MEDICAL

PATHOLOGICAL
PHARMACOLOGICA
L AND
RADIOLOGICAL
November 29, 2007
Rm. 204

CONFERENCE

2
 Approach to Patient
with

Pulmonary Tuberculosis
Subsection A4

Aquino, Elenor
Arguelles, Aldrich
Arias, Mark Anthony
Arriola, Anna Carlisa
Asuncion, Lyndon Paolo
Atanacio, Shari Ann
Atanga, Pascal
Atazan, Judy Carissa
Atienza, Bryan Jason
Atutubo, Cosette Esmeralda
3
Complete History and
Physical Examination
4
 General Data
Name: A.S.
Age: 55 years old
Religion: Catholic
Occupation: Caretaker
Address: Cavite

Chief Complaint: Melena, Chronic Cough

History of present illness

1
Day
PTA
 6 Months PTA
• Episodes of non-productive cough
with no accompanying symptoms.
• No consultation
• No medication
 4 Months PTA
• Productive cough with yellowish-
greenish phlegm.
• Medication
– Carbocisteine syrup tid for weeks, no
relief
– Guiafenessin syrup tid, partial relief
 1 Month PTA
• Intermittent epigastric pain
– aggravated by hunger
– relieved by food.
• accompanied by
• headache, nausea and vomiting.
• Medication
– Famotidine 20 mg/tab, 1 tab tid
– provided partial relief.
 1 Month PTA
• Intermittent productive cough
• Physician diagnosis : Pulmonary
Tuberculosis
– Positive AFB smear
– Sputum sensitivity
– Chest x-ray
– Lymph node biopsy
Main menu
 1 Month PTA
• Medication for PTB
– Ethambutol
– Rifampicin
• Compliance was unrecalled
 2 Weeks PTA
• persistence of symptoms
• tested for blood chemistry and
urinalysis at a local clinic
– Elevated creatinine level
• impression was Urinary tract
infection.
 2 Day PTA
• Bloody-streaked phlegm
• Chronic cough
 1 Day PTA
• persistence of the symptoms
• accompanying 10 episodes of dark
tarry stools tinged with blood.
• This prompted patient to seek
consult, hence admission.
• Hence chief complain
– CHRONIC COUGH
– MELENA
 Past Medical History
• 2000: Diagnosed with Hypertension
– highest BP was unrecalled.
– maintained on
• Metoprolol 50 mg/tab, 1 tab bid
• amlodipine 10 mg/tab, 1 tab o.d.
• 2006: Diagnosed with BPH
– was prescribed
• Terazosin HCL.
 Family History/Personal
History
• (+) asthma, brother
• No family history of HPN, DM, stroke,
cancer, tuberculosis

• Previous smoker - 35 pack years

– (20 sticks/day for 35 years)
• Previous alcoholic beverage drinker
– (80 g/day for 20 years)
 Subjective and Objective
Data on Admission
Subjective Objective
• (+) weight loss, • Respiratory Distress,
unquantified, (+) conscious, ambulatory
anorexia, (+) weakness • BP supine: 140/90,
• (+) insomnia, no fever • BP sitting: 120/70,
• (+) dyspnea, (+) • PR: 80, RR: 32 T: 36.5°
shortness of breath, (+) • Pale palpebral
cough, (+) sputum conjunctiva, dirty sclerae
production, no • (+) cervical lymph nodes
hemoptysis • Symmetrical chest
expansions,
• (+) 2 pillow orthopnea
(+) supraclavicular
occasional chest pains retractions,
• urine stream flow (+) crackles, both lung
abnormally, no dysuria fields
• (+) polyuria, (+) • No cyanosis, no edema,
polydipsia, pulses full and equal
 Subjective and Objective
Data on Nov. 22
Objective
Subjective • No respiratory Distress,
conscious, cachectic
• (+) weight loss,
• BP supine: 110/80
unquantified, (+) • BP sitting: 100/70
anorexia, (+) weakness • PR: 64, RR: 24, T: 36.5°
• (+) insomnia, no fever • Pale palpebral conjunctiva,
• (+) dyspnea, (+) dirty sclerae
• (+) cervical lymph nodes
shortness of breath, (+)
• Asymmetrical chest
cough, (+) sputum expansions,
production, (+) (+) supraclavicular and
hemoptysis intercostal retractions,
(+) crackles, (+) wheezes,
• (+) 2 pillow orthopnea dullness at lower lung
occasional chest pains fields on percussion
• urine stream flow • (+) chest tenderness, left
subcostal area
abnormally, no dysuria • No cyanosis, bipedal
• (+) polyuria, (+) edema, pulses full and
polydipsia, equal
Risk Factors for Active
Tuberculosis
• Recent Infection
• Fibrotic Lesions (spontaneously healed)
• Comorbidity
– HIV Infection
– Silicosis
– Chronic Renal Failure/ Hemodialysis
– Diabetes
– Intravenous Drug Use
– Immunosupressive treatment
– Gastrectomy
– Jejunoileal Bypass
– Posttransplantation period (renal, cardiac)
• Malnutrition and Severe Underweight
Source: Harrison’s Principles of Internal Medicine
16th Edition
Additonal Slides
AFP RESULTS Back
Actual patient x-ray

back
Actual Patient x-ray

back
 Chief Complaints
• Melena
• Chronic Cough
 Chief Complaints
• Cough - is an explosive expiration
that provides a normal protective
mechanism for clearing the
tracheobronchial tree of secretions
and foreign material.
• Acute: <3 weeks duration
• Chronic: >3 weeks duration

Harrison’s Internal Medicine

16th ed.
 Organ Systems Involved
• Pulmonary System
– Airways
• Inflammation
• Neoplasm
– Lung Parenchyma
• Cardiovascular System
– Pulmonary edema due to LVF
Symptomatology and
Physical Examination
Findings
Atienza, Bryan Jason B.
 Review of Systems
• Yellow sputum, Cough, Dyspnea,
Orthopnea
– Bacterial infection
– Cough reflex
– Dyspnea in PTB
– 2-pillow orthopnea

1 ATIENZA, Bryan Jason B., II-A3

 Review of Systems
• Anorexia, Weight change, Weakness
– Anorexia in PTB: Inflammatory cytokines
– Anorexia  Weight loss
• Clinically significant: >5% usual body weight
over 6-12 mos. (progressive)
>10% protein-energy malnutrition
>20% severe
– Anorexia  Neoplasm?
– Weakness

2 ATIENZA, Bryan Jason B., II-A3

 Review of Systems
• Insomnia
– Due to cough, dyspnea, depression
• Adenopathy
– Chronic infection
• Edema (Right leg, Abdomen)
– Right-sided heart failure
• Chest pain
– Angina pectoris, HPN, LVH?
• Polyuria, polydypsia, dysuria
– BPH, DBM.
• Depression, mood changes

3 ATIENZA, Bryan Jason B., II-A3

 Physical Examination
Findings
• Hypertension
– Hx
• Displaced apex beat
– Cardiomegaly
• Tachypnea
– Compensatory response
• Respiratory distress
– Supraclavicular, subcostal retractions
– Crackles

4 ATIENZA, Bryan Jason B., II-A3

 Physical Examination
Findings
• Abdominal tenderness
• Pale palpebral conjunctivae, dirty
sclerae

5 ATIENZA, Bryan Jason B., II-A3

Differential Diagnosis
 PROBLEM COUGH AND SPUTUM ASSOCIATED SYMPTOMS
AND SETTING

ACUTE INFLAMMATION
Bacterial Pneumonias Pneumoccocal: sputum
mucoid or purulent; maybe
blood-streaked, diffusely
pinkish or rusty
An acute illness with chills, high
fever, dyspnea and chest pain. Often
preceded by upper respiratory
infection

Klebsiella: similar; or sticky, Typically occurs in older alcoholic

red, jellylike men
CHRONIC INFLAMMATION

Postnasal Drip Chronic cough; sputum
mucoid to mucopurulent
Repeated attempts to clear the throat.
Postnasal discharge maybe sensed
by patient or seen in posterior
pharynx. Associated with chronic
rhinitis, with or without sinusitis.

Chronic Bronchitis Chronic cough; sputum Often long-standing cigarette

mucoid to purulent, maybe smoking. Recurrent superimposed
blood-streaked or even bloody infections. Wheezing and dyspnea
may develop.
Bates' Guide to Physical Examination and History Taking, 9th ed.
Bronchiectasis Chronic cough; sputum purulent,
often copious and foul-smelling;
maybe blood streaked or bloody
Lung Abscess Sputum purulent and foul-
smelling; maybe bloody
Pulmonary Cough dry or sputum that is
Tuberculosis mucoid or purulent; maybe blood
streaked or bloody
NEOPLASM
Lung CA Cough dry to productive; sputum
may be blood-streaked or bloody
CARDIOVASCULAR DISORDERS
Left Ventricular Often dry, especially on exertion
Failure or Mitral or at night; may progress to pink
Stenosis frothy sputum of pulmonary
edema or to frank hemoptysis
Pulmonary Emboli Dry to productive; maybe dark,
bright red, or mixed with blood
Bates' Guide to Physical Examination and History Taking, 9th ed.
Recurrent bronchopulmonary infections
common; sinusitis may coexist.
A febrile illness. Often poor dental
hygiene and a prior episode of impaired
consciousness.
Early, no symptoms. Later anorexia,
weight loss, fatigue, fever, night sweats
Usually long history of cigarette
smoking. Associated manifestations are
numerous.
Dyspnea, orthopnea, paroxysmal
nocturnal dyspnea
Dyspnea, anxiety, chest pain, fever;
factors that predispose to deep vein
thrombosis
RADIOLOGY
Normal Lungs (PA view)

www.umm.edu/pulmonary/cases.htm
 CXR Findings that Suggest
Active TB:
• Infiltrate or consolidation
• Any cavitary lesion
• Nodule with poorly defined margins
• Pleural effusion
• Hilar or mediastinal
lymphadenopathy

Center for Disease Control &

Prevention
Consolidation

www.umm.edu/pulmonary/cases.htm
Infiltrates

www.umm.edu/pulmonary/cases.htm
Cavitation

www.umm.edu/pulmonary/cases.htm
Nodules

www.umm.edu/pulmonary/cases.htm
Pleural Effusion

www.rad.msu.edu/.../pages/steps/step8.htm
NORMAL PATIENT’S
Ancillary Procedures
 Acid Fast Bacilli (AFB) stain
for light microscopy
• 1-hour-to-1-day
• Three sputum
specimens in am
• MTB retains certain
stains after being
treated with acidic
solution, it is
classified as an
AFB
• Ziehl-Neelsen, dyes
AFBs a bright red
www.labtestsonline.org
 Acid Fast Bacilli (AFB) stain
for light microscopy
• Other ways to visualize AFBs include an
auramine-rhodamine stain and fluorescent
microscopy
• can be used to monitor the effectiveness
of treatment and can help determine when
a patient is no longer infectious
• negative culture may mean that you do
not have an AFB infection or that the
mycobacteria were not present in that
particular specimen
www.labtestsonline.org
 PPD test (Purified Protein
Derivative)
• Give 0.1 ml of 5
Tuberculin Units
PPD intradermally
• 48 and 72 hours
• Measure the
induration(mm) -
not erythema

http://www.cdc.gov/
 PPD test (Purified Protein
Derivative)
15 or more millimeters induration is always considered
positive.
with no risk factors for tuberculosis.

10 or more millimeters induration is considered positive

for high risk groups, such as:
• Foreign-born persons from high prevalence areas ,
• Intravenous drug users known to be HIV seronegative
• Medically-underserved low income populations
• Residents of long-term care facilities (such as correctional
institutions, nursing homes, mental institutions)
• increase the risk of tuberculosis such as silicosis, being 10%
or more below ideal body weight, chronic renal failure,
diabetes mellitus, high dose corticosteroid and other
immunospressive therapy, leukemias and lymphomas other
malignancies
• Children who are in one of the high risk groups listed above
• Health care workers who provide services to any of the high
risk groups
http://www.cdc.gov/
 PPD test (Purified Protein
Derivative)
5 or more millimeters
induration is considered
positive for the highest risk
groups, such as:
• Persons with HIV infection
• Persons who have had
close contact with an
infectious tuberculosis
case
• Persons who have chest
radiographs consistent
with old, healed
tuberculosis
• Intravenous drug users
whose HIV status is
unknown http://www.cdc.gov/
 PPD test (Purified Protein
Derivative)
False positive result False negative result
• Cutaneous anergy (anergy is the
• Infection with inability to react to skin tests
because of a weakened immune
nontuberculosis system)
mycobacteria • Recent TB infection (within 8-10
weeks of exposure)
• Previous BCG • Very old TB infection (many
vaccination years)
• Very young age (less than 6
• Incorrect method of months old)
TST administration • Recent live-virus vaccination
(e.g., measles and smallpox)
• Incorrect • Overwhelming TB disease
interpretation of • Some viral illnesses (e.g., measles
reaction and chicken pox)
• Incorrect method of TST
• Incorrect bottle of administration
antigen used • Incorrect interpretation of
reaction
http://www.cdc.gov/
 Mycobacterial Culture
• solid media (egg-
based, such as
Lowenstein-Jensen
or agar such as
Middlebrook 7H11)
• incubation for 3 to
6 weeks
• Optimal
Temperature:
37C
• Optimal pH: 6.8 http://www.cdc.gov/
 Mycobacterial Culture
• A positive culture for M. tuberculosis
confirms the diagnosis of TB disease.
• Culture examinations should be
completed on all specimens,
regardless of AFB smear results.

http://www.cdc.gov/
 QuantiFERON®-TB Gold
Test
• incubation of the blood with antigens
• 16 to 24 hours
• amount of interferon-gamma (IFN-
gamma) is measured
• additional tests needed to confirm
the diagnosis of LTBI or TB disease

http://www.cdc.gov/
 QuantiFERON®-TB Gold
Test
• Results can be available within 24
hours.
• Is not subject to reader bias that can
occur with TST
• Is not affected by prior BCG (bacille
Calmette-Guérin) vaccination.

http://www.cdc.gov/
 Additional Diagnostic
Procedures
• Urine cultures:    Urine cultures can be
used to diagnose cases of genitourinary
Tuberculosis.   
   
• Gastric aspirate test:
A gastric aspirate test involves placing a
tiny nasogastric tube in the stomach early
in the morning.  Gastric contents are then
suctioned and processed for smears and
culture.     Harrison’s 16th Edition
 Additional Diagnostic
Procedures
• Lymph node biopsy:
involves removing an enlarged lymph
node and culturing a small portion.  The
remaining portion is stained and observed
under a microscope for presence of a
caseating granuloma with AFB
• Culture body fluids:
Fluid drained from the pleural space, the
pericardial space, or the peritoneal space
may be positive for AFB and culture.
Harrison’s 16th Edition
 Additional Diagnostic
Procedures
• Bronchoalveolar lavage:
performed in patients with suspected
pulmonary Tuberculosis when
sputum smears are negative.
• Fiberoptic bronchoscope with
bronchial brushings or
transbronchial biopsy
Harrison’s 16th Edition
 Pathophysiology of
Pulmonary Tuberculosis

Atutubo, Cosette
 Etiology of PTB
• Mycobacterium
tuberculosis
complex
• Non-motile, non-
spore-forming
Aerobic
bacterium
• Weakly gram (+)

Atutubo, Cosette
 Pathogenesis
• Breathe in the
droplets
• Bacteria into their
lungs
• Response:
engulfed by
alveolar
macrophages
• Hilar lymph nodes
• Beginning of
primary
tuberculosis
• Middle or lower
lobes of the Atutubo,
lungs Cosette