Tuberculosis (Tbc) and Rheumatic Disease 5/5 (1)

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Tuberkulosis (Tbc)

Tuberculosis of the lungs. “Tuberculosis-x-ray-1” (PHIL), via https://commons.wikimedia.org/wiki/

Tuberculosis (tbc) ICD-10: A15.9

Definition

Tuberculosis is a contagious bacterial disease caused by mycobacterium tuberculosis. The lungs are most often attacked, but other organs can also be infected. Rheumatic complications are infection in joints (Septic arthritis) and skeleton (osteomyelitis) with more or less pain.

  • In case of a weakened immune system as during immunosuppressive, anti-rheumatic treatment, after organ transplantation or by wood HIV infection, tuberculosis can become particularly severe.

Occurrence

There are very few infected with tuberculosis in Norway. The vast majority have been infected abroad. In total, 3-400 new cases are discovered annually. The incidence of tuberculosis is in Somalia 60 times higher and in Myanmar / Burma the whole 100 times higher than in Norway.

Contamination

Untreated infection tuberculosis between humans via air and drops as by coughing. Nevertheless, only a small portion of the vulnerable are actually infected.

Symptoms

Primary Infection

  • Symptoms of only one in three infected. The others do not notice the infection
  • Fever
  • Chest pain and pain between shoulder blades are related to enlarged lymph nodes in the chest
  • Radiological
    • Enlarged lymph nodes in lung hilus (on one or both sides)
    • Pleural effusion
    • Pulmonary infiltrates

Reactivation of latent (sleeping) infection

  • In the lungs, most of the upper parts are attacked, especially the posterior (segments of the apical posterior).
  • Symptoms
    • Fatigue / exhaustion
    • Night sweats
    • Fever
    • Progressing cough
    • Chest pain
    • Heavy breathing (dyspnea)
    • Bloody mucus in cough (hemoptysis)
    • Weight Loss
  • Fewer symptoms in people over 60 years of age and among people who use immunosuppressive drugs or for other reasons have a weak immune system
  • Increased relapse (approximately 5 x increased risk) with TNF inhibitors, high corticosteroid doses and other strong Immunosuppressive treatment
Tuberkulosis (Tbc)

Tuberculosis with abscess in the right foot and skeleton of a child. Atilganoglu SB, 2008. CC BY2.0

Rheumatic symptoms

Infection (septic arthritis / spondylitis) in joints and backs are well-known complications. Such osteo-articular manifestations can be misinterpreted as spondyloarthritis.

  • Kne that is swollen and warm (Arthritis) is most common
  • Hips can be attacked
  • Spinal vertebrae (Potts disease, tubular spondylitis)
    • Most often in the vertebral column
  • Swollen fingers or toes (dactylitis) occurs especially among children
  • Inflammation of other tissues may be due to spread through the bloodstream.
Tuberkulosis (Tbc)

Tuberculosis in vertebrae (Potts disease). Gupta AK, 2014. CC BY NC SA 3.0

Disease history must include

  • Country of birth
  • Family with tbc?
  • BCG vaccine?
  • Pirquet- Mantoux or IGRA test previously?
  • Completed treatment for TBc before?

Africans over the age of 15X and South Asians

  • If sickness history of Tbc or positive x-ray thoracic (lungs) is referred to medical specialist in infectious medicine or lung diseases
  • If the X-ray of the lungs or CT examinations is not conclusive, the patient must be followed closely

Diagnosis

  • Screening
  • X-ray of lungs
  • IGRA test (Quantiferon test): interferon alpha after tbc exposure: High specificity
    • Positive test result not after a vaccine or at most other non-tbc mycobacteria
    • Disadvantage: The IGRA test does not distinguish between active and latent tbc
  • Mantoux (False positive after vaccine)
  • PCR investigations used to an increasing extent
  • Direct microscopy (Ziehl-Neelsen dyeing)
  • Cultivation
  • Immunfluoresence
  • Rheumatological assessment if symptoms of joints, tendons or back

In case of ongoing treatment with TNF inhibitors or other immunosuppressive therapy Tbc tests will be of little value.

  •  Tbc vaccine has been taken out from the childhood vaccination program in Norway since 2009 / 10

Treatment

Treatment (active Tbc and preventive treatment) is recommended given in consultation with a specialist in the field (lung doctor, specialist in infectious diseases, pediatrics)

  • At active Tbc
    • At least 2 months chemotherapy (Isoniazid + rifampicin (Note: CYP activation may result in lesser effect of other drugs)
  • In positive IGRA tests, when adequate adequate treatment has not been given
    • By preventive treatment is meant treatment of healthy, infected persons and where active disease is excluded (Public Health Institute)
    • Preventive treatment against Tbc is given before anti-rheumatic treatment with TNF inhibitors, high doses of steroids or similar immunosuppressive therapy is started.
      • Treatment regimens are usually isoniazid in 6 months or the combination of isoniazid and rifampicin in 3 months. Combination treatment is shorter, but is at increased risk of side effects

Tbc screening prior to TNF-inhibitor treatment

Literature

Opportunistic infections, BINDEVEVSSYKDOMMER.no


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