（實用課件）結(jié)核病病例(英文版)

1、Cases PresentationCases Presentation Case HistoryCase 1:2y8m boy, fever, cant walk, abdominal pain 15ds, and progress 3dsBorn and grown up in Guizhou province. Date of admittance: Mar 23th, 2012 Case HistoryCase 1:History of present illness15ds ago, he couldnt walk, developed abdominal pain, mild fe

2、ver and cough. obvious sweat, seizure/ personality changeTreated as lower limbs pain of unknown with Abx by outpatient doctor w/o improvement. History of present illness15dsPast medical historyHealthyBCG immunization close contact active TBBirth History: normalPast medical historySocial history livi

3、ng condition is poor Socioeconomic status is lowerSocial historyPhysical ExaminationHepatosplenomegaly, Babinski sign (+), decreased muscle tone and strength (3/6) of lower limbsChest: good air entry bilaterally, crackle/wheeze Physical ExaminationHepatospleFamily medical history: Parents: His farth

4、er had pulmonary TB in 2009 and been cured. Mother is healthy.No siblingFamily medical history: Whats your possible diagnosis?Lower limbs palsy of unknownIntracranial infection?Guillain-Barre Syndrome?Intracranial space-occupying?Transverse myelitis?Whats your possible diagnosisInvestigationCBC: Hb

5、96, WBC 10.2 N 69%, Plt 420PPD: pendingBiochemistry: normalSerology for CP, MP and Legionella: all +ve TB Antibodies: (-)CSF analysis: cell 2/l, protein:1364.2 ( ), AFB (-).InvestigationCBC: Hb 96, WBC 1Mar 24th, 2012CT scan: NormalMar 24th, 2012CT scan: NormalAn oval sheet opacities at precordium,

6、suggesting CT scanMar 24th, 2012May be a tumor?Neuroblastoma?An oval sheet opacities at preMediastinal multiple lymph node calcificationMar 24th, 2012Mediastinal multiple lymph nodThoracic vertebra tuberculosisMar 24th, 2012Cold abscess formation Thoracic vertebra tuberculosisCold abscess formation

7、Mar 24th, 2012Cold abscess formation Mar 24t（實用課件）結(jié)核病病例(英文版)（實用課件）結(jié)核病病例(英文版)（實用課件）結(jié)核病病例(英文版)（實用課件）結(jié)核病病例(英文版)（實用課件）結(jié)核病病例(英文版)What is your diagnosis ?Pulmonary TBThoracic vertebra TBCold abscess formationWhat is your diagnosis ?Pulmon Case 2Case History:10 years girl, vomiting x 6dBorn and grown up in

8、 Suburban of Jinhua City, Zhejiang Province, parents are healthy. Date of admittance: Jun 8, 2011 Case 2Case History:History of present illness6 d ago, She developed vominting, 1-2times/d, no fever and cough. obvious sweat, seizure/ personality change, lost weigh for last 4 wks (BW:19.5kg)Treated as

9、 Vomiting of unknown, possible acute gastritis with Abx and Losec by outpatient doctor w/o improvement. History of present illness6 d Past medical historyHealthy BCG immunizationNo close contact active TBBirth History: normalPast medical historyFamily medical history: Parents Healthy Social history

10、living condition is poor Socioeconomic status is lowerFamily medical history: SocialPhysical ExaminationNo specific hintChest: good air entry bilaterally, crackle/wheeze CNS: Normal Physical ExaminationNo specifiWhats your diagnosis?Acute gastritis?Intracranial space-occupying?Pancreatitis?Whats you

11、r diagnosis?Investigation3CBC: Hb 120, WBC 11.7 N 89.6, Plt 540PPD: 8mmAmylase analysis: normal in serum and urineBiochemistry: NormalInvestigation3CBC: Hb 120, WBC Miliary TBTenth Thoracic vertebrae destruction with paravertebral abscessJun 8, 2011 Miliary TBTenth Thoracic vertBrain CT ScanRight he

12、misphere multiple sheet hypodenseJun 8, 2011CT scanBrain CT ScanRight hemisphere Q1:What is your diagnosis ?Miliary TBTuberculosis MeningitisThoracic vertebra TB paravertebral abscess Q1:What is your diagnosis ?Mi Case 3Case History :11 months girl, Fever and cough x 4wksBorn in Canada, parents and

13、grandparents immigrated to Canada from China 10 yrs ago. Date of admittance: Sep15th, 2008 Case 3Case History :Past medical historyHealthy BCG immunizationClose contact active TB (sputum + ve) between Jun and Aug 2008 Birth History: normalPast medical historyHistory of present illness4 wks ago, She

14、developed mild fever and non productive cough, 1wk later, high fever, almost everyday. obvious sweat, seizure/ personality changeTreated as a possible UTI (urine WBC 10-20/HPF, UCx: NG) with Abx on two courses by BCCH and GP doctor w/o improvement. History of present illness4 wkGrowth curverGrowth c

15、urverFamily medical history: Parents Mom PPD +, on INH prophylaxis Dad PPD - , has asthma and ? “hepatitis”Maternal grandfather just diagnosed active TB (sputum smear + ve), he didnt take anti-TB medicine before.3 yrs brother, healthy, on INH prophylaxis. Family medical history: Social history livin

16、g condition is poor Socioeconomic status is lowerSocial historyPhysical ExaminationNo specific hintChest: good air entry bilaterally, crackle/wheeze Physical ExaminationNo specifiInvestigationCBC: Hb 112, WBC 14.7 N 6.59, Plt 551PPD: 3mmUrine analysis: normalUrine acid fastness bacilli stain: - veUr

17、ine Cx: NGLFT: ALT 12, AST 44, alk phos 161, GGT 16 LDH 1185, bilirubin 2Serology for HBV, HCV, HIV: all -veInvestigationCBC: Hb 112, WBC the patchy area above and lateral to the right hilum would be consistent with TBSep 12the patchy area above and lateQ1:What is your diagnosis ?Pulmonary TBQ1:What

18、 is your diagnosis ?PuQ2: Further investigationGastric wash smear: AFB 2+, 2+, 3+TB culture: pendingTB PCR: pendingQ2: Further investigationGastrFinal DiagnosisTuberculosis, clinically active.Never receive therapyPulmonaryPositive bacteriologic status by Microscopy (Sep 17,18,19/08)Chest X-lay: abno

19、rmal, non-cavityPPD negative (3mm)Final DiagnosisTuberculosis, cQ2 PPD (-), why?Q2 PPD (-), why?DX of TB in Children is ChallengingClinical symptom and sign are more variable. PPD (-) does not definitely rule out TB infection, about 10-20% of children with TB develop -ve PPD reaction. Difficult to g

20、et the organism, for children rarely produce sputum. DX of TB in Children is ChallePPD false negative factorsPPD false negative factorsFalse positiveBCGNontuberculous mycobacteriaTell the difference: based solely on the size of PPD, epidemiologic and clinical features must be weight.False positiveBC

21、GDiagnosis LevelPresumable DX: Exposure history, PPD, Symptoms and signClinical DX: Images + presumable evidencesConfirmed DX: Smear, or culture, or histologyDiagnosis LevelPresumable DX: Q6: Where did them get TB?Often from adult, by household contactsQ6: Where did them get TB?OftEducation parentsT

22、reatable disease, 6-9 months, Take medicine regularly, DOT NutritionSide effectsRecurrenceDrug-resistance (chromosomal and drug selective resistant)Follow upEducation parentsTreatable dis（實用課件）結(jié)核病病例(英文版)Recommended dosages and adverse effects of first-line Drugs in children and adolescentsWHO 2006Re

23、commended dosages and adversKey contents for reviewThe common clinical manifestations of primary pulmonary tuberculosis.The common clinical manifestations and diagnostic imaging of pulmonary tuberculosis. How to definite the positive tuberculin skin test results. Please describe the clinical manifes

24、tations of reactivation pulmonary tuberculosis. Key contents for reviewThe com1. Please describe the common clinical manifestations of primary pulmonary tuberculosis Its usually an asymptomatic infection in older infants and children; Often the disease is manifested by a positive TST with minimal ab

25、normalities on the chest radiograph, such as an infiltrate with hilar lymphadenopathy or Ghon complex.; Malaise, low-grade fever, erythema nodosum, or symptoms resulting from lymph node enlargement may occur after the development of delayed hypersensitivity.1. Please describe the common 2. Please li

26、st the common clinical manifestations and diagnostic imaging of pulmonary tuberculosis The common clinical manifestations: malaise, cough, low-grade fever, erythema nodosum, weight loss, night sweat, lymphadenopathy, or symptoms resulting from lymph node enlargement. Specific image changes: Ghon com

27、plex (an infiltrate with lymphadenopathy), hilar lymphadenopathy, bilateral military infiltrates, partial bronchial obstruction caused by lymphadenopathy, cavitation, calcification, and pleural effusion.2. Please list the common clin3. How to identify the positive tuberculin skin test results in inf

28、ants, children, and adolescents.Depends on two factors: diameter of the induration and persons risk of being infected. Induration 5 mm is positive in highest risk person, such as recent contact with TB disease, immunosuppressive conditions and suspected to have TB disease; Which means the infection progressing to disease; Induration 10 mm is positive in children with increased exposure to T