Case 8

The patient was a 55-year-old male with a 2-month

history of fevers, night sweats, increased cough
with sputum production, and a 25-lb weight loss.
The patient denied intravenous drug use or
homosexual activity. He had had multiple sexual
encounters, sipped a pint of gin a day, was jailed
2 years ago in New York City, and had a history of
gunshot and stab wounds. His physical
examination was significant for bilateral anterior
cervical and axillary adenopathy and a
temperature of 39.4C. His chest radiograph
showed paratracheal adenopathy and bilateral
interstitial infiltrates. His laboratory findings were
significant for a positive HIV serology and a low
absolute CD4 lymphocyte count.

1. Bronchoalveolar lavage fluid.
BALF is the fluid or secretion that is
obtained from the alveolar and
bronchial airspaces. This fluid is
washed with sterile saline water
during the obtaining of the sample.

BALF is obtained by placing a small
fiberoptic scope into the lung of the
patient and injecting sterile saline
water into the lung and removing the
fluid.
Its value as a diagnostic specimen is
limiting because of the large range of
normal values.
2. The organism that can be positive for
an acid-fast stain are:
Mycobacterium.
Nocardia.
Corynebacterium.
3. According to medical history, the
most likely organism to be causing his
infection is:
Mycobacterium tuberculosis.

The patient is HIV positive, this
predisposes the patient to present the
disease because this patient is
immunocompromised.
Also, when the immune system responds to
TB, it increases HIV levels, and HIV
disease may progress more quickly.

4. The important factors in his medical
history that are important in his contracting
this infection with an acid-fast bacterium
are:

- weight loss.
- cough with sputum production.
- he was jailed 2 years ago.
- sipped a pint of gin a day.
- history of gunshot and stab wound.
5. PPD test.
The purified protein derivative is an
antigen that is injected into the most
superficial layer under the skin
resulting in a blister of the skin in
positive cases.
The blister is measured and
millimeters.
- 5mm : positive in individuals with
HIV or individual on steroid
therapy
- 10mm: positive for individuals with
diabetes, renal failure, and
health care workers.
- 15 mm: positive for individuals with
no known risks for TB.
The value of PPD in this patient is
limiting since he is positive HIV and
we may obtain a false negative
response.
The negative response is due to his
affected immune system.
A chest x-ray should be ordered
additionally to detect lesions in the
lung.
Positive PPD test
6. The control measures of this patient
are:
- Annual TB skin test is recommended.
- DOT (directly observed therapy) is
recommended.
- Patients should be managed by
physicians to reduce drugs
interaction.




Mycobacterium tuberculosis
Classification
Family: Mycobacteriaceae
Genus: Mycobacterium
Specie: tuberculosis

M. tuberculosis is an obligate aerobe.
The organism is a facultative intracellular
parasite. It can survive in a dry phase for
weeks but can grow only within a host
organism.




Acid-fast Gram(+) rods:
The organism presents a thick waxy
cell wall and rich in mycolic acid.
It is considered a Gram (+) due to
lack of outer membrane.
Heat is needed for stain penetration
because of the waxy cell wall.


The high concentration of lipids in the
cell wall gives:
1. Impermeability to stains and dyes.
2. Resistance to many antibiotics.
3. Resistance to osmotic lysis.
4. Resistance to acidic and alkaline
compounds.
Acid fast staining
According to Runyon division,
Mycobacterium tuberculosis belongs
to Non-photochromagen group:
May produce a white to yellow
pigment that can be intensified by the
exposition to light.

M. tuberculosis colonies are rough,
granular, dry, and nopigmented.
Diseases.
The disease caused by M.
tuberculosis is Tuberculosis.
May have different names depending
where the organism is causing
disease.
Scrofula :
affect lymphatic system and
results in swollen neck glands.

Tabes mesenterica:
TB of the abdomen.
Lupus vulgaris:
TB of the skin.
Milliary TB:
When infection invades
circulatory system.


Clinical Presentation
The organism is spread from person
to person through the air in droplets
nuclei.
A person can be infected but disease
can be absent.


Predisposing factors for TB infection
include:
- HIV infection.
- Immunodeficiency.
- Malnutrition.
- Alcoholism.
- IV drug use.
- Contact with large population of people:
prisons, dormitories, nursing homes, etc.
Symptoms:
In early phases the patient will
present not symptoms. Also, if they
have latent TB infection.

Latent infection : organism is present
but dormant.

Early infection symptoms:
- Fever.
- Sweating.
- Chills.
- Weight loss.
- Weakness.
- Fatigue.
Symptoms of chronic lung infection:
- persistent cough.
- chest pain.
- coughing up bloody sputum.
- weight loss.
- breathing difficulty.
Diagnosis.
A complete medical evaluation for TB
include:
Medical History:
- Ask about the patients history of
TB exposure, infection, or disease.


Physical examination:
- Determine whether the patient has
medical conditions, especially HIV
infection.
HIV infection increases the risk of
latent TB infection progressing to
TB disease.

Skin Tests.
1. Mantoux tuberculin skin test.
The purified protein derivative
(PPD) is an antigen that leads to a
sensitivity response.
This response can occur if
someone currently has TB or they
were exposed to it in the past.
2. QuantiFERON-TB Gold Test.
It is a blood test that measures the
patients immune system reaction to
M. tuberculosis.

Chest X-ray.
If skin test gives positive, then a
chest X-ray is ordered to detect
lesions anywhere in the lungs. These
lesions may suggest TB but cannot
be used to diagnose TB.


Microbiological diagnosis.
- Acid-fast staining:
Ziehl Neelsen.- application of
heat is needed.
Kinyon.- uses higher content of
phenol.
Auramine-rhodamine fluorochrome.
fluorescent stain.


- Cultural identification:
Lowenstein-Jensen.
Middlebrook 7H10 and 7H11.
- PCR.


Virulence Factors
- cord factor.
- mycolic acid.
- intracellular growth.
- iron capturing ability.
Treatment
The treatment consists of three drugs
that are effective against the
organism. They include:
- Isoniazid.
- Rifampin.
- Pyrazinamide.
- Streptomycin.
- Ethambutol.

The treatment for TB is very complex
because it lasts 6 to 18 months.
Multidrug resistance may appear,
which make the disease very difficult
to treat.


Prevention
BCG vaccine.
Tuberculine skin test.
Preventive antibiotic treatment if
someone is in contact with a TB
patient.
Preventive therapy of household
members

References
Centers for Disease Control and Prevention (CDC),
Department of Health and Human Services, Division of
Tuberculosis Elimination:
http://www.cdc.gov/nchstp/tb/faqs/qa.htm
Ginesu, F., P. Pirina, L.A. Sechi, P. Molicotti, L. Santoru, L.
Porcu, A. Fois, P. Arghittu, S. Zanetti, and G. Fadda. 1998.
Microbiological diagnosis of tuberculosis: a comparison of
old and new methods. Journal of Chemotherapy 10: 295-
300.
Singh, V. 2006. TB in developing countries: diagnosis and
treatment. Paediatric Respiratory Reviews 7: 132-135.