Presentation on Hepato-Billiary TB | Jindal Chest Clinic

"Hepato-Billiary TB: Clinical Symptoms, Causes, Complications, and Diagnosis"

1. HEPATO-BILLIARY TB

2. Clinical syndromes of hepato-biliary TB Congenital TB – jaundice and failure to thrive (newborn) Primary hepatic TB Disseminated / miliary TB Tuberculoma TB of biliary tract Granulomatous hepatitis TB pylephlebitis ATT induced hepatitis

3. Hepatobiliary TB Rt. Hypochondrial pain and swelling Hepatomegaly – Mildly tender Nodular or granular Miliary hepatic TB Sometimes, liver abscess - Tender hepatomegaly Jaundice Biliary duct obstruction – obstructive jaundice TB of GB

4. Hepato -biliary TB – D/D Other hepatic lesions ( Hepato-megaly ) Viral hepatitis – chronic Fatty liver, alcoholism Connective tissue diseases (SLE, Rh. arthritis) Hemosiderosis Amyloidosis Sarcoidosis Drug induced hepatitis Primary biliary cirrhosis Lymphomas Metastases

5. Genito -urinary TB: Renal Involves kidneys, ureters , urinary bladder Symptoms: Irritation and pain while voiding urine Hematuria Sterile pyuria Flank pain, renal mass Recurrent urinary tract infection Urinary calculi

6. Genital TB - Males TB of testes, epididymis , prostate, penis, urethra S/S: Hemospermia Scrotal pain and swelling Nodularity of epididymis , vas deferens, prostate Sometimes, sinus formation; perineal fistula

7. Genital TB - Females Fallopian tubes – common Endometrial Ovarian Cervix, vagina, vulva S & S: Ch. lower abd . pain abnormal discharge Altered menses Infertility Tubo -ovarian masses, ascites, adhesions etc.

8. Skeletal TB Most ancient form – pre-historic Hematogenous spread Involves spine and other bones – hip joint, knee, ankle, foot bones etc. Types: Osseus granular ( Metaphysis or epiphysis) Osseus caseus Synovial granular Synovial caseus

9. Spinal TB Lower thoracic and lumbar vertebrae Infection begins in cancellous area of vertebral body – destruction – collapse of vertebra Exudation – cold abscess Symptoms of local compression from cold abscess Spinal: paraparesis – plegia Mediastinal structures Psoas abscess

10. Pott’s paraplegia - Mechanism Extrinsic or mechanical causes Cold abscess Granulation tissue Sequestrated bone and disc Fibrous tissue Gliosis of spinal cord ii. Intrinsic or non-mechanical causes TB inflammation (spinal meningitis) Thrombosis of ant. spinal artery

11. Pott’s Spine (Spinal Kyphosis -TB)

12. D/D of spinal TB Developmental defects – hemivertebrae Infections – pyogenic , mycotic Benign neoplasms – hemangioma , aneurysm, bone cyst Primary malignant tumours (Ewing’s sarcoma, chordoma , lymphoma) Secondary deposits Langerhan’s cell histiocytosis Paget’s disease Trauma

13. Spinal Cold abscess

14. Joint TB Synovial membrane involvement – inflammation and fibrosis Insidious onset Local warmth Joint pain, tenderness Immobility – restriction of movements Joint effusion – doughy swelling Synovial fluid – thin and opalescent; contains cells and fibrin flakes Sinus formation Ankylosis ; bone destruction

15. Bone and Joint TB (Knee, Scapula)

16. Neurological TB Tuberculous meningitis TB arachnoiditis Basal Opticochiasmatic Spinal Tuberculoma Intracranial Spinal TB abscess

17. S/S of Neurological TB Symptoms: Fever, Altered sensorium , Seizures , Behavioural changes Signs: Neck rigidity, Papilloedema , Abducens nerve palsy, Hemiplegia . Facial nerve palsy, Optic atrophy, decerebration , abnormal movements, oculo -motor palsy, choroidal tubercles.

18. D/D of TB-meningitis Partially treated bac . meningitis Cryptococcal Viral meningo -encephalitis Carcinomatosus Parameningeal infections Neurosarcoidosis Neurosyphilis

19. Complications of TB meningitis Cerebral oedema , stupor Cranial nerve palsy Focal neurological deficits Hydrocephalus Tuberculoma TB abscess Visual loss TB arteritis – stroke Endocrine disturbances Diabetes inspidus

20. Cerebral TB ( Miliary , Abscesses)

21. Miscellaneous organs in TB Skin: TB chancre Lupus vulgaris Scrofuloderma Tuberculides ENT: Laryngeal TB Ear, nose, pharynx Adrenal gland: Addison’s disease Ocular TB: Choroiditis Retinitis , iritis Muscles, breasts, spleen

22. Cutaneous TB

23. Diagnosis of Pulmonary TB Clinical Features Sputum Examination Chest Radiology Bronchoscopy Mantoux test Indirect laboratory tests

24. Radiological Characteristics I. Chest: Upper Lobes/Diffuse miliary Infiltrates/Exudates/Fibrosis Multiple, thin walled cavities Lymphadenopathy , Pl.effusion II. Others: Enlargement of organs Erosions/Effusions Caseations /collections

25. Role of Chest X-ray No chest X-ray pattern is absolutely typical of TB 10-15% of culture-positive TB patients not diagnosed by X-ray 40% of patients diagnosed as having TB on the basis of x-ray alone do not have active TB X-ray is unreliable for diagnosing and monitoring treatment of tuberculosis

26. Role of bronchoscopy Valuable in early diagnosis of strongly suspected sputum-negative TB. Diagnosis of endobronchial TB/ miliary TB TBLB yield is greater (82%) than BAL (26 %) TBNA has a role in mediastinal lymph nodal tuberculosis with negative sputum smears

27. NO ROLE IN DIAGNOSIS ESR?

28. Tuberculin ( Mantoux ) Test Infection with mycobacterium tuberculosis leads delayed hypersensitivity reaction which can be detected by Mantoux test About 2 to 4 weeks after infection, intracutaneous injection of purified protein derivative (PPD) of M.tuberculosis induces a visible and palpable induration that peaks in 48 to 72 hours

29. How to do the test? Sub cutaneous Weal formation Itching – no scratch. Read after 72 hours. Induration size. 5-10-15mm

30. Mx Interpretation ( i ) Induration less than 5 mm – no exposure to tubercular bacilli . ( ii ) Induration between 5-9 mm – this can be due to atypical mycobacteria or BCG vaccination. It may suggest infection in immunocompromised children such as HIV infection or other immunosupression ; ( iii ) Induation 10 mm or more – an induration of 10 mm or more at 48-72 hours in a child with symptoms of tuberculosis should be interpreted as tubercular disease

31. Positive test

32. Clinical significance Denotes infection Does not differentiate infection from active disease A strongly positive Mantoux can support a clinical diagnosis Better negative than positive predictive value Cut-off for a positive test?

33. Tests for mycobac aetiology Smear examination Culture for mycobacteria LJ medium Rapid culture methods Nucleic acid amplification tests Polymerase chain reaction

34. Mycobacterial demonstration Samples to be tests Sputum , induced sputum Fiberoptic bronchoscopy – BAL Bronchial or transbronchial lung biopsy Gastric lavage ( Children) Pleural fluid

35. Mycobacterial Demonstration Smear: - Easiest , quickest - Requires > 10000 AFB/ml - Sensitivity 50-60%; Specificity: High Culture: - More sensitive; 10 AFB/ml - Traditional 6-8 wks - Septi Chek : Biphasic; High yield - Radiometric : BACTEC Others : - Animal pathogenicity - Antimicrobial sensitivity

36. Drug Susceptibility Methods Conventional Absolute concentration Resistant Ratio Proportion Method Rapid Methods Radiometric (BACTEC) Mycobac . Growth Indicator Tube PCR Based RFLP (DNA Finger printing)

37. Indirect Tests: Markers Biochemical: LDH, Proteins Adenosine Deaminase Bromide Partition Test Gas Chromatography – Fatty acids, alcohols etc. Immuno -diagnosis Skin test ( Mantoux ) Detection of Antibodies (Tests banned)

38. Serological Tests Low turn around time. Limitation: low sensitivity in: smear negative patients, HIV positive cases, i n disease -endemic countries with a high infection rate. Poor standardization. Banned in 2012.

39. Newer Tests Gamma Interferon Assay Test (Gold – IGRA) Genetic/Molecular techniques Gene X-pert TB Detection of DNA specific base sequences DNA amplification and detection  RNA: Presence of multiplying bacteria

40. Interferon- γ release assays An alternative to the TST in the form of a new type of in-vitro T-cell-based assay (Test-tube TST) Gold IGRA Elispot T test T cells of individuals sensitized with tuberculosis antigens produce interferon- γ when they re-encounter mycobacterial antigens High level of interferon- γ production - presumptive of tuberculosis infection

41. IGRA in LTBI In the absence of a gold standard for diagnosis of Latent TBI, the sensitivity and specificity cannot be directly estimated IGRA have higher specificity than TST Better correlation with surrogate markers of exposure to M tuberculosis ( in low-incidence setting countries) Less cross reactivity as a result of BCG vaccination than TST

42. Gene X-pert Test Detection and identification of mycobacteria directly from clinical samples Cartridge based, PCR test for detection of mycobacteria and Rifampicin resistance Rapid test. Results within hours . Costly Continuous electric supply and temperature maintenance ? Field feasibility, sensitivity and specificity in India.

43. Confirmation of diagnosis of Pulm TB Clinical features are not confirmatory. Zeil Nielson Stain Culture most sensitive and specific test. Conventional Lowenstein Jensen media 3-6 wks. Automated techniques within 9-16 days PCR is available, but should only be performed by experienced laboratories Mantoux test

44. Diagnosis of Extra Pulmonary TB Sputum or other smears are often Negative. These are difficult to use for Diagnosis and start of treatment Follow up Monitoring End point Recurrence / Relapse Mostly clinico -radio- histo /cytological Invasive procedures frequently required to obtain tissue, fluids, etc. to look for T.b . and/or histo -cytological criteria.

45. Difficulties of Extra-pulmonary Tuberculosis Largely clinical and radiological . Supported by laboratory parameters and other TB markers . Invasive procedures frequently required to obtain tissue, fluids, etc. to look for T.b . and/or histo -cytological criteria . Therapeutic trial as a diagnostic modality should not be used.

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