India accounts for 20% of all TB cases globally. The RNTCP program was established in 1962 and scaled up nationally by 2006, achieving global targets of 85% cure rates and 70% case detection. Extrapulmonary TB (EPTB) accounts for 15-20% of Indian TB cases and poses challenges including lack of uniform treatment guidelines and drug resistance. EPTB presentations are highly variable and include lymph node, abdominal, bone and joint, pleural, meningeal, and urogenital manifestations. Accurate diagnosis requires tissue-based testing and drug susceptibility testing.
The document provides guidelines for the management of abdominal tuberculosis in India. It details that abdominal TB accounts for 3% of extra-pulmonary TB cases in India. The most common sites of infection are the ileocaecal region. Diagnostic tests for abdominal TB may include ascitic fluid analysis, ultrasound, biopsy and culture. Treatment involves a standard 6 month ATT regimen of 2RHZE/4RHE. Surgery may be required in cases of bowel strictures or perforations.
This document discusses guidelines for the diagnosis and treatment of extrapulmonary tuberculosis (EPTB) in India. It notes that EPTB accounts for 15-20% of total TB cases in India. Key points include:
- Xpert MTB/RIF testing can be used as an adjunct for lymph node and TB meningitis diagnosis but has limitations.
- Steroids are recommended for TB meningitis and pericarditis but not routinely for pleural TB.
- Treatment durations vary by site but are typically 6-9 months for most EPTB forms using standard first-line ATT regimens. Strict follow-up is important to monitor treatment response and outcomes.
This document discusses tuberculosis (TB) management in special situations. It provides WHO guidelines for TB treatment regimens based on category of TB, including doses and duration of treatment. It also summarizes TB treatment considerations for pregnancy, breastfeeding, infants, liver disease, renal disease, HIV co-infection, and other groups. Key recommendations include safe drugs to use in pregnancy, dose adjustments for liver and renal impairment, and extending TB treatment duration for certain high-risk patients.
Helicobacter Pylori & Gastric Cancer - An Evidence Based Approach for Primary...Jarrod Lee
Helibacter pylori affects 50% of the world's population. It is a major cause of peptic ulcer disease and gastric cancer. We present a contemporary evidence based approach for the primary care doctor, incorporating the latest guidelines. We provide a diagnostic and management approach incorporating the latest studies, and present a contemporary approach to preventing gastric cancer
Management of tb in ckd dr Tareq tantawyFarragBahbah
This document discusses the management of tuberculosis (TB) in patients with chronic kidney disease (CKD). It outlines that TB is more common in CKD patients due to factors like uremia and immunosuppression from dialysis or transplantation. It describes the clinical presentation of TB in CKD patients, which can be nonspecific, and challenges with diagnosis. It provides recommendations on screening CKD patients for latent TB and details dosing considerations for first- and second-line anti-TB drugs in renal impairment.
A 45-year-old male presented with a 2-month history of dry cough and 1-week history of shortness of breath. He was diagnosed with disseminated tuberculosis involving the lungs and massive pericardial effusion. He was started on anti-tuberculosis medications and steroids. He developed lower limb deep vein thrombosis and was started on anticoagulation. He underwent pericardial drainage and window procedure. His treatment plan includes continuing anti-TB medications, increasing warfarin dose, and educating the patient about medication adherence and side effect monitoring.
This document discusses infectious and non-infectious complications of pediatric peritoneal dialysis. It covers topics such as peritonitis (the most common complication), peritoneal catheter exit-site and tunnel infections, gastroesophageal reflux disease, delayed gastric emptying, back pain, and pleural effusions. For each complication, it discusses causes, risk factors, clinical presentation, microbiology, diagnosis, treatment recommendations, and management strategies.
The patient is a 64-year-old man who underwent radical nephrectomy 6 weeks prior for clear-cell renal cell carcinoma (RCC), stage T3aN0. He has no signs of disease recurrence but is at high risk. The document discusses whether adjuvant therapy is indicated and reviews recent phase 3 trials of adjuvant sunitinib versus placebo, which showed improved disease-free survival but not overall survival. It also reviews ongoing adjuvant immunotherapy trials versus placebo and optimal sequencing of systemic therapies if the cancer recurs.
The document provides guidelines for the management of abdominal tuberculosis in India. It details that abdominal TB accounts for 3% of extra-pulmonary TB cases in India. The most common sites of infection are the ileocaecal region. Diagnostic tests for abdominal TB may include ascitic fluid analysis, ultrasound, biopsy and culture. Treatment involves a standard 6 month ATT regimen of 2RHZE/4RHE. Surgery may be required in cases of bowel strictures or perforations.
This document discusses guidelines for the diagnosis and treatment of extrapulmonary tuberculosis (EPTB) in India. It notes that EPTB accounts for 15-20% of total TB cases in India. Key points include:
- Xpert MTB/RIF testing can be used as an adjunct for lymph node and TB meningitis diagnosis but has limitations.
- Steroids are recommended for TB meningitis and pericarditis but not routinely for pleural TB.
- Treatment durations vary by site but are typically 6-9 months for most EPTB forms using standard first-line ATT regimens. Strict follow-up is important to monitor treatment response and outcomes.
This document discusses tuberculosis (TB) management in special situations. It provides WHO guidelines for TB treatment regimens based on category of TB, including doses and duration of treatment. It also summarizes TB treatment considerations for pregnancy, breastfeeding, infants, liver disease, renal disease, HIV co-infection, and other groups. Key recommendations include safe drugs to use in pregnancy, dose adjustments for liver and renal impairment, and extending TB treatment duration for certain high-risk patients.
Helicobacter Pylori & Gastric Cancer - An Evidence Based Approach for Primary...Jarrod Lee
Helibacter pylori affects 50% of the world's population. It is a major cause of peptic ulcer disease and gastric cancer. We present a contemporary evidence based approach for the primary care doctor, incorporating the latest guidelines. We provide a diagnostic and management approach incorporating the latest studies, and present a contemporary approach to preventing gastric cancer
Management of tb in ckd dr Tareq tantawyFarragBahbah
This document discusses the management of tuberculosis (TB) in patients with chronic kidney disease (CKD). It outlines that TB is more common in CKD patients due to factors like uremia and immunosuppression from dialysis or transplantation. It describes the clinical presentation of TB in CKD patients, which can be nonspecific, and challenges with diagnosis. It provides recommendations on screening CKD patients for latent TB and details dosing considerations for first- and second-line anti-TB drugs in renal impairment.
A 45-year-old male presented with a 2-month history of dry cough and 1-week history of shortness of breath. He was diagnosed with disseminated tuberculosis involving the lungs and massive pericardial effusion. He was started on anti-tuberculosis medications and steroids. He developed lower limb deep vein thrombosis and was started on anticoagulation. He underwent pericardial drainage and window procedure. His treatment plan includes continuing anti-TB medications, increasing warfarin dose, and educating the patient about medication adherence and side effect monitoring.
This document discusses infectious and non-infectious complications of pediatric peritoneal dialysis. It covers topics such as peritonitis (the most common complication), peritoneal catheter exit-site and tunnel infections, gastroesophageal reflux disease, delayed gastric emptying, back pain, and pleural effusions. For each complication, it discusses causes, risk factors, clinical presentation, microbiology, diagnosis, treatment recommendations, and management strategies.
The patient is a 64-year-old man who underwent radical nephrectomy 6 weeks prior for clear-cell renal cell carcinoma (RCC), stage T3aN0. He has no signs of disease recurrence but is at high risk. The document discusses whether adjuvant therapy is indicated and reviews recent phase 3 trials of adjuvant sunitinib versus placebo, which showed improved disease-free survival but not overall survival. It also reviews ongoing adjuvant immunotherapy trials versus placebo and optimal sequencing of systemic therapies if the cancer recurs.
Empiric antibiotic management for major infectionsderosaMSKCC
This document provides guidance from an infectious diseases physician on various infectious disease topics. It addresses appropriate workups, empiric antibiotic choices, and treatment durations for common infections seen at MSKCC including bloodstream infections, pneumonia, intra-abdominal infections, C. difficile colitis, skin and soft tissue infections, and febrile neutropenia. Emphasis is placed on obtaining appropriate cultures prior to antibiotics and tailoring treatment based on culture results and patient risk factors.
This document discusses a case of a 64-year-old man presenting with right flank pain and a history of smoking who is found to have clear-cell renal cell carcinoma (RCC). He undergoes a right radical nephrectomy and pathology confirms grade 3 clear-cell RCC without margins or lymph node involvement. Small lung nodules are detected 18 months later and biopsy confirms metastatic clear cell RCC. Systemic therapy options for the metastatic disease are discussed, including tyrosine kinase inhibitors, immunotherapy, and their combinations. Ongoing trials of immunotherapy in the adjuvant and metastatic settings are also summarized. Risk stratification models and their impact on treatment selection are reviewed.
Updates in GI Practice Guidelines for the Family PhysicianJarrod Lee
Slides from my talk at gutCARE symposium 2017: Updates in GI Practice Guidelines for the Family Physician. The symposium focused on international gastrointestinal guidelines published in the last 3 years, and distilled the portions relevant to primary care. My talk covered the following topics: Helicobacter Pylori Infection, Acute Diarrhea in Adults, Colorectal Cancer Screening, Gallstones and Pancreatic Cysts.
This document provides guidelines for the management of febrile neutropenia. It defines neutropenia and its levels of severity. It describes risk factors for infection and common pathogens. It outlines the evaluation, including diagnostic tests and imaging. It provides recommendations for empiric antibiotic therapy based on risk level. It also covers antifungal therapy, management of specific infections like typhlitis, and use of colony-stimulating factors. The goal is to guide clinicians in promptly diagnosing and treating potential infections in immunocompromised patients with febrile neutropenia.
This document summarizes the key guidelines from the 2008 Egyptian-Italian consensus meeting on the management of hepatitis C virus (HCV) infection. Some of the main points covered include:
1) Liver biopsy is still recommended before HCV treatment to assess fibrosis level.
2) Fibroscan and laboratory markers alone cannot replace liver biopsy.
3) Genotyping is only necessary for patients who travel abroad or are treatment failures.
4) There is no upper age limit for HCV treatment. Pegylated interferon can be used in children ages 5 years old.
5) Patients with persistently normal liver enzymes should be treated if fibrosis is F1 or above.
6) Patients with compens
1. The document contains questions and answers related to internal medicine board review topics such as infectious diseases, antibiotics treatment, and hospital-acquired infections.
2. Many questions focus on determining the most appropriate antibiotic therapy or treatment duration for various bacterial infections and hospitalized patients.
3. Other topics addressed include risk factors for ventilator-associated pneumonia, Clostridium difficile infection treatment, HACEK gram-negative bacilli, and antifungal therapy for invasive fungal infections.
This document provides an overview and discussion of pleural disease for a 47-year-old female patient presenting with a pleural effusion. It discusses evaluating the patient with labs, imaging studies like CT, and procedures like thoracentesis. For empyema, it recommends antibiotics with anaerobic coverage and chest tube placement. The document then discusses treating complicated parapneumonic effusions or empyemas with fibrinolytics or surgery if not draining. It also addresses recurrent malignant pleural effusions, comparing serial thoracentesis to pleurodesis or indwelling pleural catheters. Throughout it provides treatment guidelines and comparisons of diagnostic and management approaches for pleural infections and effusions.
This case discusses a renal transplant recipient with a history of familial Mediterranean fever who presented with persistent fever, diarrhea, abdominal pain, and neurological symptoms. Initial workup ruled out infection as a cause. The patient's symptoms correlated with higher cyclosporine levels. Literature suggests there may be a pharmacokinetic interaction between cyclosporine and colchicine that increases free drug concentrations, potentially leading to toxicity. Reducing the cyclosporine dose addressed the patient's symptoms.
This document summarizes the recommendations from ATS guidelines for the diagnosis and treatment of community-acquired pneumonia in adults. It addresses 16 questions related to testing and treatment approaches. Key recommendations include only obtaining lower respiratory samples for severe CAP patients, using prediction rules like the Pneumonia Severity Index to determine hospitalization and ICU needs, and initial antibiotic treatment with beta-lactams plus macrolides or fluoroquinolones for non-severe CAP and beta-lactams plus fluoroquinolones or beta-lactams plus doxycycline for severe CAP. Antiviral therapy is recommended for influenza-positive patients along with standard antibacterial treatment.
Nomograms provide predictions of outcomes for prostate cancer patients based on known treatment outcomes of similar patients. However, nomograms have several limitations including bias from the development cohort, lack of external validation, and lack of updates using contemporary patient populations. Additionally, nomograms often use surrogate endpoints rather than clinically meaningful endpoints and predictive accuracy is not 100%. While nomograms can help guide clinical decision making, good clinical judgement is still needed and nomograms may not accurately capture all risk factors or change clinical decisions for individual patients.
CINV (chemotherapy induced nausea & vomiting)Mohamed Abdulla
This document discusses chemotherapy-induced nausea and vomiting (CINV). It provides background on the speaker's disclosures and affiliations. It then reviews the pathophysiology of CINV, risk factors, types of CINV, and the impact of inadequate CINV control on quality of life and treatment adherence. It discusses guidelines for preventing CINV and the efficacy of different antiemetic drugs, including 5-HT3 receptor antagonists, NK1 receptor antagonists, and steroids. It also reviews the evolution of CINV prevention over time with improved antiemetic regimens.
This document discusses guidelines for treating H. pylori infection from the 2010 Maastricht IV/Florence consensus report. It recommends first-line treatments including standard triple therapy, sequential therapy, and bismuth quadruple therapy. For second-line treatment for infections that failed first-line treatment, levofloxacin-based triple therapy is recommended. However, resistance to levofloxacin is rising. Optimal treatment regimens depend on the local prevalence of clarithromycin resistance. Culture-guided, high-dose dual PPI, and rifabutin-based therapies are recommended for infections that failed two prior treatments.
This study examined predictors of contralateral breast cancer in unilateral breast cancer patients undergoing contralateral prophylactic mastectomy (CPM). The study analyzed 542 patients who underwent CPM at one cancer center between 2000-2007. Univariate analysis found that younger age, Gail risk score >1.67%, ipsilateral invasive lobular histology, additional ipsilateral moderate-high risk pathology, and multicentric ipsilateral tumor predicted higher risk of contralateral breast cancer. However, multivariate analysis identified only younger age and ipsilateral invasive lobular histology as independent predictors of contralateral breast cancer. The study aimed to help identify which unilateral breast cancer patients might most benefit from CPM.
This document discusses the treatment of non-muscle invasive bladder cancer. It begins by outlining risk stratification into low, intermediate, and high risk groups based on tumor grade and stage. For high risk disease, the primary treatment is intravesical BCG immunotherapy, with intravesical chemotherapy as an alternative. Maintenance BCG therapy provides the best chance of preventing recurrence and progression. Side effects are discussed and managed based on their severity. Second line options in the event of BCG failure include a second course of BCG, combination BCG+interferon therapy, or radical cystectomy for high risk cancers.
This document provides an overview of tuberculosis of the spine. Some key points:
- Spinal tuberculosis accounts for 50% of osteoarticular tuberculosis cases and commonly presents with back pain.
- Diagnosis relies on clinical exam, imaging, and molecular/histological tests since culture has low yield from bone. MRI is often diagnostic.
- Treatment involves antitubercular drug therapy for 9-12 months. Surgery is indicated for debridement of active lesions, neurological deficits, or deformity/instability in healed cases.
- Surgical approaches include anterior, posterior, and combined. Posterior-only approaches using instrumentation are now preferred for deformity correction and stabilization.
Febrile neutropenia is a medical emergency for patients undergoing chemotherapy. Prompt administration of broad-spectrum antibiotics is crucial to prevent life-threatening infections from progressing. Risk stratification tools can help identify low-risk patients who may be treated as outpatients. Antibiotic and antifungal prophylaxis is recommended for high-risk patients to reduce mortality and infection rates. Persistent fever requires evaluation for invasive fungal infections and catheter removal if implicated in bloodstream infection.
This document discusses treatment options for non-muscle invasive bladder cancer, including transurethral resection of bladder tumor (TURBT), bacillus Calmette-Guerin (BCG) immunotherapy, and intravesical chemotherapy. It provides details on the administration and schedule of BCG, lists its contraindications and potential side effects, and discusses options for patients who fail or are intolerant to BCG therapy, including interferon and investigational immunotherapies.
This document outlines 10 standards for tuberculosis care in India. It summarizes World Health Organization tuberculosis reports from 2016 and 2017, showing declines in TB incidence and mortality. It provides guidelines on testing and screening for pulmonary and extra-pulmonary TB, diagnostic tools, treatment regimens for drug-sensitive and drug-resistant TB, and monitoring treatment response. Standards cover appropriate testing, diagnosis of HIV and drug-resistant TB, pediatric TB diagnosis, first-line and multi-drug resistant treatment regimens, and addressing TB among people living with HIV.
Puzzles practices and evidences in tb management (final)Dr.Akhilesh kunoor
This document discusses several cases related to the diagnosis and management of tuberculosis (TB). It provides guidance on differentiating between active and latent TB, evaluating granulomatous lesions, interpreting diagnostic tests like Mantoux, IGRA, Xpert MTB/RIF and drug susceptibility testing. It also addresses challenges in managing lymph node TB, comorbidities like renal disease and drug-induced liver injury. The key recommendations are to confirm TB diagnosis using culture and molecular tests, consider drug resistance if high-risk patients test positive on Xpert, and modify treatment regimens based on comorbidities or adverse drug reactions.
Empiric antibiotic management for major infectionsderosaMSKCC
This document provides guidance from an infectious diseases physician on various infectious disease topics. It addresses appropriate workups, empiric antibiotic choices, and treatment durations for common infections seen at MSKCC including bloodstream infections, pneumonia, intra-abdominal infections, C. difficile colitis, skin and soft tissue infections, and febrile neutropenia. Emphasis is placed on obtaining appropriate cultures prior to antibiotics and tailoring treatment based on culture results and patient risk factors.
This document discusses a case of a 64-year-old man presenting with right flank pain and a history of smoking who is found to have clear-cell renal cell carcinoma (RCC). He undergoes a right radical nephrectomy and pathology confirms grade 3 clear-cell RCC without margins or lymph node involvement. Small lung nodules are detected 18 months later and biopsy confirms metastatic clear cell RCC. Systemic therapy options for the metastatic disease are discussed, including tyrosine kinase inhibitors, immunotherapy, and their combinations. Ongoing trials of immunotherapy in the adjuvant and metastatic settings are also summarized. Risk stratification models and their impact on treatment selection are reviewed.
Updates in GI Practice Guidelines for the Family PhysicianJarrod Lee
Slides from my talk at gutCARE symposium 2017: Updates in GI Practice Guidelines for the Family Physician. The symposium focused on international gastrointestinal guidelines published in the last 3 years, and distilled the portions relevant to primary care. My talk covered the following topics: Helicobacter Pylori Infection, Acute Diarrhea in Adults, Colorectal Cancer Screening, Gallstones and Pancreatic Cysts.
This document provides guidelines for the management of febrile neutropenia. It defines neutropenia and its levels of severity. It describes risk factors for infection and common pathogens. It outlines the evaluation, including diagnostic tests and imaging. It provides recommendations for empiric antibiotic therapy based on risk level. It also covers antifungal therapy, management of specific infections like typhlitis, and use of colony-stimulating factors. The goal is to guide clinicians in promptly diagnosing and treating potential infections in immunocompromised patients with febrile neutropenia.
This document summarizes the key guidelines from the 2008 Egyptian-Italian consensus meeting on the management of hepatitis C virus (HCV) infection. Some of the main points covered include:
1) Liver biopsy is still recommended before HCV treatment to assess fibrosis level.
2) Fibroscan and laboratory markers alone cannot replace liver biopsy.
3) Genotyping is only necessary for patients who travel abroad or are treatment failures.
4) There is no upper age limit for HCV treatment. Pegylated interferon can be used in children ages 5 years old.
5) Patients with persistently normal liver enzymes should be treated if fibrosis is F1 or above.
6) Patients with compens
1. The document contains questions and answers related to internal medicine board review topics such as infectious diseases, antibiotics treatment, and hospital-acquired infections.
2. Many questions focus on determining the most appropriate antibiotic therapy or treatment duration for various bacterial infections and hospitalized patients.
3. Other topics addressed include risk factors for ventilator-associated pneumonia, Clostridium difficile infection treatment, HACEK gram-negative bacilli, and antifungal therapy for invasive fungal infections.
This document provides an overview and discussion of pleural disease for a 47-year-old female patient presenting with a pleural effusion. It discusses evaluating the patient with labs, imaging studies like CT, and procedures like thoracentesis. For empyema, it recommends antibiotics with anaerobic coverage and chest tube placement. The document then discusses treating complicated parapneumonic effusions or empyemas with fibrinolytics or surgery if not draining. It also addresses recurrent malignant pleural effusions, comparing serial thoracentesis to pleurodesis or indwelling pleural catheters. Throughout it provides treatment guidelines and comparisons of diagnostic and management approaches for pleural infections and effusions.
This case discusses a renal transplant recipient with a history of familial Mediterranean fever who presented with persistent fever, diarrhea, abdominal pain, and neurological symptoms. Initial workup ruled out infection as a cause. The patient's symptoms correlated with higher cyclosporine levels. Literature suggests there may be a pharmacokinetic interaction between cyclosporine and colchicine that increases free drug concentrations, potentially leading to toxicity. Reducing the cyclosporine dose addressed the patient's symptoms.
This document summarizes the recommendations from ATS guidelines for the diagnosis and treatment of community-acquired pneumonia in adults. It addresses 16 questions related to testing and treatment approaches. Key recommendations include only obtaining lower respiratory samples for severe CAP patients, using prediction rules like the Pneumonia Severity Index to determine hospitalization and ICU needs, and initial antibiotic treatment with beta-lactams plus macrolides or fluoroquinolones for non-severe CAP and beta-lactams plus fluoroquinolones or beta-lactams plus doxycycline for severe CAP. Antiviral therapy is recommended for influenza-positive patients along with standard antibacterial treatment.
Nomograms provide predictions of outcomes for prostate cancer patients based on known treatment outcomes of similar patients. However, nomograms have several limitations including bias from the development cohort, lack of external validation, and lack of updates using contemporary patient populations. Additionally, nomograms often use surrogate endpoints rather than clinically meaningful endpoints and predictive accuracy is not 100%. While nomograms can help guide clinical decision making, good clinical judgement is still needed and nomograms may not accurately capture all risk factors or change clinical decisions for individual patients.
CINV (chemotherapy induced nausea & vomiting)Mohamed Abdulla
This document discusses chemotherapy-induced nausea and vomiting (CINV). It provides background on the speaker's disclosures and affiliations. It then reviews the pathophysiology of CINV, risk factors, types of CINV, and the impact of inadequate CINV control on quality of life and treatment adherence. It discusses guidelines for preventing CINV and the efficacy of different antiemetic drugs, including 5-HT3 receptor antagonists, NK1 receptor antagonists, and steroids. It also reviews the evolution of CINV prevention over time with improved antiemetic regimens.
This document discusses guidelines for treating H. pylori infection from the 2010 Maastricht IV/Florence consensus report. It recommends first-line treatments including standard triple therapy, sequential therapy, and bismuth quadruple therapy. For second-line treatment for infections that failed first-line treatment, levofloxacin-based triple therapy is recommended. However, resistance to levofloxacin is rising. Optimal treatment regimens depend on the local prevalence of clarithromycin resistance. Culture-guided, high-dose dual PPI, and rifabutin-based therapies are recommended for infections that failed two prior treatments.
This study examined predictors of contralateral breast cancer in unilateral breast cancer patients undergoing contralateral prophylactic mastectomy (CPM). The study analyzed 542 patients who underwent CPM at one cancer center between 2000-2007. Univariate analysis found that younger age, Gail risk score >1.67%, ipsilateral invasive lobular histology, additional ipsilateral moderate-high risk pathology, and multicentric ipsilateral tumor predicted higher risk of contralateral breast cancer. However, multivariate analysis identified only younger age and ipsilateral invasive lobular histology as independent predictors of contralateral breast cancer. The study aimed to help identify which unilateral breast cancer patients might most benefit from CPM.
This document discusses the treatment of non-muscle invasive bladder cancer. It begins by outlining risk stratification into low, intermediate, and high risk groups based on tumor grade and stage. For high risk disease, the primary treatment is intravesical BCG immunotherapy, with intravesical chemotherapy as an alternative. Maintenance BCG therapy provides the best chance of preventing recurrence and progression. Side effects are discussed and managed based on their severity. Second line options in the event of BCG failure include a second course of BCG, combination BCG+interferon therapy, or radical cystectomy for high risk cancers.
This document provides an overview of tuberculosis of the spine. Some key points:
- Spinal tuberculosis accounts for 50% of osteoarticular tuberculosis cases and commonly presents with back pain.
- Diagnosis relies on clinical exam, imaging, and molecular/histological tests since culture has low yield from bone. MRI is often diagnostic.
- Treatment involves antitubercular drug therapy for 9-12 months. Surgery is indicated for debridement of active lesions, neurological deficits, or deformity/instability in healed cases.
- Surgical approaches include anterior, posterior, and combined. Posterior-only approaches using instrumentation are now preferred for deformity correction and stabilization.
Febrile neutropenia is a medical emergency for patients undergoing chemotherapy. Prompt administration of broad-spectrum antibiotics is crucial to prevent life-threatening infections from progressing. Risk stratification tools can help identify low-risk patients who may be treated as outpatients. Antibiotic and antifungal prophylaxis is recommended for high-risk patients to reduce mortality and infection rates. Persistent fever requires evaluation for invasive fungal infections and catheter removal if implicated in bloodstream infection.
This document discusses treatment options for non-muscle invasive bladder cancer, including transurethral resection of bladder tumor (TURBT), bacillus Calmette-Guerin (BCG) immunotherapy, and intravesical chemotherapy. It provides details on the administration and schedule of BCG, lists its contraindications and potential side effects, and discusses options for patients who fail or are intolerant to BCG therapy, including interferon and investigational immunotherapies.
This document outlines 10 standards for tuberculosis care in India. It summarizes World Health Organization tuberculosis reports from 2016 and 2017, showing declines in TB incidence and mortality. It provides guidelines on testing and screening for pulmonary and extra-pulmonary TB, diagnostic tools, treatment regimens for drug-sensitive and drug-resistant TB, and monitoring treatment response. Standards cover appropriate testing, diagnosis of HIV and drug-resistant TB, pediatric TB diagnosis, first-line and multi-drug resistant treatment regimens, and addressing TB among people living with HIV.
Puzzles practices and evidences in tb management (final)Dr.Akhilesh kunoor
This document discusses several cases related to the diagnosis and management of tuberculosis (TB). It provides guidance on differentiating between active and latent TB, evaluating granulomatous lesions, interpreting diagnostic tests like Mantoux, IGRA, Xpert MTB/RIF and drug susceptibility testing. It also addresses challenges in managing lymph node TB, comorbidities like renal disease and drug-induced liver injury. The key recommendations are to confirm TB diagnosis using culture and molecular tests, consider drug resistance if high-risk patients test positive on Xpert, and modify treatment regimens based on comorbidities or adverse drug reactions.
The National TB Elimination Programme has changed its nomenclature from the Revised National TB Control Programme to the National TB Elimination Programme from January 2020. India has the highest burden of both TB and MDR-TB globally. An estimated 71,000 cases of MDR-TB emerge annually from notified pulmonary TB cases in India. The objectives of the programme are to improve case detection and ensure complete treatment for all TB patients. The document outlines case definitions, diagnostic tools, treatment regimens, and follow-up procedures for both drug sensitive and drug resistant TB cases under the new programme.
This document summarizes diagnostic methods for female genital tuberculosis (FGTB). It discusses the following:
1. Smear examination is the first choice method under RNTCP due to its low cost and simplicity, but has low sensitivity around 22-78% compared to culture. Sensitivity can be improved to around 10% higher using fluorescent microscopy.
2. Culture is the gold standard but is slow, taking weeks, and has low sensitivity. Methods to improve detection include using carbon dioxide production, oxygen consumption, and radiometric or fluorescent techniques to decrease turnaround time by half.
3. Gene Xpert provides results in 2 hours and is sensitive and specific for detecting Mycobacterium tuberculosis, including in
This document summarizes the management of prostate carcinoma. It discusses clinical features, risk stratification, treatment options including active surveillance, radical prostatectomy, radiation techniques, adjuvant and salvage radiation therapy, brachytherapy, and androgen deprivation therapy. Treatment is tailored based on risk factors, tumor characteristics, and patient factors. Image-guided radiation therapy helps ensure accurate targeting of the prostate. Dose escalation and addition of hormones improves outcomes for intermediate- and high-risk disease.
This document discusses various diagnostic modalities for pulmonary and extrapulmonary tuberculosis. It describes the characteristics of Mycobacterium tuberculosis and provides global burden statistics. It also discusses extra-pulmonary TB locations. Molecular techniques for diagnosis include Xpert MTB/RIF, which can simultaneously detect TB and rifampin resistance in under two hours. Other techniques discussed are line probe assays, drug susceptibility testing, radiology, tests for latent TB, and examinations of body fluids and biopsies. The document provides details on sensitivities and specificities of different diagnostic tests.
Dr. Arjun Singh, a 52-year-old male, presented for his annual health checkup. He has a family history of prostate cancer as his father had it. His PSA levels have been monitored every few years and were previously normal, but are now elevated at 4.5 ng/ml. A digital rectal exam found no abnormalities in the prostate. Given his rising PSA and family history, a prostate biopsy was recommended to evaluate for possible prostate cancer.
what is new in prevention, diagnosis and treatment of tuberculosis tb short.pptxPathKind Labs
Many changes have been made recently in Tuberculosis. The first important change is that instead of control now the focus is on eradication. for that to happen we need to change the way we detect, diagnose and treat tuberculosis.
Differentiated Thyroid cancer American cancer guidelines. Risk grouping and radioactive Iodine Ablation Low dose vs High dose RAI Ablation. Initial assessment of a thyroid nodule
This document discusses central nervous system tuberculosis, including tuberculous meningitis, tuberculomas, and other forms. Some key points:
1. Tuberculous meningitis accounts for 5% of extrapulmonary TB and has a high mortality rate of 30% despite treatment.
2. Diagnosis is challenging as bacterial yield from CSF is low. Imaging and laboratory tests also have limited sensitivity and specificity.
3. The recommended treatment for CNS TB is a 2 month intensive phase of isoniazid, rifampin, pyrazinamide, and ethambutol followed by a 10 month continuation phase of isoniazid and rifampin. Adj
This document summarizes the management of pancreatic carcinoma. It discusses the anatomy, epidemiology, risk factors, hereditary syndromes, pathophysiology including pre-cancerous lesions, types of pancreatic cancer, staging, prognostic factors, diagnostic techniques, treatment including surgery, chemotherapy, targeted therapy, radiotherapy and historical prospective studies. It provides a comprehensive overview of pancreatic carcinoma covering all relevant aspects of the disease.
Radiosurgery in urological malignancies can be effectively used to treat prostate cancer, renal cell cancer, and urinary bladder cancer. For prostate cancer, Cyberknife allows for hypofractionated radiotherapy with its ability to track tumor motion and correct for it during treatment. Studies have shown dose escalation and hypofractionated regimens improve local control rates for prostate cancer while maintaining low toxicity rates when delivered with precision techniques like Cyberknife. Cyberknife is particularly useful for treating prostate cancer given its ability to track and correct for intra-fraction motion of the prostate tumor.
Hepatoblastoma- Investigations and managementARJUN MANDADE
This document summarizes information about hepatoblastoma, a rare type of liver cancer that mostly affects young children. It discusses the history and terminology of hepatoblastoma. Key points include: hepatoblastoma typically affects children under 3 years old and accounts for about 1% of childhood cancers. Complete surgical resection is the main treatment when possible but less than 50% of patients are resectable at diagnosis. The addition of cisplatin-based chemotherapy has improved outcomes by increasing resectability. Prognosis remains suboptimal for patients with unresectable or metastatic disease after chemotherapy. Chemoembolization and liver transplantation are promising alternative treatments in these cases.
This document discusses recent updates in lung cancer. It begins by noting that lung cancer is the leading cause of cancer death in the US and is often diagnosed at an advanced stage. Screening with low-dose CT scans can detect lung cancer earlier and has been shown to decrease lung cancer mortality by 20% compared to chest x-rays. The National Lung Screening Trial established low-dose CT screening as an effective screening method for those at high risk. Biomarker testing is important to identify driver mutations and guide targeted therapy options, though barriers like tissue availability and turnaround time exist. Osimertinib has demonstrated superior progression-free survival compared to earlier EGFR TKIs for patients with EGFR-mut
National Tb pragramme, Has been in operation since 1962
Inadequacies that led to RNTCP :
Treatment success rates were unacceptably low.
There is no unique diagnostic method.
No Treatment Protocol.
Only 30% is diagnosed, so death and default rates remained high.
In 1993 to overcome the drawbacks mentioned, the NTP was revitalized and RNTCP was formulated.
Implemented in a phased manner, by 2000 it covered the whole country.
Objectives:
Achievement of at least 85 percent cure rates of infectious cases of TB.
Augmentation of case finding activities through quality sputum microscopy to detect atleast 70 percent of estimated cases.
1. Intensified active case finding
2. Diagnostic Criteria Changes :
Changes in few definitions like Defaulters → Loss to follow up , Relapse Tb → Recurrent TB.
In Adults – CBNAAT/ True NAAT is done in all cases of TB ( earlier CBNAAT was performed only for high risk cases )
In Paediatric age group – Chest X-ray and TST to be done first.
3. Treatment Criteria Changes :
Regimens with injectable agents are no longer recommended. Currently, for any case of TB only All Oral regimens are initiated
For Drug Sensitive TB 2months of HRZE and 4 months of HRE
For INH resistant TB – RZE + Levofloxacin for 6 months
In All oral MDR Rx regimen : only continuous phase for 18 months
✓ BEDAQUILINE or DELAMANID × 6 months
✓ LEVOFLOXACIN , LINEZOLID , CLOFAZAMINE , CYCLOSERINE × 18 months
Isoniazid Preventive therapy is given for all contact.
Decentralized Tuberculosis unit and DMC (Designated microscopy
centre) and Peripheral Health Institute at the door steps of the patients.
SMEAR MICROSCOPY FOR ACID FAST BACILLI
RAPID DIAGNOSTIC MOLECULAR TESTING
RADIOGRAPHY where available
TUBERCULIN SKIN TEST
CULTURE
S.No CBNAAT TruNAAT
1 PCR based PCR based
2 Cartridge based Chip based
3 AC environment needed No need
4 Cartridge to be stored in cold atmosphere No need
5 Continuous power supply needed Battery operated
6 Less manual work Semi automatic (Technician oriented )
7 Detects MTB as well as Rif resistance simultaneously Need separate chips for MTB and Rif resistance detection
8 Cross contamination unlikely Cross contamination possible
9 TAT : 112 min TAT : 60 min for MTB
60 min for Rif resistance
10 Intermediate level labaratories Point of care level
MTB not Detected
MTB detected, High/medium/low/very low, rifampicin resistance detected
MTB detected, High/medium/low/very low , rifampicin resistance not detected
MTB detected, High/medium/low/very low , rifampicin resistance indeterminate, Repeat the test in new sample.
Invalid result (Retest in fresh specimen)
Error (Repeat the test in same sample)
Clinical evaluation Laboratory based evaluation
History and physical examination Random blood sugar (RBS)
Height HIV testing following counselling
Weight Complete blood count (Hb, TLC, DLC, platelet count)
Psychiatric evaluation if required Liver function tests(including serum proteins)
TSH levels
Urine examination –
Tumor Markers in Clinical Biochemistry.pptxJaideepNaikMN
This document discusses tumor markers and their use in clinical biochemistry. It begins by defining tumor markers as substances produced by tumor cells or in response to tumors that can be detected in body fluids or tissues. The document then lists the key characteristics of an ideal tumor marker and various indications for tumor marker testing, including cancer screening, diagnosis, staging and monitoring treatment. It provides examples of specific tumor markers like PSA for prostate cancer screening and diagnosis. The document concludes by presenting a clinical case study of a patient exhibiting symptoms of prostate cancer and details the diagnostic workup and tumor marker testing, including an elevated PSA level, that confirmed prostate adenocarcinoma.
Chemoprevention aims to prevent prostate cancer using pharmaceutical agents. Some key points about chemoprevention of prostate cancer include:
- Finasteride and dutasteride, 5-alpha reductase inhibitors, have been shown to reduce the risk of prostate cancer, especially low-grade cancer, but may increase the risk of higher grade cancers.
- Selenium and vitamin E supplements have been studied but did not show a clear benefit and in some cases increased risk.
- Dietary factors like lycopene from tomatoes and phytoestrogens from soy products are thought to possibly reduce prostate cancer risk but evidence is limited.
- Larger randomized controlled trials of pharmaceutical agents like the PCPT and REDU
Anti tubercular therapy in Skeletal TBNeelaBiradar
The document discusses management of osteoarticular tuberculosis. It provides an overview of the strategic framework and pillars to end TB in India, including prevent, detect, and treat. Diagnostic tests for tuberculosis are described such as CBNAAT, LPA, MGIT, and IGRAs. Classification of TB based on drug resistance includes mono, poly, rifampicin resistant, MDR, and XDR tuberculosis. Terminologies used in NTEP are also defined.
Modern imaging techniques are improving the management of prostate cancer. Multiparametric MRI is now mandatory for locally advanced disease to assess extraprostatic extension and seminal vesicle involvement. While isotopic bone scans remain standard, newer techniques like sodium fluoride and choline PET scans show promise in detecting bone metastases and recurrence. Precise staging allows for personalized treatment selection between surgery, radiation, or systemic therapies and guides monitoring for progression.
This document provides an overview of the management of hepatocellular carcinoma (HCC). It discusses the diagnosis, staging, prognostic factors and various treatment modalities for HCC including surgery, chemotherapy, targeted therapy, radiotherapy, radiofrequency ablation, and transarterial chemoembolization. It provides details on specific surgical procedures, chemotherapy regimens, targeted agents like sorafenib, and radiotherapy techniques including three-dimensional conformal radiotherapy, stereotactic body radiotherapy, and charged particle therapy. It also covers follow-up and potential complications like radiation-induced liver disease.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Kat...rightmanforbloodline
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
2. India accounts for 20% of all TB incidence cases in the world
Non-HBCs
20%
Pakistan
3%
Ethiopia
3%
Philippines
3%
South Africa
5%
Bangladesh
4%
Nigeria
5%
Indonesia
6%
China
14%
India
20%
Other 13 HBCs
16%
Source: WHO Global Report 2009
3. Evolution of TB Control in India
• 1950s-60s Important TB research at TRC and
NTI
• 1962 National TB Program (NTP)
• 1992 Program Review
•only 30% of patients diagnosed;
•of these, only 30% treated
successfully
• 1993 RNTCP pilot began
• 1998 RNTCP scale-up
• 2001 450 million population covered
• 2004 >80% of country covered
• 2006 Entire country covered by RNTCP
4. Impact - RNTCP
oNearly 22 million deaths have been saved since 1995.
o 45% decrease in death due to TB since 1990
o Global target of 85% cure rate and 70% of case detection
rate consistently achieved 2003 onward
o Case fatality reduced from 29% to 4% in NSP cases
5. Current views leading to change in
regime to daily regime
•High rates of “relapse” in RNTCP ~ 12 - 15%
•Increasing INH Resistance remain high( 20-40%)
SMCSI MC 22 - 03 - 2016 5
6.
7. Magnitude of The problem
• 15%-20% of all TB cases in India in HIV negative
Immunocompetent
• >50%( 45-56%) – HIV Positive
• Usually Paucibacillary
• 75% have lymph node or pleural TB
• Occur in all age groups but incidence is higher in children /
young
11. Principles
• Patient Centred approach
• Promote early diagnosis
• Access to tissue based diagnosis
• Addressing Drug resistance
• Avoiding unnecessary , invasive and costly tests.
• Access to HIV Testing
• Identify patients with concurrent active Pulmonary TB
• Ensuring effective treatment with appropriate regimen
• Promoting adherence
• Record keeping and public health promotion
12. Major questions raised by providers
• Use of tuberculin skin testing
• Role of the Xpert MTB/RIF test in diagnosing EPTB
•
• Role of other polymerase chain reaction (PCR)-based tests in diagnosing EPTB
• Empirical treatment
• Corticosteroids in EPTB
• Duration of anti-tuberculosis treatment (ATT) in EPTB
• Definition of treatment failure in terms of clinical parameters prompting
extended treatment, revised diagnosis, or consideration of drug resistance.
16. LYMPHNODE TB
Additional test to conventional smear microscopy, culture and
cytology in FNAC specimens.(Strong)
Quick diagnosis,Reduced stigma from overdiagnosis,R Resistnace
TB MENINGITITIS
Adjunctive test for tuberculous meningitis (TBM).
A negative Xpert result does not rule out TBM.
Decision to give ATT should be based on clinical features and CSF
profile.( Conditional)
PLEURAL TB
Should not be routinely used to diagnose pleural TB (Strong)
18. TB MENINGITIS ( HIV Negative)
TBM in HIV-negative -RECOMMENDED
Duration of steroid treatment should be for at least 4 weeks, with
tapering as appropriate.(Strong)
TBM(HIV Positive)- May be used where other life-threatening
opportunistic infections are absent.
( Conditional)
19. • TB Pericarditis(HIV Negative)- Recommended for HIV-negative
patients with TB pericarditis with pericardial effusion.(Conditional)
• TB Pericarditis(HIV Positive)- Recommended for HIV-positive patients
with TB pericarditis with pericardial effusion.(Conditional)
• Pleural TB(Irrespective of HIV Status)
- Not routinely recommended in pleural TB.( Conditional)
22. •Peripheral LN TB - 6 months ATT standard first-line regimen
(2RHZE/4RHE) is recommended for peripheral lymph node
TB.(Strong)
•Abdominal TB- 6 months ATT standard first-line regimen is
recommended for abdominal TB( Strong)
•TB Meningitis- TB meningitis should be treated with
standard first-line ATT for at least 9 months.(Conditional)
26. Diagnostic
Method
Selected patients Comments
Lumbar
puncture
All Lymphocytic
Pleocytosis with Low
Serum/CSF Glucose ratio
HIV testing All Integrated Counselling For
Seropositive
Chest Xray All Active /past TB
CT Brain All R/O hydrocephalus
MRI Brain Selected cases Diagnostic uncertainty
28. •Minimum 6 ml needed for adults ;3 ml for children
CSF Gram stain ,AFB Smear,TC
CSF / Serum Glucose Ratio
Mycobacterial culture ,Species identification& DST
Rule out other causes- Viral/ Cryptococcal/
Bacterial/Fungal
Genexpert-Adjunctive test. Negative Doesnot rule out
TBM .1 ml optimal for Xpert( High False Neg)
Sensitivity-80.5% Specifcity -97.8%)
IGRA Not recommended
ADA is not useful
Diagnostic accuracy of Other PCR test highly variable
29. 2 HRZE+7 HRE
Referral – As early as
possible
Follow up till 2 years
at regular interval
DR suspect-
Poor response to
ATT/or MDR
contact
Steroids indicated
Dexa ( 0.4 mg/kg/24 hr in
divided doses) and taper
30. Alternate Regimen( Tech.Advisory Sub comitee)
Streptomycin in IP Phase instead of Ethambutol in visual
impairment or cannot be assessed
Pyrazinamide instead of Ethambutol in CP Phase
Total Duration can be extended upto 12 months
Stopping Treatment- Clinical resolution
Residual neurological deficit should not be used as a sign of activity
Surgery-V/P Shunt
32. Presumptive Tuberculoma
•Any patient presenting with seizures, headache,
fever or focal neurological deficits with
neuroimaging features consistent with a mass lesion
of inflammatory nature.
33. Diagnosis
Previous history and contact with TB case
CXR and CT for looking alt sites
HIV
MRI – Confirmatory
CSF- May be Normal / finding of TBM
Culture – sensitivity low
PCR test validity doubtful.
Stereotactic/ open biopsy- Invasive
34. 9-12 months
Repeat MRI after 3 ,9 &12
months
Failure- If lack of reduction in
size /increase in size after 3-
6 months of Tt
Paradoxical Reaction-if
increase in size / number
after 3 months-Steroid/ ATT
Before putting second line in suspected MDR assess Risk/Benefit
ratio.
Tissue diagnosis- Sent H/P, AFB Culture,
36. Clinical Features
•Localised back pain>6 weeks with tenderness in
spinous process with or without fever, Wt loss with
or without spinal cord compression.
• Patient with advanced disease may have spinal
deformity, paraspinal muscle wasting
• In children failure to thrive, night cry, inability to
walk/cautious gait
37. Test Patient Comment
Chest X ray All Rule out PTB
HIV All Integrated Counselling and test
Xray Spine Limited Lesion will be delayed presentation
in CXR
( 3-6 months)
Follow up and monitoring
MRI Spine All Confirmation
Extend of Disease
Early Identification
CT Spine Selected cases Limited use in spinal cord involvement
Biopsy All P/C or Open
Send Specimen For
A)Routine and AFB Culture
B)Microscopy and AFB Smear
C)Histopathology and Cytology
Genexpert/PCR test Not Insufficient evidence
38. TREATMENT
• Start ATT if Clinico radiological evidence even if Biopsy is
not possible after assessing risk of procedure
• 2 HRZE+10 HRE ( Maximum upto 18 months of Tt)
• Surgery For Diagnosis, Spinal deformity, Neurological
Deficit
39. Follow up
• If any new signs of Neurological deficit report immediately
• Patient with Neurological Deficit weekly monitoring with
neural chart
• X ray spine every 3 months
• MRI at 6,9,12,18 following Tt Initiation
• Follow up every 6 months for 2 years after stopping
treatment
• Report to physician if any new signs after Stopping RX
40. Bone & Joint TB
• MC in Immuno suppressed and Old TB
• In the early course, aspiration of synovial fluid/ pus usually
not diagnostic but should send for Microscopy and Culture
• Biopsy of the affected structure/ sinus tract curettage /
Edge biopsy can be done and to be send for microscopy and
culture and H/P
• CBNAAT limited role
• Treatment Regimen 2 HRZE+ 10-16 HRE
45. Type Symptoms
Presumptive Peripheral LN TB LNE >1 cm in axilla, neck, groin+
Constitutional features
Mediastinal TB Constitutional features
Cough,fever
Hilar enlargement in CXR and/or
Mediastinal widening in CT
Chest in the absence of evidence
of active PTB
Abdominal LN TB Dull, colicky abdominal pain,
distension
Constitutional features
Abdominal LNE on USG ,CT or
MR
46. DIAGNOSIS
TEST PATIENT COMMENT
CXR All Cases Active/Old PTB
HIV All cases Integrated counselling &
tests
USG/CT chest&/or
abdomen
Selected cases Uncertain diagnosis
FNAC All Gene Xpert/AFB
Smear/AFB Culture&
DST/Cytology
Excision Biopsy Selected •If FNAC inconclusive
•Alternate diagnosis
Gene Xpert/AFB
smear/AFB Culture &
DST,Histopath
47. • Specimen should be taken before starting ATT
• Non dependant Aspiration by Z technique for superficial
LNE
• Image guided Aspiration for Deep LNE
• Abdominal LNE- CT Guided/USG Guided FNAC or Biopsy
• Mediastinal LNE- EBUS guided FNAC if facility available
Genexpert should be used as an additional test to cytology
( Strong)
Sensitivity -83.1% Specificity -93.1%
48. PERPIPHERAL LNE
2 HRZE+4 HRE
Follow up after 4 Months
Worsening in 1St 3 months- paradoxical reaction
If Residual LNE ( largest LN)< 1 cm at the end of Tt- No active TB
If largest LN>1 cm- Partial responders
Expert Group suggest additional 3 months of ATT - Biopsy / AFB
Culture if failed to respond to that
Some group suggest further ATT not needed
( insufficient data)
49. Follow up – 4 Months
If CXR s/o no improvement------------- CT Chest
WHEN TO STOP ATT?
if no improvement after 4 months of Tt documented
clinicoradiologically ( Difference of opinion)
Mediastinal LNE
2HRZE+ 4 HRE
51. Test Patient Comments
CXR/HIV All Rule out PTB
Integrated counselling
Ascitic fluid All Cytology,ADA,Albumin
and protein,AFB
Smear,AFB
culture,Routine C& S
USG abdomen All Ascites,Omental
thickening, Mesentric
adenopathy
USG Guided FNAC/Core
biopsy from Mesentric or
RPLN
,omentum,peritoneum
Selected Microscopy &Culture of
FNAC/Biopsy specimen
than fluid alone
Send for H/P,M/C copy,
Culture
CT/MRI Abdomen Selected Diagnostic Uncertainty
Laproscopy Selected( Cost, Invasive) Tubercles in thickened
peritoneum,omentum and
Liver
Fibro-adhesive
peritonitis
Targeted Diagnostic
SAAG<1.1
High protein (>2.5 g/DL)
ADA >39 IU/L
Sensitivity in Smear AFB
and AFB Culture Low
PCR – Variable accuracy
( No Recommendation)
52. Test Patients Comments
Ileocolonoscopy (
Retrograde ileoscopy)
All cases
Rule Out IBD
Sent for H/p,AFB
Culture
CT/MR enterography
/enteroclysis
Selected •Short Segment
stricture
•Necrotic Nodes
•Ileocaecal wall
thickening
UGIE Selected
Barium study Selected UGIE Contraindicated
or
Small Bowel stricture
PCR BASED -NOT RECOMMENDED – HIGHLY
VARIABLE ACCURACY
53. TREATMENT
2 HRZE+4 HRE
Extension as per
Physician’s discretion
All Presumptive GI TB
should be referred to GI
Follow Up after 3 & 6
Months
Surgery
Stricture-Endoscopic
Dilatation/Resection of stricture
P/c or Endoscopic biliary
stenting,Drainge of Liver abscess
55. SYMPTOMS
• Lower urinary symptoms
( frequency, urgency, nocturia) with dysuria and/or
hematuria for 2 weeks which has not responded with 5 day
course of antibiotics
• ( Avoid FQ if suspecting TB)
• Generalised symptoms
56. CXR/HIV/RFT All cases
Urine M/c and aerobic culture( Non
mycobactrial
Sterile pyuria( s/oTB)
Asso.TB
Bacterial infection
Early Morning Urine sample 3 -5sample needed for smear AFB and
AFB Culture. Low sensitivity ; but culture
confirmative
USG KUB All cases ( Normal in early disease; if pick
up hydronephrosis s/o TB)
IV urography ( plain Xray) Selected cases( widely available; Low
sensitivity)
Contrast enhanced CT urography Selected cases( More Sensitivity)
MR urography without contrast Selected( Expensive; but no need of
contrast, more sensitive
FNAC/Biopsy AFB Smear/ Culture & DST/H/P
57. Urethroscopy with or
without bladder biopsy
Selected cases
Biopsy Most of the cases( AFB
smear , Culture/HP), DST)
58. Diagnosis
CXR/HIV Test All Cases
USG or CT abdomen or Chest Selected cases
FNAC All( AFB Smear, Culture with
DST, Cytology, Xpert)
Excision Biopsy Selected ( If FNAC
inconclusive or alt .diagnosis)
AFB Smear,Culture&
DST,Xpert, Histopath
Genexpert Sensitivity -87-100% Specificity-92-98%
61. Test Patients Comments
Chest Xray All Water Bottle Sign
HIV All
ECG All Low Voltge ,T wave
flattening
ECHO All Pericardial Effusion
CT and Cardiac
MRI
Selected
62. •Microbiological Diagnosis Poor yield
•Xpert – Not Recommended
•ADA- Contributory
• 2 HRZE+4 HRE
•FUP after 4 Months
•Steroids indicated
63. TAKE HOME MESSAGE
• Treatment of EPTB is to be individualised
• Clinician is having discretion in deciding duration of
treatment ,methods of obtaining tissue for sampling etc
• Sensitivity of Newer techniques in EPTB low so that
diagnostic utility will vary depends on site of involvement
• Further study needed in certain areas – Researches should
be encouraged