复旦大学：《传染病学 Infectious Disease》课程教学资源（MBBS）教案案例（英文）Dyspnoea, weight loss, fever, and headache caused by extrapulmonary tuberculosis in a prison inmate

Case report Liu gian gian 2016-6-2

Case Report Liu qian qian 2016-6-2

Case report Dyspnoea, weight loss, fever, and headache caused by extrapulmonary tuberculosis in a prison inmate Musharaf Tarajia, Fabio Jaramillo, Amaranta Pernett, Nelson Santamaria Amador goodridge Lancet2014;384:1400

2 Dyspnoea, weight loss, fever, and headache caused by extrapulmonary tuberculosis in a prison inmate Musharaf Tarajia, Fabio Jaramillo, Amaranta Perne8, Nelson Santamaría, Amador Goodridge Lancet 2014; 384: 1400 Case Report

Medical history This is a 55-year-old male, prisoner. v He presented with a 10-day history of breathing difficulty, chest pain, fever, headache, and had also lost more than 10 kg in weight over the previous 2months v His past medical and family history was unremarkable v However he had been in contact with inmates who had had chronic cough for 2 years

3 ü This is a 55-year-old male, prisoner. ü He presented with a 10-day history of breathing difficulty, chest pain, fever, headache, and had also lost more than 10 kg in weight over the previous 2 months. ü His past medical and family history was unremarkable. ü However, he had been in contact with inmates who had had chronic cough for 2 years. Medical history

Physical examination v His vital signs were normal, apart from a respiratory rate of 28 breaths per minute v Wasting and diminished breath sounds at the basal area of the right lung and pleural friction rub Y Neurological examination showed normal mental status, normal reflexes and negative meningeal signs v The rest physical examination were normal

Physical examinaEon 4 ü His vital signs were normal, apart from a respiratory rate of 28 breaths per minute. ü WasDng and diminished breath sounds at the basal area of the right lung and pleural fricEon rub. ü Neurological examinaDon showed normal mental status, normal reflexes and negaDve meningeal signs. ü The rest physical examinaDon were normal

Laboratory tests Anemia WBC:12000/μL V Ahigh neutrophil count v Serum chemistry tests showed mild hyponatremia An HIV test was negative

Laboratory tests 5 ü Anemia ü WBC: 12000/μL ü A high neutrophil count ü Serum chemistry tests showed mild hyponatremia ü An HIV test was negaDve

Imageological examination A Y Chest X-ray showed a right pleural u effusion CT of the chest showed substantial pleural thickening in the right lower 0D lobe. figure A

Imageological examinaEon 6 ü Chest X-ray showed a right pleural effusion. ü CT of the chest showed substanDal pleural thickening in the right lower lobe.( figure A)

Laboratory tests Pleural effusion test 1. an exudate with 80% lymphocyte predominance 2. glucose: 850 mg/L(serum glucose: 1040 mg/L) 3.pH=755( norma764) 4.ADA: 112 U/L 5. Acid-fast bacilli smear, Gram stain, Xpert MTB/Rif test, and culture for Mycobacterium in pleural fluid were all negative.y 6. Pleural biopsy was not done

Laboratory tests 7 ü Pleural effusion test: 1. an exudate with 80% lymphocyte predominance 2. glucose: 850 mg/L (serum glucose: 1040 mg/L) 3. pH=7.55 (normal 7.64) 4.ADA: 112 U/L 5. Acid-fast bacilli smear, Gram stain, Xpert MTB/Rif test, and culture for Mycobacterium in pleural fluid were all negaDve. 6. Pleural biopsy was not done

Supplementary medical history 8 v Then the patient was started on cefotaxime v On the fifth day in hospital, he showed signs of acute disorientation and neck stiffness Y CT of brain showed supratentorial ventricular dilation figure B)

Supplementary medical history 8 ü Then the paDent was started on cefotaxime. ü On the fich day in hospital, he showed signs of acute disorientaDon and neck sDffness. ü CT of brain showed supratentorial ventricular dilaDon.( figure B )

Supplementary medical history v CSf test 1.90% predominance of neutrophils 2. the ratio of glucose and serum glucose was less than 0. 2.(normal ratio is 0.6 3.Acid-fast bacilli smear test was positive 4.latex test was negative 5.An Xpert MTB/Rif test suggested the presence of Mycobacterium tuberculosis susceptible to rifampicin

Supplementary medical history 9 ü CSF test: 1.90% predominance of neutrophils 2.the raDo of glucose and serum glucose was less than 0.2. (normal raDo is 0.6) 3.Acid-fast bacilli smear test was posiEve. 4.latex test was negaDve. 5.An Xpert MTB/Rif test suggested the presence of Mycobacterium tuberculosis suscepDble to rifampicin

Diagnosis and treatment Y Diagnosis: tuberculous meningitis and pleural tuberculosis V Treatment: rifampicin, isoniazid, pyrazinamide, ethambutol and dexamethasone v He showed signs of clinical improvement and recovered full consciousness 2 days after treatment initiation v He was discharged 21 days after admission under directly observed treatment

Diagnosis and treatment 10 ü Diagnosis: tuberculous meningiDs and pleural tuberculosis. ü Treatment: rifampicin, isoniazid, pyrazinamide, ethambutol, and dexamethasone. ü He showed signs of clinical improvement and recovered full consciousness 2 days acer treatment iniDaDon. ü He was discharged 21 days acer admission under directly observed treatment