Clinical diagnosis Nov cough by benbenzhou

VIEWS: 45 PAGES: 24

More Info
									                        Clinical_diagnosis_Nov2009.ppt

                                           Instructor’s Guide and Teaching Notes
Slide 1



                                           Module: Clinical Presentation and Diagnosis of
                                           Tuberculosis
                                           ISTC Standards covered: 1 – 5
                                           Module Time: Approximately 60 minutes

                                           Alternate slides: Introductory ISTC slides.
                                           Interactive options: Ideas for interactive discussions are
                                           offered on many of the slides in this module. Participant
                                           discussion can enhance active learning, but will add more time
                                           to the lecture and must be planned for.
                                           Slide-show Animation: A second version of this talk is
                                           available with slide animations: Clinical Presentation and
                                           Diagnosis of TB (Animated).
                                           Additional Material: Slides containing related material may
                                           be found in the following modules: Microbiological diagnosis
                                           of Tuberculosis, TB and HIV Infection: Introduction and
                                           Diagnosis.
                                           Test Questions: May be attached or inserted within
                                           presentation for discussion purposes, or alternatively,
                                           combined with questions from other modules to produce
                                           evaluation tool.

                                           The full text of the ISTC and all supporting references are
                                           available at www.istcweb.org
                                           Other useful Resources/References:
                                               • Management of tuberculosis training for health
                                                    facility staff. World Health Organization, 2003.
                                                    www.who.int/tb
                                               • Radiographic Manifestations of Tuberculosis: A
                                                    Primer for Clinicians, Second Edition. Francis J.
                                                    Curry National Tuberculosis Center.
                                                    www.nationaltbcenter.ucsf.edu
                                               • Toman’s tuberculosis. Case detection, treatment and
                                                    monitoring, 2nd Edition. Freiden TR ed., World
                                                    Health Organization, 2004. www.who.int/tb
                                               • A Tuberculosis Guide for Specialist Physicians. Jose
                                                    A. Caminero Luna, IUATLD, Sept. 2004.
                                                    www.tbrieder.org
                                           [Image credit: World Lung Foundation/Jad Davenport]




          Clinical_diagnosis_Nov2009.ppt                                                Page 1 of 24
Slide 2
                                               •   It is intended that after completion of this
                                                   module the student will be able to describe
                                                   the approach to diagnosis of TB and the
                                                   proper role of diagnostic testing, particularly
                                                   sputum microscopy, in that process.

                                               •   [Review objectives from slide]
Slide 3




                                               •   Overview of Clinical Presentation and
                                                   Diagnosis of TB
                                                   [Review content of slide]
                                               •   Lecture/module includes International
                                                   Standards 1 - 5
                                               •   [Image of sputum smear photomicrograph
                                                   reveals Mycobacterium tuberculosis bacteria
                                                   using acid-fast Ziehl-Neelsen stain]

                                           [Image credits: World Lung Foundation/Jad Davenport (top);
                                           CDC Public Health Image Library/Dr. George P. Kubica
                                           (bottom)]
Slide 4




                                               •   In introducing the Standards for Diagnosis
                                                   of TB, it is important to recognize: [Review
                                                   content of slide]

                                           [Image credit: World Lung Foundation/Virginia Arnold]




          Clinical_diagnosis_Nov2009.ppt                                       Page 2 of 24
Slide 5
                                               •   Therefore, two fundamental points that
                                                   should be stressed are: [Review content of
                                                   slide]

                                               •   To diagnose TB, we must Think TB.

                                           [Image credit: World Lung Foundation/Pierre Virot]
Slide 6




                                           Begin with: Classic TB clinical presentation

                                               •   The most common symptom of pulmonary
                                                   TB is persistent productive cough, often
                                                   accompanied by nonspecific constitutional
                                                   symptoms, such as fever, night sweats, and
                                                   weight loss.
                                               •   Extra-pulmonary TB, such as
                                                   lymphadenopathy, may be noted, especially
                                                   in patients with HIV infection.
Slide 7




                                               •   Nonspecific systemic, constitutional
                                                   symptoms may include:
                                                   [Review content of slide]
                                               •   It is important to also recognize that there
                                                   are many cases of TB, up to 10-20%, that
                                                   may present without any symptoms at all.




          Clinical_diagnosis_Nov2009.ppt                                        Page 3 of 24
Slide 8
                                           The diagnosis of TB with HIV co-infection can be
                                           more difficult.

                                              •   Symptoms may be more nonspecific, but
                                                  fever and weight loss may be more
                                                  prominent at presentation.
                                              •   Cough and hemoptysis are less common
                                                  because there may be less cavitation,
                                                  inflammation and endobronchial irritation in
                                                  HIV patients.
                                              •   CXR findings can be more variable, with
                                                  both “typical, post-primary or reactivation
                                                  TB” and “atypical, primary TB” CXR
                                                  patterns commonly seen. In people
                                                  infected with HIV, obtaining a timely CXR
                                                  plays an important role in shortening delays
                                                  in diagnosis and should be performed early
                                                  in the investigation of a TB suspect.
                                              •   The diagnosis of TB may be further
                                                  complicated by the broader range of possible
                                                  alternative diagnoses. The physical signs of
                                                  respiratory infection in patients with
                                                  pulmonary TB (PTB) do not readily
                                                  distinguish PTB from other chest diseases
                                                  and chest examination may even be normal.
                                                  Because of the broader differential
                                                  diagnosis, access to and utilization of culture
                                                  and more invasive diagnostic become more
                                                  important issues.
                                              •   An accurate TB diagnosis may be further
                                                  complicated due to the higher rate of
                                                  extrapulmonary and disseminated disease in
                                                  HIV-infected individuals.
Slide 9




                                              •   So what guidance do the International
                                                  Standards for TB Care offer for prioritizing
                                                  who to evaluate for the diagnosis of TB?

                                              •   Standard 1: [Read Standard]


                                           [Image credit: WHO]




          Clinical_diagnosis_Nov2009.ppt                                    Page 4 of 24
Slide 10
                                            •   Although most patients with pulmonary TB
                                                have cough, the symptom is not specific to
                                                TB; it can occur in a wide range of
                                                respiratory conditions, including acute
                                                respiratory tract infections, asthma, and
                                                chronic obstructive pulmonary disease.
                                            •   While the presence of cough for 2-3 weeks
                                                is nonspecific, traditionally, having cough of
                                                this duration has served as the criterion for
                                                defining suspected TB and is used in most
                                                national and international guidelines,
                                                particularly in areas of moderate- to high-
                                                prevalence of TB.
                                            •   Data from India, Algeria, and Chile
                                                generally show that the percentage of
                                                patients with positive sputum smears
                                                increases with increasing duration of cough,
                                                and a more recent assessment from India
                                                demonstrated that by using a threshold of >2
                                                weeks to prompt collection of sputum
                                                specimens, the number of TB cases
                                                identified increased by 46%. Simply
                                                inquiring about cough can increase yield of
                                                cases identified.
                                            •   Certainly, duration of cough is not the only
                                                criterion that should raise suspicion for
                                                tuberculosis, other features of the
                                                presentation may raise your concern for TB
                                                in patients with a shorter duration or even
                                                absence of cough, therefore clinical intuition
                                                plays an important role in the evaluation for
                                                TB. This is particularly true with HIV co-
                                                infection where TB presentation may be
                                                more atypical and lack of cough more
                                                common.
                                            •   [Reference: Santha T., et al. Comparison of cough 2
                                                and 3 weeks to improve detection of smear-positive
                                                tuberculosis cases among out-patients in India. Int J
                                                Lung Dis 2005;9(1):61-8]




           Clinical_diagnosis_Nov2009.ppt                                     Page 5 of 24
Slide 11
                                            In evaluating persons who have symptoms that my
                                            be caused by TB it is important to identify risk
                                            factors for either:

                                               •   Recent infection with M.tb due to
                                                   transmission risks and/or factors that may
                                                   increase the likelihood of progression to
                                                   active TB once an individual is infected.

                                               •   The presence of any of these factors should
                                                   raise the clinician’s suspicion for TB.

                                               •   Significant risk factors for possible recent
                                                   infection include:
                                                    [Review content of slide]
Slide 12




                                               •   Significant risk factors that may increase the
                                                   likelihood of progression to active TB once
                                                   an individual is infected include:
                                                   [Review content of slide]

                                               •   [Interactive option – ask participants what
                                                   risk factors are most prevalent in their local
                                                   areas and practices? Are there any other
                                                   special groups or settings not listed here that
                                                   are important to their region?]
Slide 13




                                               •   The physical examination is non-specific in
                                                   TB but useful to identify sites of TB:
                                               •   [Review content of slide]




           Clinical_diagnosis_Nov2009.ppt                                    Page 6 of 24
Slide 14
                                                •    In persons who are suspected of having TB
                                                     based on symptoms and/or physical findings,
                                                     every effort must be made to identify the
                                                     causative agent.
                                                •    The first important step is highlighted by the
                                                     International Standard 2: [Read Standard]
                                                •    [Note: Guidelines have recently changed
                                                     from three sputum smears to at least two
                                                     sputum smears. The change is reflected
                                                     above and differs from the wording in the
                                                     original published ISTC]
                                                •    [Image shows sputum smear with
                                                     carbolfuchsin-based stain demonstrating
                                                     typical acid-fast bacilli morphology]

                                            [Image credit: CDC Public Health Image Library /Dr. George
                                            P. Kubica]
Slide 15




                                                •    While a definitive microbiological diagnosis
                                                     can only be confirmed by culturing M.
                                                     tuberculosis complex (or, under appropriate
                                                     circumstances, identifying specific nucleic
                                                     acid sequences) from clinical specimens, in
                                                     practice, there are many settings where these
                                                     tests are not currently feasible (due to
                                                     resource limitations).
                                                •    Fortunately, microscopic examination of
                                                     stained sputum, i.e. an AFB smear, is
                                                     feasible in nearly all settings.
                                                •    In almost all clinical circumstances in high
                                                     prevalence areas, finding acid-fast bacilli in
                                                     stained sputum is highly specific and, thus,
                                                     is the equivalent of a confirmed diagnosis.
                                                •    In addition to being highly specific for M.tb,
                                                     identification of AFB by smear is
                                                     particularly important for three reasons:
                                                          •  It is the most rapid method for
                                                             determining if a person has TB
                                                          •  It identifies persons who are at
                                                             greatest risk of dying from the
                                                             disease*
                                                          •  And it identifies the most likely
                                                             transmitters of infection
                                            *[Note that in persons with HIV infection, mortality rates are
                                            greater in patients with clinically-diagnosed TB who have
                                            negative sputum smears than among HIV-infected patients
                                            who have positive sputum smears.]


           Clinical_diagnosis_Nov2009.ppt                                           Page 7 of 24
Slide 16
                                                •   The limitation of sputum smear microscopy
                                                    is its sensitivity.
                                                •   As illustrated in the table: compared with
                                                    culture, sputum smear microscopy is 68%
                                                    sensitive in detecting M. tuberculosis.
                                                •   Of all specimens that are AFB positive
                                                    nearly 86% are detected by examining one
                                                    specimen and an additional 12% are found
                                                    on the 2nd specimen; thus, the incremental
                                                    yield of the 3rd specimen is very low. A
                                                    similar increment is found for the sensitivity
                                                    of the 2nd and 3rd specimens.
                                                •   The yield is better with a single early
                                                    morning specimen than with a spot specimen
                                                    obtained at other times during the day.

                                            [Reference: Mase SR, et al. Yield of serial sputum specimen
                                            examinations in the diagnosis of pulmonary tuberculosis: a
                                            systematic review. Int J tuberc Lung Dis 2007;11(5): 485-95]
Slide 17




                                            While we often focus on the pulmonary presentation
                                            and evaluation for TB, it is important to remember
                                            that TB may present in many ways.

                                                •   Can this case be TB?

                                                    “A 54 year-old man with three months of
                                            focal low back pain” presents with this radiographic
                                            finding.

                                            [Interactive option – ask participants to respond to
                                            question of TB for this case.]

                                            [Image credit: Francis J. Curry National Tuberculosis Center,
                                            University of California, San Francisco]




           Clinical_diagnosis_Nov2009.ppt                                         Page 8 of 24
Slide 18
                                            Yes, this is a patient presenting with spinal TB, or
                                            “Pott’s disease”, with radiographic evidence of
                                            vertebral destruction.

                                                •   Site specific symptoms are often the catalyst
                                                    for discovery of extrapulmonary sites of
                                                    involvement.
                                                •   While the radiographic findings in this case
                                                    may easily bring TB into the differential
                                                    diagnosis for this patient, often with
                                                    extrapulmonary disease, pertinent TB risk
                                                    factors must be recognized by the astute
                                                    clinician for TB to be considered and proper
                                                    diagnostic testing (which include both
                                                    culture and histopathologic sampling if
                                                    available) be initiated.

                                            [Interactive option – Ask participants for their
                                            experiences with cases of extrapulmonary TB where
                                            the diagnosis was a surprise. What kind of
                                            sampling/testing for extrapulmonary disease is
                                            available to them in their practice? Any creative
                                            solutions to difficulties encountered in obtaining
                                            diagnostic samples or possibilities for shared
                                            resources?]

                                            [Image credit: Francis J. Curry National Tuberculosis Center,
                                            University of California, San Francisco]




           Clinical_diagnosis_Nov2009.ppt                                         Page 9 of 24
Slide 19
                                            Standard 3 reinforces these points: [Read Standard
                                            3]

                                                •   Clearly, appropriate specimens may be
                                                    difficult to obtain from some
                                                    extrapulmonary sites.
                                                •   In spite of the difficulties, however, the basic
                                                    principle that bacteriological confirmation of
                                                    the diagnosis should be sought still holds.
                                                •   Generally, there are fewer M. tb organisms
                                                    present in extrapulmonary sites, so
                                                    identification of acid-fast bacilli by
                                                    microscopy in specimens from these sites is
                                                    less frequent and culture is more important.
                                                •   If tissue biopsy material is obtained,
                                                    diagnosis of TB may also be suggested by
                                                    histopathologic demonstration of appropriate
                                                    granulomatous lesions.

                                            [Instructor Notes: If the Microscopic Diagnosis
                                            module will not be covered in your curriculum,
                                            consider reviewing the Microscopic Diagnosis
                                            module for additional speaking points or slides that
                                            would be of interest for this topic.]

                                            [Image credit: IUATLD www.tbreider.org]
Slide 20




                                                •   Extrapulmonary TB (without lung
                                                    involvement) accounts for 15-20% of TB in
                                                    populations with a low prevalence of HIV
                                                    infection.
                                                •   In populations with a high prevalence of
                                                    HIV infection, the proportion of cases with
                                                    extrapulmonary TB is higher.
                                                •   Here, as a general example, is the
                                                    breakdown of extrapulmonary involvement
                                                    by site as reported in the United States.
                                                    [Review content of slide]




           Clinical_diagnosis_Nov2009.ppt                                     Page 10 of 24
Slide 21
                                            Other examples of extrapulmonary presentations:

                                                •   Tuberculous pleural effusion

                                                •   CNS tuberculomas (two enhancing lesions
                                                    seen on CT scan of head).

                                                •   Tuberculous adenitis (sometimes referred to
                                                    as “scrofula”). Patient had both an enlarged
                                                    anterior cervical node as well as a draining
                                                    cutaneous fistula from supraclavicular
                                                    nodes.

                                            [Image credit: Francis J. Curry National Tuberculosis Center,
                                            University of California, San Francisco (left and top right);
                                            Austin Brewin, MD (bottom right)]
Slide 22




                                            [Image credit: Francis J. Curry National Tuberculosis Center,
                                            University of California, San Francisco]
Slide 23




                                                •   While CXR examination can be a useful tool
                                                    in the diagnosis of TB, remember that it is a
                                                    sensitive, but not specific test for detecting
                                                    TB.
                                                •   Key point: A diagnosis of TB cannot be
                                                    established by radiography alone.
                                                    Reliance on the chest radiograph as the only
                                                    diagnostic test for TB will result in both
                                                    over-diagnosis of TB and missed diagnosis
                                                    of TB and other diseases.
                                                •   Thus, the importance of Standard 4: [Read
                                                    Standard]

                                            [Image credit: Francis J. Curry National Tuberculosis Center,
                                            University of California, San Francisco]




           Clinical_diagnosis_Nov2009.ppt                                       Page 11 of 24
Slide 24
                                            Can this case be TB?

                                            [Interactive option – ask participants to respond to
                                            the question (this will likely illicit a quick “yes”
                                            response and will confirm what they know)]


                                            [Image credit: Francis J. Curry National Tuberculosis Center,
                                            University of California, San Francisco]
Slide 25




                                            Yes - This is an example of a classic radiographic
                                            pattern many would describe as a “typical pattern”
                                            or a reactivation/post-primary TB pattern.

                                                •   The distribution of disease is often cited as:
                                                    [Review content of slide]

                                                •   Note that the presentation of an isolated
                                                    upper lobe anterior segment infiltrate on
                                                    CXR is unusual for M. tb, and may hint at
                                                    another etiologic organism (e.g. M.avium
                                                    complex). The anterior segment of the
                                                    upper lobe in this CXR is clear.

                                            [Image credit: Francis J. Curry National Tuberculosis Center,
                                            University of California, San Francisco]
Slide 26




                                                •   Specific radiographic patterns seen on CXR
                                                    that may be associated with
                                                    reactivation/post-primary TB include:
                                                    [Review content of slide]

                                                •   This radiograph shows a small area of
                                                    opacity with cavitation in the left upper lobe.

                                            [Image credit: Francis J. Curry National Tuberculosis Center,
                                            University of California, San Francisco]




           Clinical_diagnosis_Nov2009.ppt                                       Page 12 of 24
Slide 27
                                            Can this case be TB?

                                                •   [Top CXR: Focal right mid-lung infiltrate
                                                    with hilar adenopathy]
                                                •   [Bottom CXR: Focal left lower lobe
                                                    infiltrate]

                                                •   [Interactive option – ask participants to
                                                    respond to question. There may be less
                                                    certainty in participant response because
                                                    these CXR findings are common for other
                                                    infectious pneumonias.]

                                            [Image credits: Francis J. Curry National Tuberculosis
                                            Center, University of California, San Francisco]
Slide 28




                                            Yes, both of these patients had TB and represent
                                            examples of “atypical” patterns” of CXR
                                            presentation: [Review content of slide]

                                                •   An “atypical pattern” may often be
                                                    associated with Primary TB and also be
                                                    commonly seen in patients with TB and
                                                    HIV/AIDS co-infection.

                                            [Image credits: Francis J. Curry National Tuberculosis
                                            Center, University of California, San Francisco]
Slide 29




                                            Can this be TB?

                                                •   [Interactive option – ask participants to
                                                    respond to question.]


                                            [Image credits: Francis J. Curry National Tuberculosis
                                            Center, University of California, San Francisco (left);
                                            University of California, San Francisco/Walter Finkbeiner,
                                            MD (right)]




           Clinical_diagnosis_Nov2009.ppt                                        Page 13 of 24
Slide 30
                                            Yes, these are all examples of the fine, stippled
                                            pattern of small nodules seen in miliary TB by chest
                                            radiograph (which correspond to the gross
                                            pathology demonstrating scattered granulomatous
                                            lesions seen on the right).

                                                •    This pattern of nodules, which reflects the
                                                     hematogenous spread of disease, can also be
                                                     appreciated well by chest CT imaging.

                                                •    Note that a miliary pattern may be seen in
                                                     either primary or reactivation/post-primary
                                                     disease.

                                            [Image credits: Francis J. Curry National Tuberculosis
                                            Center, University of California, San Francisco (left and
                                            center); University of California, San Francisco/Walter
                                            Finkbeiner, MD (right)]
Slide 31




                                            Can this case be TB?

                                                •    [Interactive option – ask participants to
                                                     respond to question.]


                                            [Image credits: Francis J. Curry National Tuberculosis
                                            Center, University of California, San Francisco]
Slide 32




                                            Yes, these are examples of residual radiographic
                                            findings that can be found as the sequelae of prior
                                            active TB. [Review content of slide]

                                                •    Note that the age and activity of disease
                                                     cannot be determined by a single CXR.

                                                •    [Top: Ca+ granuloma and hilar node
                                                     calcification - Ranke complex]
                                                •    [Left: Apical pleural thickening]
                                                •    [Right: Apical fibrosis with volume loss]

                                            [Image credits: Francis J. Curry National Tuberculosis
                                            Center, University of California, San Francisco]




           Clinical_diagnosis_Nov2009.ppt                                         Page 14 of 24
Slide 33
                                                •   Important issues regarding use of CXR for
                                                    diagnosis of tuberculosis need to be
                                                    considered: [Review content of slide].
Slide 34




                                                •   Over-reliance on CXR without the use of
                                                    sputum microscopy is a common practice in
                                                    some areas.
                                                •   Data from a study done in a high-incidence
                                                    country demonstrates just how misleading
                                                    reliance on the CXR alone can be.
                                                    [Review content of slide]
                                                •   Overall, radiographic examination for the
                                                    evaluation of TB is most useful when
                                                    applied as part of a systematic approach --
                                                    particularly, as we will discuss next, in the
                                                    evaluation of persons whose symptoms
                                                    and/or findings suggest TB, but who have
                                                    negative sputum smears.

                                            [Reference: Nagpaul DR, Proceedings of the 9th Eastern
                                            Region Tuberculosis Conference and 29th National
                                            Conference on Tuberculosis and Chest Diseases. 1974 Delhi,
                                            as cited in Toman’s tuberculosis. Case detection, treatment
                                            and monitoring, 2nd Edition. Freiden TR ed. Geneva: World
                                            Health Organization, 2004]




           Clinical_diagnosis_Nov2009.ppt                                       Page 15 of 24
Slide 35
                                                •   The designation of “sputum smear-negative
                                                    tuberculosis” presents a difficult diagnostic
                                                    dilemma.
                                                •   On average, sputum smear microscopy is
                                                    only about 50-60% sensitive when compared
                                                    with culture.
                                                •   When clinical judgment suggests a high
                                                    suspicion for TB, it is important that a
                                                    rigorous approach be taken to evaluate fully
                                                    for this diagnosis, despite the finding of
                                                    three negative sputum smears.
                                                •   Standard 5 addresses the diagnosis of smear-
                                                    negative TB. To diagnose smear negative
                                                    TB, the following criteria should be met:
                                                    [Read Standard]

                                            [Note: Guidelines (WHO 2009 pending publication) have
                                            recently changed from three sputum smears to at least two
                                            sputum smears. The change is reflected above and differs
                                            from the wording in the original published ISTC.]
Slide 36




                                            Continued: [Read Standard]




           Clinical_diagnosis_Nov2009.ppt                                        Page 16 of 24
Slide 37                                    A number of algorithms have been developed as a means to
                                            systematize the diagnosis of smear-negative TB, although
                                            none has been adequately validated under field conditions. In
                                            particular, there is little information or experience on which to
                                            base approaches to the diagnosis of smear-negative TB in
                                            persons with HIV infection when culture is not routinely
                                            available.
                                            Here, as an example of a systematic approach, is a composite
                                            algorithm modified from algorithms developed by WHO:
                                                 • Begin with the clinical suspicion for TB (TB
                                                     Suspect).
                                                 • The most important first step toward making a
                                                     diagnosis would be to obtain sputum for AFB
                                                     microscopy. HIV testing is also of significant
                                                     importance, particularly in areas of high HIV or
                                                     TB/HIV prevalence .
                                                 • If at least two smears are negative, the next step takes
                                                     into consideration HIV status and the severity of
                                                     presentation. The algorithm continues on the next
                                                     two slides.

                                                •    Note: This is one example of an algorithm that
                                                     incorporates the fundamental principles
                                                     recommended for diagnosing TB, and in practice,
                                                     some local or national programs may follow a
                                                     different sequence.
                                                •    Caution: First, it should be emphasized that the
                                                     completion of all of the steps requires a substantial
                                                     amount of time; thus, the algorithm should not be
                                                     used for patients with an illness that is worsening
                                                     rapidly. This is especially true in patients with HIV
                                                     infection in whom TB may be rapidly progressive (as
                                                     will be outlined on next slide).
                                                •    Second, several studies have shown that patients with
                                                     TB may respond, at least transiently, to broad
                                                     spectrum antimicrobial treatment. Such a response
                                                     may lead to a delay in diagnosis of TB. Empiric
                                                     fluoroquinolone monotherapy for respiratory tract
                                                     infections has been associated with delays in
                                                     initiation of appropriate anti-TB therapy and acquired
                                                     resistance to the fluoroquinolones.
                                                •    Finally, following the above approach may be quite
                                                     costly to the patient and deter her/him from
                                                     continuing with the diagnostic evaluation.
                                                •    Given these concerns, application of such an
                                                     algorithm in patients with at least two negative
                                                     sputum smears must be done in a flexible manner.

                                            [Reference: World Health Organization. Treatment of tuberculosis.
                                            Guidelines for national programmes. Geneva: WHO 2003]




           Clinical_diagnosis_Nov2009.ppt                                           Page 17 of 24
Slide 38
                                                •    In HIV-positive or seriously ill patients the
                                                     tempo of the evaluation and initiation of
                                                     treatment must be accelerated. Empiric broad
                                                     spectrum antibiotic treatment is recommended in
                                                     seriously ill patients and empiric treatment for P.
                                                     jiroveci pneumonia (PCP) should be considered
                                                     if HIV-positive. One or more of the following
                                                     danger signs would suggest that a patient is
                                                     seriously ill: inability to walk unaided,
                                                     respiratory rate over 30 breaths per minute, fever
                                                     of more than 39 C, or pulse rate of over 120
                                                     beats per minute.
                                                •    Although, sputum smear microscopy is the first
                                                     test of choice, culture should be included as an
                                                     important step in evaluating cases of smear-
                                                     negative suspects. Properly done, culture adds
                                                     a significant layer of complexity and cost but
                                                     also increases sensitivity , which should result in
                                                     earlier case detection. Although the results of
                                                     culture may not be available until after a
                                                     decision to begin treatment has to be made,
                                                     treatment can be stopped subsequently if cultures
                                                     from a reliable laboratory are negative, the
                                                     patient has not responded clinically, and the
                                                     clinician has sought other evidence in pursuing
                                                     he differential diagnosis.
                                                •    For seriously ill patients (particularly patients
                                                     with HIV infection) a clinical decision to start
                                                     treatment often must be made without waiting
                                                     for the results of cultures. Such patients may die
                                                     if appropriate treatment is not begun promptly.
                                                     [Review contents of slide]
                                                •    It should be noted that even when the diagnosis
                                                     is TB, patients may respond to a course of
                                                     antibiotic treatment. As noted in Standard 5, the
                                                     use of fluoroquinolones as empiric treatment for
                                                     respiratory track infections may confuse the
                                                     picture by causing a transient improvement of
                                                     TB, and therefore should be avoided.

                                            [Reference: World Health Organization. Improving the diagnosis and
                                            treatment of smear-negative pulmonary and extrapulmonary
                                            tuberculosis among adults and adolescents. Recommendations for
                                            HIV-prevalent and resource-constrained settings. Geneva: WHO
                                            2007]




           Clinical_diagnosis_Nov2009.ppt                                          Page 18 of 24
Slide 39
                                                •   In patients who do not present with
                                                    signs/symptoms of a serious level of illness,
                                                    i.e. those considered ambulatory, or in
                                                    those who are HIV-negative with non-severe
                                                    illness, the evaluation may be managed
                                                    along a somewhat different path.
                                                •   If the smears are negative and the initial
                                                    clinical evaluation deems a diagnosis of TB
                                                    unlikely, it is reasonable to give treatment
                                                    for alternative diagnoses more time and fully
                                                    assess the response before considering a re-
                                                    evaluation for TB. [Review contents of
                                                    slide]
                                                •   Again, obtaining cultures can be of key
                                                    importance, particularly in smear-negative
                                                    suspects who are not responding to empiric
                                                    non-TB interventions.
                                            [World Health Organization. Improving the diagnosis and
                                            treatment of smear-negative pulmonary and extrapulmonary
                                            tuberculosis among adults and adolescents. Recommendations
                                            for HIV-prevalent and resource-constrained settings. Geneva:
                                            WHO 2007]
Slide 40




                                                •   While this lecture has reviewed many of the
                                                    classic features of the clinical presentation of
                                                    TB, it is worth repeating that it is a disease
                                                    that may attempt to fool even the most astute
                                                    clinician. A great range in presentation
                                                    exists, especially if HIV is present (where
                                                    atypical presentations are more common).
                                                •   One should remember: [Review content of
                                                    slide]
                                                •   Therefore it is important to realize that TB
                                                    can present in many ways beyond the classic
                                                    description. The ISTC offer guidelines to
                                                    help prioritize our investigations in the
                                                    initial recognition and diagnostic workup for
                                                    TB.




           Clinical_diagnosis_Nov2009.ppt                                       Page 19 of 24
Slide 41
                                               •    To summarize, the key points of this
                                                    presentation were:
                                                    [Review content of slide]

                                               •    And above all, Think TB.
Slide 42




                                               •    And in summary, the International Standards
                                                    reviewed: (abbreviated)
                                                    [Review content of slide]
Slide 43




                                            [Continued - Review content of slide]


                                            [End]
Slide 44




                                               •    Alternate Slides: Offer additional options
                                                    that may be added or substituted into
                                                    module.

                                               •    See Facilitator’s Guide for further
                                                    information.




           Clinical_diagnosis_Nov2009.ppt                                    Page 20 of 24
Slide 45
                                            The International Standards for Tuberculosis
                                            Care (ISTC):
                                               • Are intended to unite public and private
                                                   sectors in providing a uniformly accepted
                                                   level of care for all patients with, or
                                                   suspected of having, TB.
                                               • Describes the essential elements of TB care
                                                   that should be available everywhere.
                                               • Provides a vehicle for mobilizing
                                                   professional societies globally in support of
                                                   TB programs.
                                               • Serves as a powerful advocacy tool to ensure
                                                   that the essential elements are available.

                                            [Image Credit: World Lung Foundation/Jad Davenport ]




           Clinical_diagnosis_Nov2009.ppt                                     Page 21 of 24
Slide 46                                    •   The ISTC consist of 21 evidence-based
                                                standards. The original 17 standards from 2006
                                                were revised and renumbered in 2009.
                                            •   Standards differ from existing guidelines in that
                                                standards present what should be done, whereas,
                                                guidelines describe how the action is to be
                                                accomplished.
                                            •   To meet the requirements of the Standards,
                                                approaches and strategies, determined by local
                                                circumstances and practices and developed in
                                                collaboration with local and national public
                                                health authorities, will be necessary. There are
                                                many situations in which the level of care can,
                                                and should, go beyond what is specified in the
                                                Standards.
                                            •   The Standards should be viewed as a living
                                                document that will be revised as technology,
                                                resources, and circumstances change. Revisions
                                                to the original document released December
                                                2005 are currently underway.
                                            •   Funded (Oct 1, 2004) by USAID via TBCTA,
                                                development was supervised by an international
                                                steering committee (28 members / 14 countries)
                                                chosen to represent perspectives relevant to
                                                tuberculosis care and control.
                                            •   The Standards are also intended to serve as a
                                                companion to and support for the Patients’
                                                Charter for Tuberculosis Care developed in
                                                tandem with the Standards.
                                            •   A Handbook for using the International
                                                Standards for Tuberculosis Care is also
                                                available (2007). The Handbook presents
                                                suggestions and guidance, based mainly on
                                                country-level experiences, for using the ISTC as
                                                a tool to foster and guide the delivery of high-
                                                quality care by all practitioners providing TB
                                                care.
                                                [Resource: www.istcweb.org]




           Clinical_diagnosis_Nov2009.ppt                                 Page 22 of 24
Slide 47
                                               •   The Standards are addressed to all healthcare
                                                   providers, private and public, who care for
                                                   persons with proven tuberculosis or with
                                                   symptoms and signs suggestive of TB.
                                               •   Three categories of activities are addressed
                                                   by the Standards: diagnosis, treatment, and
                                                   public health responsibilities of all
                                                   providers. The ISTC are intended to be
                                                   complementary to local and national TB
                                                   control policies that are consistent with
                                                   the World Health Organization (WHO)
                                                   recommendations.
                                               •   In many parts of the world there is great
                                                   variability in the quality of tuberculosis care,
                                                   and poor quality care continues to plague
                                                   global tuberculosis control efforts. Effective
                                                   engagement of all providers in providing
                                                   high quality care in collaboration with TB
                                                   control programs is key to the promotion of
                                                   sound tuberculosis control.
Slide 48




                                               •   Questions: May be used for interactive
                                                   discussion, course evaluation, or continuing
                                                   medical education purposes.

                                               •   See Facilitator Guide for further
                                                   information.
Slide 49




                                            Correct Answer: C




           Clinical_diagnosis_Nov2009.ppt                                   Page 23 of 24
Slide 50
                                            Correct Answer: D
Slide 51




                                            Correct Answer: C




           Clinical_diagnosis_Nov2009.ppt                       Page 24 of 24

								
To top