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Suggest treatment for lymph node TB

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Posted on Thu, 13 Apr 2017
Question: Lymph Node TB and Brain TB

Hello Doctors,
Good Evening.
My mom has been diagnosed with Lymph node TB (swelling of lymp nodes) and Brain TB. Here is the history
2012 - Diagnosed with TB of lungs. TB treatment for 8 months and was cured.
Feb 2015 - Diagnosed with lymph node TB. TB treatment started (4 TB treatment tablets)
March 2015 - She had a seizure, MRI SCAN showed brain TB. Continued same medicines and 60 injections(streptomycin). MDR TB test was Negative
Nov 2015 - MRI SCAN showed that TB in the brain increased. TB of lymp node reduced. Continued with the same tablets.Lymph nodes TB almost reduced completely.
July 2016 - MRI Scan showed great improvement, moderate decrease of TB in the brain. Reduced to 1 TB tablet for the next 6 months XXXXXXX 2017 - She was feeling weak, dizzy, slight headaches etc
March 2017 - MRI SCAN shows significant increase in brain TB as compared to July 2016 scan. No visible swelling of lymph node TB
Doctor advised to continue 1 TB tablet and also prescribed Descort 30mg for 10 days and advised to come back after 10 days

Here are some of my questions, Doctor
(1) She was tested Negative for MDR TB in July 2015, is it likely for the bacteria to become MDR now while she has been on TB treatment?
(2) Do we have to go for second line of TB drugs? If so, how many months/years of treatment is required?
(3) She has been taking Descort 30 for the last 5 days and has been feeling much better, does that mean the drugs are working fine, and how long can Descort tabets be continued?

Please advise. Thank You so much
doctor
Answered by Dr. Kaushal Bhavsar (4 hours later)
Brief Answer:
We should first check about the dosage of anti tubercular drugs.

Detailed Answer:
Thanks for your question on Healthcare Magic.
I can understand your concern.

Answer to your 1st question.

Yes, if suboptimal doses are given then TB bacilli can turn into MDR (multi drug resistance) bacilli. So first of all let me her weight and dosage of anti tubercular drugs.

Answer to your 2nd question.

Without documented evidence of MDR TB infection, it is better not to jump directly to the second line anti tubercular drugs. Better to get done CSF Genexpert, CSF AFB culture and sensitivity. If she is having tuberculoma like lesions in brain then brain biopsy from the lesion will be more informative. If any of these show MDR TB then only your should start treatment for MDR TB. Usual treatment duration is 2 years.

Answer to your 3rd question.

Desocort is steroid. I reduces brain edema and raised intracranial tension (ICT). Usually it is given in tapering dose. Start with 30mg for 10-15 days. Then give 15 mg for next 10-15 days. Then give 6 mg for next 10-15 days then stop.

Hope I have solved your query. I will be happy to help you further. Wishing good health to your mother. Thanks.
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Kaushal Bhavsar (22 hours later)

Thank You for your detailed answers, Dr. XXXXXXX Bhavsar.
I will give you the medicine dosage details in a day as I don't have them handy. I do have a few follow up questions
(1) Can you tell a little about CSF Genexpert, CSF AFB culture and sensitivity, on which part of the body they are done and how accurate they are?
(2) Do CSF Genexpert, CSF AFB culture and sensitivity tell you if its a MDR TB?
(3) Is brain biopsy risky in anyway as it might involve operating on the brain? Is it more accurate than CSF Genexpert, CSF AFB culture and sensitivity?
(4) You mentioned not to go for second line of drugs if its not MDR TB. If its not MDR TB what kind of medication is recommended as she has been on the regular TB medication for the past 2 years.

Please advice. Thank You once again for your help.
doctor
Answered by Dr. Kaushal Bhavsar (3 hours later)
Brief Answer:
CSF is cerebro spinal fluid.

Detailed Answer:
Thanks for your follow up question on Healthcare Magic.
I can understand your concern.
CSF is cerebro spinal fluid. It is fluid present around brain. This fluid is infected in the brain TB. An hence we can test CSF for brain TB.
CSF is obtained by lumber puncture.
Lumber puncture is done by doctor. Through lower intervertebral space, long needle is introduced and CSF is collected. CSF is sterile fluid in normal individuals. So high protein, normal sugar and raised lymphocytes in CSF suggest TB infection.
This can be further confirm by Genexpert an culture sensitivity (C/S) report.
Genexpert is 99% sensitive.
Genexpert and C/S will tell you if there MDR TB infection or drug sensitive TB.
Brain biopsy is risky procedure. But it is indicated only if there is mass or nodule or space occupying lesion (SOL) - tuberculoma. So please let me know MRI brain report.
If this comes to drug sensitive tb then we need to add few of the second line drugs in addition of first line drug. Bu choice of second line drug will be only on the basis of sensitivity report. Levofloxacin I th preferred one along with kanamycin injection.
Hope I have solved your query. I will be happy to help you further. Wishing good health to your mother. Thanks.
Above answer was peer-reviewed by : Dr. Kampana
doctor
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Follow up: Dr. Kaushal Bhavsar (2 days later)
Thank You for your detailed explanation Dr. XXXXXXX Bhavsar. That was very helpful. We are planning to get the Genexpert done.

(1) Can CSF sample be used for Genexpert culture sensitivity/AFB culture/MGIT 960?

(2) Doctor also mentioned AFB culture, how accurate is this?

(3) Compared to MGIT 960 and AFB culture which is more accurate and which one would you recommend?

(4) Is CSF sample generally taken by the Doctor (Neurologist) or can this be done at a diagnostic center?

Please advise and once again Thank You for your patience.
doctor
Answered by Dr. Kaushal Bhavsar (1 hour later)
Brief Answer:
Yes, CSF can be used for all these tests.

Detailed Answer:
Thanks for your follow up question on Healthcare Magic.
I can understand your concern.

Answer to your 1st question.

Yes, CSF can be used for all these tests.

Answer to your 2nd question.

There are two types of culture media for TB. Solid culture an liquid culture (MGIT). Report of MGIT will come within 2 weeks while I report from solid culture (LJ media) will come after 2-3 months. So for rapidity MGIT is better. But for accuracy solid culture is good. Most rapid one will be Genexpert. It will be give results in just 1 day.

Answer to your 3rd question.

Your should गोली for both, MGIT and solid culture. Best would be solid culture. MGIT will be give you a result in 2 weeks so diagnosis can be made early and treatment can be start.

Answer to your 4rth question.

Yes, CSF sample is taken by doctors only, mostly anaesthetist or by physicians or by neurologist in indor facility only, not in diagnostic laboratory.

Hope I have solved your query. I will be happy to help you further. Wishing good health to your mother. Thanks.
Above answer was peer-reviewed by : Dr. Remy Koshy
doctor
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Follow up: Dr. Kaushal Bhavsar (18 hours later)

Thank You Doctor. I am a little confused though. Please help me understand.

(1) When you said solid culture, were you talking about AFB or something else?

(2) Can CSF sample be used for solid culture or some other sample be used? If so, from where?

Please advise and once again Thank You for your patience.
doctor
Answered by Dr. Kaushal Bhavsar (2 hours later)
Brief Answer:
Both are culture techniques for AFB only.

Detailed Answer:
Thanks for your follow up question on Healthcare Magic.
Sorry for confusion.
AFB means Acid Fast Bacilli-bacteria causing tuberculosis.
And to grow any bacteria outside the body, we need culture medias.
There are many culture medias for AFB.
But most commonly used are solid culture (LJ media) and liquid culture (MGIT).
Solid culture gives report in 2-3 months time while liquid culture will give in 2 weeks. So early diagnosis is possible in MGIT.
As far as accuracy is concerned, solid culture is best than MGIT.
So you can use any sample (like CSF) in any culture (solid or liquid) to identify the AFB growth.
Am I clear now?
I know it's difficult to understand for non medico person.
May I know whom are you consulting for your mother? I am TB specialist or neuro physician?
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Kaushal Bhavsar (21 hours later)
Thank You for the clarification Doctor. It is clear now.

We are consulting both pulmonologist and a neuro surgeon. My mom also had Lymph node TB (swelling of the lymph nodes), which is almost gone. Will be taking a ultrasound to confirm that.

The TB specialist recommended PET Scan, Gen expert and AFB, which we will be doing this week. Let me know if you have any suggestions or information. Thank you once again, Dr. XXXXXXX Bhavsar .
doctor
Answered by Dr. Kaushal Bhavsar (5 hours later)
Brief Answer:
Do let me her progress.

Detailed Answer:
Thanks for your follow up question on Healthcare Magic.
I can understand your concern.
It's always encouraging for doctors to hear positive feedback from patients. I am glad that my advice is helping you.
Do let me know her progress.
Hope I have solved your query. If you are not having further queries, then please close the conversation and rate my answer.
You can ask me directly on bit.ly/askdrkaushalbhavsar. Wishing good health to your mother. Thanks.
Above answer was peer-reviewed by : Dr. Nagamani Ng
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Dr. Kaushal Bhavsar

Pulmonologist

Practicing since :2008

Answered : 14925 Questions

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Suggest treatment for lymph node TB

Brief Answer: We should first check about the dosage of anti tubercular drugs. Detailed Answer: Thanks for your question on Healthcare Magic. I can understand your concern. Answer to your 1st question. Yes, if suboptimal doses are given then TB bacilli can turn into MDR (multi drug resistance) bacilli. So first of all let me her weight and dosage of anti tubercular drugs. Answer to your 2nd question. Without documented evidence of MDR TB infection, it is better not to jump directly to the second line anti tubercular drugs. Better to get done CSF Genexpert, CSF AFB culture and sensitivity. If she is having tuberculoma like lesions in brain then brain biopsy from the lesion will be more informative. If any of these show MDR TB then only your should start treatment for MDR TB. Usual treatment duration is 2 years. Answer to your 3rd question. Desocort is steroid. I reduces brain edema and raised intracranial tension (ICT). Usually it is given in tapering dose. Start with 30mg for 10-15 days. Then give 15 mg for next 10-15 days. Then give 6 mg for next 10-15 days then stop. Hope I have solved your query. I will be happy to help you further. Wishing good health to your mother. Thanks.