Case 03
Shown here is a swollen right ankle and diffuse macular rash in a young female with cystic fibrosis.
i. What is the diagnosis?
ii. What is the medical treatment and prognosis?
Case 04
17 This is the chest X-ray of a 16- year-old male who presented with a 3- week history of a dry cough and fevers.
i. What does the chest X-ray show?
ii. What is the likely diagnosis?
iii. What contact tracing procedures should be instigated?
Answer Case 03
i.The illustration shows a diffuse vasculitis involving the skin and synovium. Vasculitis of the skin may also be nodular or purpuric (without thrombocytopenia). It is associated with severe pulmonary disease and chronic Pseudomonas aeruginosa infection. It has been attributed to an overspill into the systemic circulation of immune complexes resulting from the hyperimmune stimulation associated with chronic pulmonary disease.
ii. Medical treatment consists of short-term, high-dose oral steroids. This will usually produce complete resolution. Immunosuppressive agents have been used, but experience with them is limited.
Answer Case 04
i. Unilateral enlarged paratracheal lymph nodes.
ii. Primary pulmonary TB. The initial infection with Mycobacterium tuberculosis in children with no prior history of exposure to the disease leads to a small primary focus of infection, usually in the middle to lower zones on the chest X-ray when visible, and associated with enlarged mediastinal nodes on the affected side. The mycobacteria disseminate into the blood from the enlarged nodes and can therefore be seeded throughout the body, but they have a predilection for areas of relatively high oxygen tension such as the apices of the lungs, the CNS, and the metaphyses of the long bones.
Primary disease causes symptoms in only a minority of patients (less than 10%), usually resolves spontaneously (often leaving a tuberculoma), and is associated with conversion to a positive tuberculin skin test after 6 weeks. However, primary disease can be complicated by progressive local disease within the lungs, bronchial obstruction by enlarged nodes (especially the middle lobe, leading to bronchiectasis), bronchogenic TB due to the rupture of a caseating node into the bronchial tree, pleural or pericardial effusions, miliary TB, and tuberculous meningitis.
iii. Contact tracing is initiated to identify (a) cases who have caught TB from the index case, (b) the potential source of infection for the index case, and (c) other patients who may have been infected by this source. Recommendations vary between countries but usually suggest the screening of all subjects who live with the index case and other close contacts such as school classmates.
Screening requires a clinical history, chest X-ray, and tuberculin skin testing (at least in children or those who have not been given the BCG vaccine). The new gamma-interferon blood tests for TB identify whether the patient has circulating lymphocytes that recognize an antigen specific for M. tuberculosis, and may provide a more specific and sensitive test for identifying infected patients than tuberculin skin testing.
Shown here is a swollen right ankle and diffuse macular rash in a young female with cystic fibrosis.
i. What is the diagnosis?
ii. What is the medical treatment and prognosis?
Case 04
17 This is the chest X-ray of a 16- year-old male who presented with a 3- week history of a dry cough and fevers.
i. What does the chest X-ray show?
ii. What is the likely diagnosis?
iii. What contact tracing procedures should be instigated?
Answer Case 03
i.The illustration shows a diffuse vasculitis involving the skin and synovium. Vasculitis of the skin may also be nodular or purpuric (without thrombocytopenia). It is associated with severe pulmonary disease and chronic Pseudomonas aeruginosa infection. It has been attributed to an overspill into the systemic circulation of immune complexes resulting from the hyperimmune stimulation associated with chronic pulmonary disease.
ii. Medical treatment consists of short-term, high-dose oral steroids. This will usually produce complete resolution. Immunosuppressive agents have been used, but experience with them is limited.
Answer Case 04
i. Unilateral enlarged paratracheal lymph nodes.
ii. Primary pulmonary TB. The initial infection with Mycobacterium tuberculosis in children with no prior history of exposure to the disease leads to a small primary focus of infection, usually in the middle to lower zones on the chest X-ray when visible, and associated with enlarged mediastinal nodes on the affected side. The mycobacteria disseminate into the blood from the enlarged nodes and can therefore be seeded throughout the body, but they have a predilection for areas of relatively high oxygen tension such as the apices of the lungs, the CNS, and the metaphyses of the long bones.
Primary disease causes symptoms in only a minority of patients (less than 10%), usually resolves spontaneously (often leaving a tuberculoma), and is associated with conversion to a positive tuberculin skin test after 6 weeks. However, primary disease can be complicated by progressive local disease within the lungs, bronchial obstruction by enlarged nodes (especially the middle lobe, leading to bronchiectasis), bronchogenic TB due to the rupture of a caseating node into the bronchial tree, pleural or pericardial effusions, miliary TB, and tuberculous meningitis.
iii. Contact tracing is initiated to identify (a) cases who have caught TB from the index case, (b) the potential source of infection for the index case, and (c) other patients who may have been infected by this source. Recommendations vary between countries but usually suggest the screening of all subjects who live with the index case and other close contacts such as school classmates.
Screening requires a clinical history, chest X-ray, and tuberculin skin testing (at least in children or those who have not been given the BCG vaccine). The new gamma-interferon blood tests for TB identify whether the patient has circulating lymphocytes that recognize an antigen specific for M. tuberculosis, and may provide a more specific and sensitive test for identifying infected patients than tuberculin skin testing.
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