Зapa Dahiliye Gьnleri

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Çapa Dahiliye Günleri

• Tüberküloz Olgu Sunumu
• Cerrahpasa Tip Fakültesi
• Enfeksiyon Hastaliklari ve Klinik Mikrobiyoloji
  AD
• Dr Uluhan Sili
• 2.Nisan.2009
• Prof Dr Ali MERTin bir olgusundan uyarlanmistir.

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Olgu

• 23 y, erkek hasta
• 4 hafta önce sistemik lupus eritematozus (SLE)
  tanisi konmus
• Ates, halsizlik, istahsizlik, kilo kaybi,
  bulanti/kusma
• Sistemik LAP, splenomegali
• Trombositopeni, lökopeni, ESR? (60mm/saat),
  CRPN, proteinüri, mikroskopik hematüri, piyüri,
  ALT ve AST ?
• Anti-dsDNA (), ANA (-), C3 ve C4?
• Böbrek bx mezengioproliferatif lupus nefriti

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Klinik kötülesme...

• Steroid tedavisinin 4. haftasinda
• Klinik yanit alinmaya baslandigi sirada kötülesme
• Ates, kuru öksürük
• CRP? (x20)
• Kültürlerde üreme yok
• Akc PA N

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SLE reaktivasyonu düsünülerek...

• Pulse steroid siklofosfamid baslaniyor
• Bu tedavinin 2. haftasinda klinik yanit yok
• Haftalik çekilen akc grafisi ve YÇBT ile takip
  ediliyor

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Tani Miliyer TB

• BAL ARB (-)
• Empirik anti-TB (INH/RIF/PZA/EMB) baslaniyor
• BAL ve TB hemokültürde pansensitif M.
  tuberculosis üremesi

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Anti- TB tedavinin 4. ayi içinde...

• Biraz düsme egiliminde olan atesleri tekrar ?
• Hafifleyen öksürükleri artiyor ve dispne ekleniyor

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YÇBT Miliyer odaklarda ilerleme

• Sayilari ve büyüklükleri artmis
• Üst loblardaki nodüllerde kaviteler gelismis
• BAL ARB ve PCR (-), kültür (-)
• TB hemokültür (-)

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Paradoksal Reaksiyon

• Yol tedaviye devam
• Anti-TB tedavinin 6. ayinda atesleri düsüyor ve
  taburcu ediliyor

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Taburcu edildikten 1 ay sonra

• Birden biçak batar gibi ciddi sol yan agrisi
• Gittikçe artan solunum darligi

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TANI Pnömotoraks(Paradoksal reaksiyon sonucu)

• Dren konulup akc genislemesi saglaniyor
• Anti-TB tedavini 8. ayinda PPD ()lesiyor
• Tedavi 12 ay sürdürülüyor
• Tedavi bitiminin 12. ayinda miliyer odaklar
  kayboluyor

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Sonuç olarak...

• Miliyer TB, yeni atesi gelisen tüm immün düskün
  hastalarda mutlaka akla getirilmelidir.
• Bir derlemede miliyer TB olgularinin 20sine
  tani post mortem konmus UpToDate
• Miliyer infiltratlar saptanir saptanmaz anti-TB
  tedavi baslanmalidir. Mert A, 2001, Respirology
• Ilginiz için tesekkürler!

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Underlying medical conditions in patients with
miliary tuberculosis (UpToDate)
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Symptoms in patients with miliary tuberculosis
(UpToDate)
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HRCT (UpToDate)

• more sensitive for miliary TB than plain chest
  radiography
• numerous, 2 to 3 mm nodules can be visualized,
  distributed throughout the lung
• However, while sensitive these findings are not
  necessarily specific.

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Differential diagnosis of febrile illness with
miliary chest x-ray infiltrates (UpToDate)

• Infectious Diseases
• Mycobacterial
• Mycobacterium tuberculosis, atypical mycobacteria
• Fungal
• Endemic fungi (histoplasmosis, coccidioidomycosis,
  blastomycosis, paracoccidioidomycosis)
• Bacterial
• Legionella micdadei infection, Nocardiosis
• Staphylococcus aureus, Haemophilus influenzae and
  other pyogenic bacteria
• Psittacosis, Tularemia, Bartonellosis,
  Brucellosis, Meliodosis
• Viral
• Varicella, Cytomegalovirus, Influenza, Measles
• Parasitic
• Toxoplasmosis, Strongyloidiasis, Schistosomiasis,
  
• Neoplastic diseases
• Lymphoma, Lymphangitic spread of carcinoma,
  Mesothelioma
• Other diseases
• Sarcoidosis, Amyloidosis, Hypersensitivity
  pneumonitis, Pneumoconioses
• Foreign-body induced vasculitis related to
  injection drug use

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Frequency of positive smear or culture in
patients with miliary tuberculosis
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PCR for diagnosis of miliary TB (UpToDate)

• more sensitive than standard techniques in some
  series examining respiratory specimens, CSF, bone
  marrow, or liver biopsy specimens.
• PCR of the blood was positive in 100 percent of
  a small number of patients with disseminated
  disease (defined as involvement of two or more
  noncontiguous extrapulmonary organs), and in no
  controls (healthy patients or patients with
  positive PPDs).

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Treatment (UpToDate)

• Isoniazid and rifampin are then administered for
  at least six months
• Tailored to the underlying immune status of the
  host, the burden of infection as well as the
  clinical and microbiologic response
• Longer therapy should be considered in the
  following patients with miliary TB
• Children and immunocompromised hosts, including
  those with HIV infection and iatrogenic
  immunosuppression
• Those with lymphadenitis, a site of early relapse
  in anecdotal reports
• large organism burden, for example those with
  anergic or non-reactive tuberculosis
• slow microbiologic or clinical response