TOPIC 1 FEVER/ PULMONARY TUBERCULOSIS

SubGroup1| September 28, 2020

CASE ON FEVER PHYSICAL EXAMINATION

GENERAL SURVEY
GENERAL DATA Awake, conscious and coherent
▪ Patient is CA
▪ 50/M VITAL SIGNS
▪ from Agoo, La union BP: 100/70, HR: 90, RR: 24, T: 38.2
Height 5’5”, weight 45 kg,
CHIEF COMPLAINT BMI=16.5 patent is underweight
▪ Fever
HEENT
HISTORY OF PRESENT ILLNESS Pink conjunctiva
anicteric sclera
▪ 1 Month PTC:
(-) neck vein distension
o the patient began to experience on and off cough productive
(+) R cervical lymph adenopathy,1x1 cm
of whitish to yellowish sputum.
o In palpating lymphadenopathy, what is the feature of
▪ Over the next few weeks:
lymphadenopathy which is malignant : immovable, painless
o he lost his appetite and started to lose weight. He also
o Infection: lymph node is painful and movable usually benign
experienced intermittent fever sometimes associated with
o Location of lymphadenopathy- left supraclavicular area and
chills.This prompted consult at the OPD.
px presented fecal occult blood (+) or with gastric
▪ For the history at your level, you should be good at this, it should
symptoms: Virchow’s node
be detailed, not necessary to put the history in text but at least
mention important things, you should mention if there are consults
CHEST AND LUNGS
done, medications taken and also not only the pertinent positives
o Right chest lag
but also the pertinent negatives. For example, here you could
o bronchovesicular breath sound
mention if there is fever, difficulty in breathing, hemoptysis. From
o decreased breath sounds R lower lung field with dullness
the hx we already thinking of diagnosis. In history and PE 70% we
on percussion
already arrived with the diagnosis without the aid of diagnostic test
o no crackles
o if there is dullness on percussion what does it mean? There
PAST MEDICAL HISTORY is presence of effusion
➢ No hypertension/Diabetes/asthma
➢ No unknown allergies (may be this is no known allergies) HEART
o No heaves of thrills
▪ Is there hx of TB?Some patients do not know TB, so if you o apex beat at 5th ICS MCL, normal rate, regular rhythm
will ask your patients better ask them if they took o good s1
medications for 6months then you can say that they are o no murmurs
being treated for TB
ABDOMEN
FAMILY MEDICAL HISTORY o Flat abdomen
▪ Father: Died of lung cancer (“mahina ang baga”) o normoactive bowel sounds
▪ Mother: Died of breast cancer o soft non-tender
▪ For this patient what are your 2 strongest d/dx. Yes, its lung o no organomegaly
cancer, you cannot rule out lung cancer because the patient
presented 1 month cough, and prolonged cough can be due to EXTREMITIES
malignancy, hemoptysis on the other hand is not only attributed to o Pink nail beds
TB but also with malignancy o full and equal pulses
o no cyanosis
PERSONAL/SOCIAL HISTORY o no clubbing
▪ Smoker, consumes 2 packs/day for the past 20 years o grade 1 pitting edema
▪ 2packs/day x 20years = 40 pack year
▪ Moderate intake of alcohol SALIENT FEATURES
▪ Married, 4 children
▪ Jeepney driver

▪ How did you compute for pack- years?

o #of pack of cigarettes smoked /day x years of smoking
o #of sticks per day/20(sticks per pack) x years of smoking
o 7sticks per day/20 x 5 years = 1.75 pack -year

REVIEW OF SYSTEMS
▪ (-) nausea
▪ (-) vomiting
▪ (+) easy fatigability
▪ (-) abdominal pain
▪ (-) diarrhea
▪ (-) constipation
▪ (-) dysuria/ hematuria
DEPARTMENT OF INTERNAL MEDICINE
DIFFERENTIAL DIAGNOSIS
▪ Pulmonary Tuberculosis
▪ Lung Cancer
▪ COPD
▪ Community Acquired Pneumonia
▪ Lung Abscesses

▪ You can have lymphadenopathy in pneumonia due to infectious

processes INFECTION AND MACROPHAGE INVASION. The interaction of M.
▪ In COPD; there is no dullness but there is hyperresonance due to tuberculosis with the human host begins when droplet nuclei
hyperaeration. Have you seen CXR of px with copd- it is suPer containing viable microorganisms propelled into the air by infectious
black, hyperluscency. You can also have fever here if there is patients are inhaled by close bystander. Although the majority of
concomitant pneumonia inhaled bacilli are trapped in the upper airways and expelled by ciliated
▪ Infection – common trigger of COPD attacks mucosal cells, a fraction (usually <10%) reach the alveoli, a unique
▪ COPD Patients who are admitted they have concomitant immunoregulatory environment. There, alveolar macrophages that
pneumonia that’s why they are febrile but if COPD alone there is have not yet been activated (prototypic alternatively activated
no fever macrophages) phagocytose the bacilli. Adhesion of mycobacteria to
macrophages results largely from binding of the bacterial cell wall to a
IMPRESSSION: PULMONARY TUBERCULOSIS (Presumptive) variety of macrophage cell-surface molecules, including complement
receptors, the mannose receptor, the immunoglobulin GFcgamma
RATIONALE receptor,and type A scavenger receptors. Phagocytosis is enhanced
History by complement activation leading to opsonization of baclli with C3
o Low socio-economic status activation products such as C3b and C3bi. (Bacilli are resistant to
o Intermittent fever and chills complement-mediated lysis.) Binding of certain receptors, such as the
o Productive cough mannose receptor, regulates postphagocytic events such as
o Weight loss phagosome-lysosome fusion and inflammatory cytokine production.
o Family history After a phagosome forms, the survival of M. tuberculosis within it
o What is the other risk factor of the patient aside from low seems to depend in part on reduced acidification due to lasck of
socioeconomic status and smoker? assembly of a complete vesicular proton-adenosine triphosphate. A
o Breathing Philippine air itself is a risk factor for us to acquire complex series of events is generated by the bacterial cell-wall
TB. One of the risk factor is that patient is living in the lipoglycan lipoarabinomannan (ManLAM). ManLAM inhibits the
Philippines even if he is not smoker as long as he is exposed intracellular increase of Ca2+. Thus, the Ca2+/calmodulin pathway
then he is of high risk. (leading to phagosome-lyssome fusion) is impaired, and the bacilli
survive within the phagosomes. The M. tuberculosis phagosome has
P. E. been found to inhibit the production of phosphatidylinositol 3-
o Dullness on percussion and consolidation in right lower lung phosphate (PI3P). normally, PI3P earmarks phagosomes for
field membrane sorting and maturation, including phagolysosome
o Cervical lymphadenopathy (Scrofula) formation, which would destroy the bacteria. Bacterial factors have
also been found to block the host defense of autophagy, in which the
cell sequesters the phagosome in a double-membrane vesicle
(autophagosome) that is destined to fuse with lysosomes. If the bacilli
are successful in arresting phagosome maturation, then replication
begins and the macrophage eventually ruptures and releases its
bacillary contents. Other uninfected phagocytic cells are then recruited
to continue the infection cycle by ingesting dying macrophages and
their bacillary content, thus in turn becoming infected themselves and
expanding the infection. (Harrison’s 19th ed.)

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BELIM | CEREZO | CORPUZ | CUDYAM | PATEL, RAVI
“You will never always be motivated. You have to learn to be disciplined.”
DEPARTMENT OF INTERNAL MEDICINE
Extrapulmonary Tuberculosis

Lymph node TB (Tuberculous Lymphadenitis)

▪ Seen frequently in HIV infected patients (40%)
▪ Symptoms: Painless swelling of lymph nodes most commonly at
cervical & supraclavicular sites (scrofula)
▪ Lymph nodes are usually discrete in early disease but develop into
a matted non-tender mass over time.
▪ Diagnosis is established by FNA biopsy (with a yield of up to 90%)
or surgical excision biopsy
▪ Cultures are positive in 70-80% of cases
▪ Among HIV-infected patients, granulomas are less well organized
and are frequently absent entirely, but bacterial loads are heavier
than in HIV-seronegative patients with higher yields from
microscopy & culture

Pleural TB
▪ Accounts for 20% of extrapulmonary cases
▪ May result from recent primary infection or contiguous
parenchymal spread from post primary disease
▪ The collection of fluid in the pleural space represents
hypersensitivity response to mycobacterial antigens
▪ Symptoms: Fever, pleuritic chest pain, dyspnea
▪ P.E. findings: Dullness to percussion & absence of breath sounds
▪ AFB smear & culture has low yield
CLINICAL MANIFESTATION OF PTB
▪ Cough that lasts 3 weeks or longer (90%) TB of the Upper Airways
▪ Chest pain ▪ A complication of advanced cavitary pulmonary TB
▪ Coughing up blood or sputum (20%) ▪ Symptoms: Hoarseness, dysphonia, & dysphagia in addition to
o Results from erosion of BVs or rupture of dilated vessel in chronic productive cough
the cavity (Rasmussen’s Aneurysm) ▪ Acid-fast smear of the sputum is often positive
▪ Other symptoms of TB disease are
o Weakness or fatigue Genitourinary TB
o Weight loss ▪ 15% of all Extrapulmonary cases
o No appetite ▪ Any part of the GUT get infected
o Chills ▪ Symptoms: Urinary frequency, dysuria, hematuria & flank or
o Fever abdominal pain
o Sweating at night ▪ Diagnosed more commonly in female than in male patients
▪ Symptoms of TB disease in other parts of the body depend on the ▪ Culture of morning urine specimens yields a definitive diagnosis
area affected. in nearly 90% of cases.
Remember: Hemoptysis is not required to suspect TB, but cough that
lasts >2 weeks. Skeletal TB
▪ Responsible for 10% of extrapulmonary cases
▪ Reactivation of hematogenous foci or to spread from adjacent
paravertebral lymph nodes
▪ Involvement of weight bearing parts like spine (40%), hip (13%),
and knee (10%)
▪ Spinal TB (Pott’s Disease) often involves 2 or more adjacent
vertebral bodies
▪ The upper thoracic spine is the most common site of spinal TB in
children
▪ The lower thoracic & upper lumbar vertebrae usually affected in
adults

TB Meningitis & Tuberculoma

▪ Accounts for 5% of extrapulmonary cases
▪ Seen most often in young children but also develops in adults,
especially those infected with HIV
▪ Results from the hematogenous spread of primary or postprimary
pulmonary TB or from the rupture of a subependymal tubercle
subarachnoid space
▪ Real time automated nucleic acid amplification (the Xpert
MTB/RUF assay) has a sensitivity of up to 80% and is preferred
initial diagnostic option
▪ Culture of CSF is diagnostic in up to 80% of cases and remains
the gold standard

Gastrointestinal TB
▪ Uncommon, making up only 3.5% of extrapulmonary cases
▪ May arise from swallowing of sputum with direct seeding,
hematogenous spread

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BELIM | CEREZO | CORPUZ | CUDYAM | PATEL, RAVI
“You will never always be motivated. You have to learn to be disciplined.”
DEPARTMENT OF INTERNAL MEDICINE
▪ The terminal ileum & the cecum are the sites most commonly
involved
▪ Abdominal pain & swelling, obstruction, hematochezia, and a
palpable mass in the abdomen are common findings at
presentation
▪ Fever, weight loss, anorexia, and night sweats are also common
Pericardial TB (Tuberculous Pericarditis)
▪ Direct extension from adjacent mediastinal or hilar lymph nodes
to hematogenous spread
▪ Has often been a disease of the elderly in countries with low TB
prevalence
▪ Case-fatality rates are as high as 40%
▪ Symptoms: Dyspnea, fever, dull retrosternal pain, pericardial
friction rub
Miliary or disseminated TB
▪ Results from hematogenous spread of tubercle bacilli
▪ Spread is due to entry of infection into pulmonary vein producing
lesions in different extra pulmonary sites
▪ In children it is often the consequence of primary infection, in
adults it may be due to either recent infection or reactivation of old
disseminated foci
▪ Lesions are usually yellowish granulomas 1-2 mm in diameter that
resemble millet seeds
▪ Clinical manifestation are non-specific: fever, night sweats,
anorexia, weakness and weight loss in the majority of cases
LESS COMMON EXTRA PULMONARY TB
▪ Chorioetinitis, uveitis, panophthalamitis and painful
hypersensitivity related phlyctenular conjunctivitis
▪ Tuberculous otitis is rare and preents as hearing loss, otorrhea
and tympanic membrane perforation
DIAGNOSIS
▪ MONORESISTANT TB – resistance to only one first line anti-TB
drug
▪ POLYDRUG-RESISTANT TB – resistance to more than one first
line anti-TB drug
▪ MULTIDRUG-RESISTANT TB (MDR-TB) – resistance to at least
both isoniazid and rifampicin
▪ EXTENSIVELY DRUG-RESISTANT TB (XDR-TB) – Resistance
to any fluoroquinolone and to at least one of three second-line
injectable drugs, in addition to multidrug resistance
▪ RIFAMPICIN-RESISTANT TB (RR-TB) – resistance to rifampicin
detected using phenotypic or genotypic methods, with or without
resistance to other anti-TB drugs
DIAGNOSTICS
▪ 2016 CPG guidelines: still DSSM (Direct Sputum Microscopy) ,
however nowadays at the hospital we already request directly for
sputum gene Xpert.
▪ The consultant of the TB DOTS in ITRMC already told us that I
think the next guidelines that would be released it would already
be sputum gene Xpert, the first diagnostic to be requested.
DIRECT SPUTUM SMEAR MICROSCOPY
▪ primary diagnostic method for a definitive diagnosis of active TB
▪ Two sputum specimens should be sent (should be collected within
3 days, at most)
▪ first specimen (spot) at time of consultation and second spot after
at least one hour (spot-spot one hour apart) or
▪ Spot-early morning specimens
▪ At least one sputum smear-positive is considered bacteriologically
confirmed TB
RAPID MOLECULAR DIAGNOSTIC TESTS (Xpert MTB/ RIF
Assay)
▪ Gene Xpert testing for the presence of Mycobacterium
tuberculosis and rifampicin resistance
▪ Sputum sample should be at least 1mL
BELIM | CEREZO | CORPUZ | CUDYAM | PATEL, RAVI
“You will never always be motivated. You have to learn to be disciplined.”
▪ Should be used for TB diagnosis among:
▪ Smear-negative adults with CXR findings suggestive of TB
▪ Presumptive drug resistant TB
▪ Individuals with HIV and manifestations of TB
TB CULTURE AND DRUC SUSCEPTIBILITY TEST
▪ primarily recommended for patients at risk for drug resistance
▪ it is recommended in the following smear-positive patients
o all cases of retreatment
o all cases of treatment failure
o all other cases of smear positive patients suspected to have
one or multi-drug resistant TB
o all household contacts of patients with MDR-TB
o in patients with HIV
TUBERCULIN SKIN TEST
▪ Mantoux tuberculin skin test (TST)
▪ Screening tool for TB infection in children
▪ How?
o The TB skin test is performed by injecting a small amount of
fluid (called tuberculin) into the skin on the lower part of the
arm.
o A person given the tuberculin skin test must return within 48
to 72 hours to have a trained health care worker look for a
reaction on the arm.
o The result depends on the size of the raised, hard area or
swelling.
▪ Positive skin test: This means the person’s body was infected
with TB bacteria. Additional tests are needed to determine if the
person has latent TB infection or TB disease.
▪ Negative skin test: This means the person’s body did not react
to the test, and that latent TB infection or TB disease is not likely.
CHEST X-RAY
▪ Recommended for patients suspected to have PTB whose sputum
smears are negative
▪ Should be an erect PA and left lateral projection performed during
full inspiration, and should include both lung apices and
costophrenic sulci.
▪ Sensitivity 86% and Specificity: 89%
▪ Findings:
o pneumonic consolidation (homogenous dense opacity or
patchy opacification mostly in middle and lower lobes with
or without hilar lymphadenopathy called Ghon complex.
o miliary opacities or pleural effusion or pulmonary oedema
(Kerely B line)
o fibrosis
o persistent calcification
o tuberculoma
▪ it can usually seen in the apex of the lungs, but it can also be seen
anywhere. There is no strict rule for the Chest x-ray findings for
PTB. That is why the definitive diagnosis is still the sputum.
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DEPARTMENT OF INTERNAL MEDICINE
DIAGNOSTICS ALGORITHM

PHARMACOLOGICAL AND NON-PHARMACOLOGICAL

TREATMENT

PHARMACOLOGICAL
▪ two aims of TB treatment are :
1. to prevent morbidity and death by curing TB while
preventing the emergence of drug resistance and
2. to interrupt transmission by rendering patients noninfectious

▪ Four major drugs are considered first-line agents for the treatment
of TB: isoniazid, rifampin, pyrazinamide, and ethambutol
▪ What we have in the hospital is the quad tab, 4 drugs in 1 tablet.
▪ If the patient is 30-37 kg, we give them 2 tabs/day given before
breakfast. For 38-54kg: 3 tabs/day. 55-70 kg – 4 tabs/day. >70kg
– 5 tabs/day.

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BELIM | CEREZO | CORPUZ | CUDYAM | PATEL, RAVI
“You will never always be motivated. You have to learn to be disciplined.”
DEPARTMENT OF INTERNAL MEDICINE
SIDE EFFECTS DRUG MANAGEMENT
RESPONSIBLE
Minor side effects (may continue anti-TB drugs and check doses)
Anorexia, nausea, Pyrazinamide, Give drug with small
abdominal pain Rifampicin, meals or at bedtime
Isoniazid
Joint pains (from Pyrazinamide Give aspirin or
hyperuricemia) NSAID
Peripheral Isoniazid Pyridoxine (Vitamin
Neuropathy B6) 500-100 mg
daily for treatment;
10 mg daily for
prevention
Orange/ Red- Rifampicin Reassure the
colored urine patient
drowsiness Isoniazid Reassure and give
drug at bedtime
Flu-like symptoms Rifampicin Give anti-pyretics
(e.g. fever, bone
pain, malaise)

SIDE EFFECTS DRUG MANAGEMENT

RESPONSIBLE
Major Side Effects
Severe skin rash Any drug (especially
(hypersensitivity) streptomycin)
Jaundice due to Any drug (especially
hepatitis isoniazid, rifampicin,
pyrazinamide) Discontinue
Visual impairment Ethambutol taking the
(optic neuritis) medications and
Deafness, tinnitus Streptomycin refer to clinician
and dizziness urgently
Decreased urine Streptomycin,
output rifampicin
Psychosis and Isoniazid
convulsion
Thrombocytopenia, Rifampicin
anemia, shock

NON-PHARMACOLOGICAL TREATMENT
▪ PREVENTION
o The best way to prevent TB is to diagnose and isolate
infectious cases rapidly and to administer appropriate
treatment until patients are rendered noninfectious (usually
2–4 weeks after the start of proper treatment) and the
disease is cured. Additional strategies include BCG
vaccination and treatment of persons with LTBI who are at
high risk of developing active disease.

▪ For your patient, example your patient would positive for DSSM,
patient category is Cat. 1. Refer to the table above.
▪ The patient is diagnose with PTB then the patient started with
anti-TB drugs, how long will it take for him to be non-infectious? –
2 weeks. For patients you don’t need to isolate them for 6 months.
If patients really taking the meds everyday for 2 weeks, after 2
weeks the patient is no longer infectious.
▪ If you are going to enroll the patient for Tb drugs what other drugs
will you give them aside form anti-TB? – Vitamin B complex. Give
Vit. B complex because of the side effect of Isoniazid.
▪ Side effects of Rifampicin: red or orange urine.
▪ Advise the patient to take Vit. B complex together with the Anti-TB
drugs. Take the drugs before breakfast and take them regularly.

2
BELIM | CEREZO | CORPUZ | CUDYAM | PATEL, RAVI
“You will never always be motivated. You have to learn to be disciplined.”