29 Sep 2020

7/22/20: Disseminated Tuberculosis

7/22/2020 Morning Report: Disseminated TB

In morning report today, PGY2 Saul Barajas Nuno presented a case of a 43 year old M with recently diagnosed cirrhosis who presents with SOB and cough x3 days along with increase in bilateral LE swelling x 2 weeks. He was diagnosed with cirrhosis likely 2/2 ETOH about a month ago at OSH where he presented with distended abdomen. At the time, a 7.5L paracentesis was positive for SBP and EGD showed trace PHG, negative for EVs. ROS today is significant for SOB, cough, DOE and b/l LE swelling. Physical exam significant for scleral icterus, diminished breath sounds on L lower lung field, mildly distended abdomen, spider angiomata on shoulders and chest and 3+ pitting edema in bilateral LE.

Labs:
BMP and liver panel significant for the following:
Na 125/K 5.7/Cl 91/HCO3 18/BUN 50/Cr 1.7< Glucose 48
ALP 103> T.protein 6.3/Albumin 2.5/AST 50/ALT 20/Tbili 11.3/Dbili 7.1

CXR:
MR SNB

Thoracentesis and Paracentesis performed with the following results:

Pleural fluid:

  • Color: orange
  • Nucleated cell count: 990 (49% neutrophils, 31% lymphocyte, 20% monocytes)
  • LDH: 568 (serum LDH 206)
  • Protein: 3.9 (serum protein 6)
  • Glucose: 35 (serum glucose 85)
  • ADA: 50.1 (normal <9.2)
  • Cytology: negative for malignant cells

Ascitic fluid:

  • Color: Red
  • Nucleated cell count 393 (3% neutrophils, 64% lymph, 33% monocytes)
  • Albumin: 2.1 (serum albumin 3.7)
  • Protein: 3.6
  • Culture: negative

Of note, blood culture and UA negative for infection. COVID test negative. TTE showed EF of 70-75%, normal ventricles and valves. US Abd showed evidence of cirrhosis and portal HTN, small to moderate ascites and a concern for a 4.8cm hypoechoic mass within the R hepatic lobe which on CT liver 4-phase was not arterially enhancing, likely representing an area of focal fatty sparing.

2 weeks later, the pleural fluid culture grew MTB! Communicable Pulmonary TB rule out initiated and AFB and MTB PCR both positive.

Treatment:
Patient initially being for infectious with antibiotics due to decompensation with evidence of septic shock requiring intubation and vasopressor support. Once the MTB grew, he was started on liver sparing TB medications: levofloxacin, amikacin and ethambutol. The patient was not a candidate for liver transplant given disseminated TB.

Take Home Points:

  • 3 things to consider when cirrhotics come with SOB:
    • Hepatopulmonary syndrome
    • portopulmonary HTN
    • hepatic hydrothorax
  • Always rule out infection in cirrhotics that come in decompensated (remember: infection, infection, infection)
  • In heart failure patients, diuretics can cause an exudative effusion so to differentiate, look at serum effusion albumin gradient (<1.2 indicate CHF)
  • In pleural fluid, ADA is a marker for pleural TB (>40) but malignancy (lymphoma) or collagen vascular disease (ex. RA) can also cause an elevated ADA

Sentinel Article:
Pulmonary Complications in Chronic Liver Disease

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