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Case Conferences

   

August 28, 2013

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Total Posts: 16

Joined 2014-04-02

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No PMHx, presents with L draining ear x two wks, not improving with Amoxicillin, 3 days increasing SOB. Hear the discussion and more!

     
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Total Posts: 24

Joined 2014-05-05

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what are the diagnostic tests performed apart from CT ?

     
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Total Posts: 10

Joined 2014-05-06

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case:1——-was wondering if CT abdomen was done to rule out adrenal tuderculosis.This case looked like a case of miliary TB with addisons crisis with bacterial CSOM.was CSOM culture swab sent and blood culture done.Did the fundus show papilloedema and was guarded lumber puncture done?results of these will alter management.with this pulmonary TB picture dissemination to the brain is common and we get such lesions in brain.we give short course of steroids with AKT to prevent paradoxical worsening of patient due to brain oedema once AKT is started.If patients develop AKI we give renal sparing drugs including INH,rifa and PZA.we invariably drain a psaos abscess and also drain pleural effusion to prevent pleural thickening and to prevent loss of lung compliance.
Case @ ;we woul like to treat TB at whatever stage it has been detected rather than wait for pregnancy to end.in the long run it helps both the mother and child and avoids spread.

                            Dr anita basavaraj

     
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Total Posts: 8

Joined 2014-05-30

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case:1——-was wondering if CT abdomen was done to rule out adrenal tuderculosis.This case looked like a case of miliary TB with addisons crisis with bacterial CSOM.was CSOM culture swab sent and blood culture done.Did the fundus show papilloedema and was guarded lumber puncture done?results of these will alter management.with this pulmonary TB picture dissemination to the brain is common and we get such lesions in brain.we give short course of steroids with AKT to prevent paradoxical worsening of patient due to brain oedema once AKT is started.If patients develop AKI we give renal sparing drugs including INH,rifa and PZA.we invariably drain a psaos abscess and also drain pleural effusion to prevent pleural thickening and to prevent loss of lung compliance.
Case @ ;we woul like to treat TB at whatever stage it has been detected rather than wait for pregnancy to end.in the long run it helps both the mother and child and avoids spread.


In response to the first question about additional tests, I am presuming the question relates to Case #1.  Additional tests in patients with sepsis (with pulmonary infiltrates) included a urine pneumococcal antigen, urine legionella antigen, sputum gram stain and bacterial culture, nasopharyngeal aspirate for respiratory viral panel (our standard panel includes influenza a and b, RSV, human metapneumovirus, adenovirus, parainfluenza; a rapid DFA is done, if negative viral cultures are performed), blood cultures to evaluate for bacteremia (and fungemia), sputum fungal cultures.  Mycobacterial testing includes AFB smear and culture from all sites of suspected disease.  Fungal culture is also performed from sites of suspected disease.  Urine Histo Antigen is sent in HIV patients in whom disseminated Histo is a consideration.  Cryptococcal antigen and other fungal serologies are also available as needed.  In immunosuppressed patients with suspected invasive aspergillosis, galactomannan is also often sent.  Other tests/imaging included an echocardiogram to assess cardiac function in the setting of hypotension and also to assess valves and evaluate for vegetations.

To answer the second post question, a pan-CT was done that included abdominal CT imaging.  There was no evidence of adrenal involvement.  Hypotension was attributed to sepsis physiology with systemic vasodilation.  There was also no evidence of papilledema on fundoscopic exam.  The patient had an MRI of the brain which shows the lesions (see slides).  All of our CNS TB cases get adjunctive steroid therapy, though it is usually our practice to give steroids with a slow taper over 6 weeks with many cases requiring prolonged steroids due to worsening brain edema later in the treatment course after steroids are withdrawn. As for abscesses, it is generally the practice that we drain all abscesses and pleural effusions.  That said, there is actually debate in the literature about medical management vs percutaneous interventions vs open drainage for TB related fluid collections.  While it is common practice to drain TB fluid collections from most body sites, there have been reports of good response with medical management alone with pleural disease, but we would agree that often we will drain to avoid any residual pleural fibrosis/thickening.  There have been reports of fistula formation with drainage of some TB abscesses (see some of our other case studies/webinars), prompting some debate.

     
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Total Posts: 21

Joined 2014-05-04

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In the case with CSOM with lung problem. The chest Xray shows left side pleural effusion . Was it tapped ? Why were 2nd line drugs used from the start rather than trying primary drugs and seeing the response under close monitoring. AKI could have been a part of sepsis or was it due to suspected miliary TB?