TB

TUBERCULOSIS (TB)—”THE WHITE PLAGUE”–”PHTHISIS”(WASTING)–CONSUMPTION
AN ARCHIBACTERIA (INTRACELLULAR)—ATYPICAL MYCOBACTERIAL
PRACTICALLY DIVIDED INTO: MYCOBACTERIUM TUBERCULOSIS AND ATYPICAL MYCOBACTERIA
CONVENTIONAL TB–MUST BE ANY TUBERCLE BACILLUS–MTB, B. BOVIS (BCG), M. AFRICANUM—-PRIMARILY AN INHALANT WHICH AFFECTS THE LUNGS
NON-TUBERCULOUS/ATYPICAL (NTM)—TYPICALLY AFFECTS CHILDREN AND IMMUNOCOMPROMISED ADULTS—M. AVIUM COMPLEX, M. KANSASII=CRITERION FOR AIDS——LESS VIRULENT, OPPORTUNISTS, UBIQUITOUS—CLASSIFIED BY RUNYON BY THEIR PIGMENTATION
ANY TIME YOU GET ANY KIND OF TB—THINK OF POSSIBLE HIV
MYCOBACTERIUM TUBERCULOSIS (CONVENTIONAL)
TYPICALLY MANIFESTS WITH PULM Dz—GALLOPING CONSUMPTION (CIRCULAR CIRCULATION), GHON COMPLEX–PLEURAL AND HILAR GRANULOMAS (TENDS TO LIKE THE LUNG APICES)—TRACTION ESOPHAGEAL DIVERTICULUM
AFFECTS INTER-ARYTENOID REGION OF LARYNX
LESS THAN 1% OF CASES INVOLVE THE EAR—BUT THIS CAN BE THE ONLY ORGAN AFFECTED
CLASSICALLY PAINLESS, AFEBRILE–MULT PERFS WITH ABUNDAANT PALE GT AND THIN WATERY DRAINAGE—+PREAURICULAR LAD
RECENTLY–SINGLE LARGE PERF WITH DULL THICKENED TM, DILATED BV’S, LITTLE OR NO OTALGIA OR FEVER
CAN PRESENT WITH CHRONICALLY DRAINING EAR—DEHISSENT MASTOID SKIN INCISION
USED TO BE THOUGHT TO COME UP THE ETT—NOW THOUGHT TO ARRIVE TO EAR HEMATOGENOUSLY
CERVICAL TB–USED TO BE THOUGHT OF AS A MANIFESTATION OF DISSEMINATED Dz—-BUT CAN BE ISOLATED DZ–SCOFULA “KERNALS”–CERVICAL LAD—RARE—CHECK A CXR (OFTEN NEGATIVE) AND A SPUTUM—MAY NOT BE CONTAGEOUS—USED TO BE DUE TO M. BOVIS SECONDARY TO UNPASTEURIZED MILK—CAN ALSO BE ASSOC WITH PAROTITIS
POTT’S Dz = VERTEBRAL OSTEO (HEMATOGENOUS)
Dx: Hx, CXR, ANERGY PANEL, PPD/TYNE TEST/MANTOUX,  FNA–ZIEL NIELSON STAIN, FNA–Cx–LOWENSTEIN JENSEN MEDIUM(CAN TAKE 6 WEEKS)—CONSIDER HIV TEST
Rx: CHEMO–ISOLATION—USUALLY START 4 DRUG REGIMEN AND KEEP ISOLATED—-ID CONSULT—LATER GO TO 2 DRUGS FOR 8-12 MONTHS
INH——PROPHYLACTIC DRUG OF CHOICE—NEUROTOXIC IN SLOW ACETYLATORS (B6-PYRIDOXINE HELPS)
RIFAMPIN–ORANGE SWEAT AND URINE—-OFTEN FLU LIKE SYMPTOMS
ETHAMBUTOL–OPTIC NEURITIS AND GI SIDE EFFECTS
STREPTOMYCIN–OTO—-VESTIBULO/NEPHRO/NMJ TOXIC
PYRANZINAMIDE–LIVER NECROSIS
FLOROQUINOLONES—INHIBITS CARTILAGE SYNTHESIS
USUALLY Rx FOR 9 MONTHS
ADD: IN THE LATE 40’S AND EARLY 50’S DIHYDROSTREPTOMYCIN WAS USED—-CAUSED A DELAYED COCHLEOTOXICITY–SNHL—PTS WENT DEAF ABOUT 6 MONTHS LATER (VS STREPTOMYCIN—VESTIBULOTOXIC)
MTB
CERVICAL LAD USALLY BILATERAL—SUPRACLAVICULAR/POST TRIANGLE, OLDER, PPD >10-15MM, +Hx CONTACT, ABNL CXR,—-Rx CHEMO
VS
ATYPICAL MYCOBACTERIUM—NON TUBERCULOUS MYCOBACTERIUM—NTM
SEE MORE IN CHILDREN AND IMMUNOCOMPROMISED HOSTS
USUALLY M. AVIUM-INTRACELLULARE OR M. SCROFULACEUM
USUALLY INFECTS FROM THE ORAL CAVITY AND CAN BE CULTURED FROM THEIR IN CHILDREN
PAROTID INVOLVEMENT IS COMMON
+ CERVICAL LAD USUALLY UNILATERAL–ANT TRIANGLE–PRIMARILY OVER LEVELS I AND II—OVERLYING SKIN LOOKS INFLAMMED, YOUNGER, <10-15MM PPD(SLIGHTLY + IN 50%), NL CXR, OFTEN NO HISTORY OF EXPOSURE—-USUALLY NO CONSTITUTIONAL SYMPTOMS (FEVER, MALAISE, WT LOSS)
Dx BY A FNA–SEE GRANULOMA-GT
Rx—OLD DOGMA—– SURGICAL(COMPLETE EXCISION ADVOCATED TO AVOID A CHRONIC FISTULA)
NEW DOGMA—CHEMO (ANTIBIOTICS) PREVIOUSLY THOUGHT NOT TO BE EFFECTIVE—NEW LIT ON ZITHROMAX OR BIAXIN/ AND RIFABUTIN—FNA AND CURRETAGE (TUNKEL)—-PROBABLY WISE TO GENTLY CURRETAGE OVER THE FACIAL NERVE—-NEW LIT CONFIRMS THIS IS A GOOD OPTION (PROLONGED MACROLIDE AND GENTLE CURRETAGE)–THUS ALL TB—CONVENTIONAL AND ATYPICAL IS NOW PRIMARILY TREATED WITH CHEMOTHERAPEUTICS!

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