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Case Conferences

   

February 25, 2013

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Total Posts: 16

Joined 2014-04-02

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Should skin/soft tissue TB abscesses be drained? What is the role of surgical treatment (i.e. pre-vertebral abscess) vs. medical management? How is the duration of steroids for treatment of TB pericarditis modified with HIV and ART usage? Hear the discussion on these questions and more!

     
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Total Posts: 24

Joined 2014-05-05

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plural fluid biochemistry was done ?

     
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Joined 2014-05-30

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Pleural fluid is usually evaluated for ph, WBC with differential, LDH, Total Protein.  Occasionally an ADA is also sent.  In the interest of time, they were not presented in this case, but my recollection is that the pleural fluid was lymphoctytic and exudative by Light’s criteria.

     
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Total Posts: 24

Joined 2014-05-05

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Thank yu so much Maunak

     
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Joined 2014-05-05

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These are really good cases for discussion since resurgence of TB and in HIV pandemic, one very often sees these kind of cases arising all over.

In the first case after I & D for abscess, it should have been sent for ZN staining & culture.  I think we need to keep a strong index of suspicion to diagnose TB lymphadenitis so as to avoid delayed TB diagnosis and treatment initiation.

Case 2: Scrofula, Tuberculous cold abscess of chest wall and lower neck is increasing in day to day practice, probably due to heightened hypersensitivity reaction to tubercular protein or as a paradoxical reaction. Cases should be screened properly & combined surgical and medical intervention required.
Evidence shows that surgical excision of the scrofula does not work well for M. tuberculosis infections, and has a high rate of recurrence and formation of fistulae. Scrofula caused by NTM, on the other hand, responds well to surgery, but is usually resistant to antibiotics.

Case 3: Specific risk factors identified for TB-IRIS include multiple prior opportunistic infections, low CD4 count at initiation of antiretroviral therapy, rapid rise in CD4 cell count following initiation of antiretroviral therapy, and a rapid drop in HIV RNA levels following initiation of antiretroviral therapy.
Based on recently released data from three randomized trials, the WHO Guidelines therefore recommend starting antiretroviral therapy as soon as tuberculosis therapy is tolerated —specifically, as soon as possible (and within 8 weeks) of initiation of anti-TB therapy.

Numerous anecdotal reports and small clinical trials have suggested corticosteroids help reduce inflammation in the setting of TB-IRIS.  Specific formulations and doses used in reports have included intravenous methylprednisolone 40 mg every 12 hours and prednisone 20 to 70 mg per day in tapering doses

In a recent cohort study of South African patients, 10% of the patients with suspected TB-IRIS were found to have previously undiagnosed rifampicin-resistant TB. Hence, in this case I think drug resistance TB should have been ideally ruled out, specifically in patients with active TB and a presentation consistent with TB-IRIS, especially if administration of corticosteroids is being considered.


Sangita Shelke

     
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Joined 2014-05-07

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We discussed an article yesterday in our Journal Club in which there was no significant difference in the treatment outcomes ( a composite of death,recurrence and failure) in HIV positive patients with new smear positive and culture positive pulmonary TB with early ( at the end of 2 weeks ) versus delayed ( at the end of 6 months) initiation of ART after starting anti tuberculosis treatmentThe patients had a CD4 count of more than 22 cells/uL.

     
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Total Posts: 21

Joined 2014-05-04

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The steroids are generally advised for 2 to 3 weeks and tapered over 2 to 3 weeks - TBM, Pericarditis? Does longer duration of steroids are beneficial ?