indicates chronic progression of TB ,location is in 6th segment of the right lung is typical of Tuberculosis,clear contours of rounded shadow indicates the process of fibrotic capsule around the rounded shadow,absence of bacteria excretion by PCR and microscopic is characteristic of this clinical form
.since caseous is capsulated and doesn’t communicate with the bronchi or process of recombinant allergen test carried out in case was 21mm in duration is hyperegic and positive MBT indicates the presence of inactive TB in the body
3. List necessary tests to be performed in specific institutions
* in specialized institutions of TB lab diagnosis exam of two samples of reminiscence microscopy:one sample for molecular genetic analysis(gene pert 1liquid media and dense media2 for second for culture for growth and drug sensitivity
*Test for HIV and hepatitis B and C
4. Determine the role of immunodiagnosis
*all methods such microscopic,molecular genetic methods, seeding, immune -diagnosis is one of main ,chest X-ray and rounded shadow we can talk about TB
5:treatment strategies
* we don’t have information about drug resistance so we prescribe first regimen chemotherapy and we can use surgical treatment after two months of intensive chemotherapy we give resection of the 6th segment
Task 104
Patient V. was 37 years old. The patient called an ambulance and was taken to the emergency mul- tiprofile hospital because of complaints of severe pain in the thoracic and lumbar spine, which was not relieved by analgesics. The pain appeared two months ago. It intensified if the patient changed the position of the body. The pain also radiated to the left leg. It was accompanied by increasing weakness in the legs, increasing body temperature up to 38 °С, and cough with mucous sputum. The patient had HIV, which was diagnosed 4 years ago in prison. The patient also took psychoac- tive substances. After his release from prison, he did not register with the Center on Prevention and Control of AIDS. He did not receive antiretroviral therapy. Two years ago, he underwent chest X- ray, further examination was not required. Examination of the spine revealed tension of the back muscles, protrusion of the spinous process of the Th7 vertebra, axial loading test was positive, and therefore the patient had to be in a bent position. Paresis of the lower extremities and dysfunction of the pelvic organs were not revealed. Complete blood count was performed with the following re- sults: erythrocytes 3.6×1012 / l, hemoglobin 95 g / l, leukocytes 12.4×109 / l, eosinophils 3%, band neutrophils 7%, segmented neutrophils 71%, lymphocytes 7%, monocytes 12%, and ESR 62 mm /
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h. CD 4+ was 190 cl / ml, viral load was of 630000 copies / ml. The patient underwent chest CT (scans for diagnosing are attached). The test with RTA was negative.
Task:
1. On the presented sections of chest CT, determine the changes in the pulmonary parenchyma, mediastinum and spine. List lung and spine diseases with similar syndromes based on the differen- tial diagnosis.
2. List clinical syndromes, risk factors, interpret clinical tests, and justify a preliminary clinical diagnosis.
3. Make a plan for the doctor of the primary health care facility when working with an HIV- positive patient with symptoms suggestive of tuberculosis.
4. List the necessary tests to be carried out at a specialized anti-TB facility to verify the dis- ease.
5. The cartridge PCR GeneXpert System identified MTB DNA with rifampicin resistance. De- termine the treatment strategy for the patient, taking into account the revealed drug resistance of the pathogen
- Diagnosis: HIV, stage 4B (late-stage), progression phase without antiretroviral therapy, with the
manifestation of multiple secondary conditions. Generalized tuberculosis involving intratho-
racic lymph nodes and spine. - On the presented sections of chest CT, we can see enlarged bronchial primary lymph nodes on both sides and also we can see dimming in the lung parenchyma around the bronchial primary lymph nodes
*few miliary focal shadows can be lymphogenesis in the 3 rd segment of the right lung and left lung
*CT of the vertebrae column we can see changes on the vertebrae,we can see spine kyphosis in the body of the vertebrae,Thoracic 7 and 8, and thoracic 2 has changes we can see foci of destruction of the vertebrae
*conclusion :chest CT has root pathology syndrome ,focal shadow syndrome ### CT of vertebrate (pathology of the vertebral column
### differential diagnosis
CT of lungs
-TB of the intrathoracic lymph nodes
-sarcoidosis of the intrathoracic lymph nodes
-lymphogranolomatosis
CT of spine
-Tuberculosis of spondylitis
-Osteomyelitis
-Tumor metastasis to the spine
## justify the diagnosis
*data of Hiv since for years ago ,stage 4B progression phase without antiretroviral therapy with manifestation of secondary diseases and generalized TB with lesions of intrathoracic lymph nodes and spine,we can also talk about TB of intrathoracic lymph nodes and TB spondylitis,preminary diagnosis is based on the HIV infection in the stage of immune deficiency we can see CD 4 cells is 190 cells perml which is very low, and it manifest it self in the course of the disease severe pain syndrome that doesn’t relieve with analgesics, severe intoxication with fever up to 38 c ,inflammatory changes in CBC, we can see lymphopenia,monocytosis,leukocytosis and left shift, increased ESR and anemia
###Clinical syndromes
*Bronchitis
*cough with sputum
*social risk factors such as prison ,inpatient with co-infection with decreased immunity,
*Tb of multiple localization is determined as we can see on CT of lungs we can see bilateral intrathoracic lymphoadenopathy and TB spondylitis - Make a plan for a doctor
*With the data of hiv and CT data of this patient,the patient should be consulted by a tuberculosis specialist doctor to determine the clinical form of the TB and transferred to a tuberculosis specialized facility
4: list necessary tests in a specialized facility
* in specialized institutions of TB lab diagnosis exam of two samples of reminiscence microscopy:one sample for molecular genetic analysis(gene pert 1liquid media and dense media2 for second for culture for growth and drug sensitivity
*Test for HIV and hepatitis B and C
* we can also use bronchoscopy
*we can use ultrasound of abdominal cavity,
*endobronchial ultrasound and take some aspirates for histological and cytological studies
5:The gene xpert system rifampicin resistance
*This case has multi drug resistance the appropriate regimen is 3rd regimen for multi-drug resistance
###prepare during 6months intensive phase :linezolid,cycloserine, levofloxacin,pyrazinamide and Ethanbutol ,moxifloxacin 6 anti TB drugs during intensive phase for 6 months and continuous phase 12-18months 3-4 anti TB drugs which will be levofloxacin,linezolid and cycloserine plus ethanbutol or pyrizanamide
Task 105
Patient N., 13 years old, was referred to a phthisiologist based on the results of immunodiagnostic tests conducted at school. The patient had no complaints. The child’s family was wealthy; the living conditions were satisfactory. The patient was vaccinated with Bacillus Calmette–Guérin vaccine in the maternity hospital on the 3rd day of life, a 5-mm scar. The patient was revaccinated with BCG at the age of 7, with a 4-mm scar. The boy spent summer with his grandmother in the village, where several patients with active tuberculosis were being treated at the first aid station.
Dynamics of immunodiagnostic tests:
Up to 7 years of age, immunodiagnostic tests were not performed based on the decision of parents. 7 years – Mantoux test – 1 mm induration,
8 years – test with RTA – 2 mm bruise,
9 years – test with RTA – 1 mm induration,
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10 years – test with RTA – 1 mm induration,
11 years – test with RTA – 1 mm induration,
12 years – testwith RTA – 1 mm induration,
13 years – test with RTA – 11 mm induration, referred to a phthisiologist.
Objective examination findings: the patient’s condition was satisfactory; no intoxication symptoms were noted. His physical development corresponded to his age. The skin was clear and dark. Pe- ripheral lymph nodes were not enlarged. Respiration was vesicular, clear. Heart sounds were clear, rhythmic. The abdomen was soft and painless.
Complete blood count: erythrocytes 3.6×1012 / l, hemoglobin 120 g / l, leukocytes 7.8×109 / l, eo- sinophils 1%, band neutrophils 3%, segmented neutrophils 63%, lymphocytes 25%, monocytes 8%; ESR 8 mm / h.
Chest CT did not reveal any pathology. Abdomen ultrasound did not reveal any pathology.
The preventive chemotherapy prescribed by the phthisiologist was not carried out due to the refusal of the parents. The second test with RTA was run after three months with a size of induration of 15 mm. The patient developed weakness, sweating, periodic rise of body temperature in the evenings up to 37.7 ̊С.
Clinician-observed: condition of moderate severity. The skin was pale, wet on palpation. There was a decrease in skin turgor. Peripheral lymph nodes (occipital, submandibular, cervical, supraclavicu- lar, axillary, and inguinal) were up to 0.6-0.8 cm on palpation; their consistency was mildly elastic. The lymph nodes were painmobile, and not connected to the surrounding tissue and among themselves. During physical examination in the lungs: percussive pulmonary sound, vesicular breath sounds, no abnormal breath sounds. The heart sounds were clear and rhythmic. The abdomen was soft and painless.
A plain X-ray of the chest organs was performed.
Sputum microscopy and sputum and urine cultures on MTB were negative.
Complete blood count: erythrocytes 3.4×1012 / l, hemoglobin 110 g / l, leukocytes 8.2×109 / l, eo- sinophils 1%, band neutrophils 1%, segmented neutrophils 62%, lymphocytes 30%, monocytes 6%. ESR was 17 mm / hour.
Task:
1. Describe the chest X-ray pattern. Highlight the primary syndrome that can be detected on the chest X-ray. List diseases with similar syndromes based on the differential diagnosis.
2. List the clinical syndromes, interpret the results of the RTA test, clinical tests. Identify risk factors for tuberculosis. Establish a preliminary clinical diagnosis and justify it.
3. List the necessary tests to be carried out at a specialized anti-TB facility to verify pulmonary tuberculosis.
4. Determine the role of immunodiagnostic methods in the differential diagnosis of tuberculo- sis. List the methods and their purposes.
5.Determine the strategy of treatment and follow-up in the tuberculosis dispensary.
1.Description of chest X-ray
* in direct projection and right side lateral projection
*we can see definition of expansion and non structure of the roots of the right lung ,pathology has bronchial groups of intrathoracic lymph nodes
* contours of these changes are clear, lung parenchyma has no changes
*conclusion: x ray syndrome is pathology root syndrome
##differenial diseases
*Tb of intrathoracic lymph nodes of the right lung
*lymphogranulomatosis
*lymphosarcoma
2:list clinical syndromes and interpret
##Clinical syndromes
*Intoxication syndrome
*lymphoproliferative syndrome
## laboratory results:anemia ,increased ESR
## risk factors of possible contact with Tb in the Anamesis data we can see the age of the patient, and refusal of the preventive AntiTB therapy by the parents ,the results of the immunodiagnosis of the Tb infection up to 13 years and at the moment Tb recombinant allergen test is positive with transition to hyperreagic and x ray exam data is necessary to think of TB of intrathoracic lymph nodes and this diagnosis is made in the basis of patients complaints such as weakness ,increased body temperature,data from CBC,exposure to where many TB patients were treated , test with Tb recombinant allergen
* we can see 11 mm i duration we characterized it has MBT positive
3:list necessary tests
* in specialized institutions of TB lab diagnosis exam of two samples of reminiscence microscopy:one sample for molecular genetic analysis(gene pert 1liquid media and dense media2 for second for culture for growth and drug sensitivity
*Test for HIV and hepatitis B and C
*material for patient is sputum
4:Determine the role of immunodiagnosis
##role
-we can use tests in vivo and TB test with recombinant allergen tests information when child was 12 it was negative and when he was 13 it was positive also we can use Diagnostic test of TB in vitro,TB spot test,manitoux and Tb in vivid
5.strategy of treatment
* since no MBT was found in all test
* Final diagnosis in this is case is Tb of intrathoracic lymph nodes of the right lung in the infiltrative phase MBT negative
* chemotherapy regimen to use is 1st regimen HRZE
###dispensary group;patient has 1st group of dispensary group observation because he started treatment
