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Suggest treatment for lymph node tuberculosis in pregnancy

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Posted on Wed, 25 Jun 2014
Question: Dear Doctor,

I have been in touch with an OBGYN doctor on this website, which was very helpful. I wanted to get a second opinion and ask a few more further questions.
My wife is 18weeks pregnant (almost 19weeks) and she was diagnosed with Lymph Node Tuberculosis last week at a hospital in Beijing, CHINA. There are a few opinions from different doctors.
1. The Tuberculosis Doctor (very experienced) at the Beijing Tuberculosis Hospital said that her condition is not serious so she should not take any TB medicine until she gives birth and even after the birth the Lymph Node TB could have gone away already. He said this Lymph Node TB happened because she was wasn't feeling and eating well during her Nausea period which ended about 2 weeks ago. So if she eats well now it could increase her level of Immune system etc.
2. There are other doctors (not chinese) saying that the pregnancy is already in a safe state to take Tb medicine and actually not taking any medicine is more dangerous than taking the TB medicine (afraid of any side effects).

It seems that chinese doctors are more cautious and do not want to encourage to take TB medicine even if its considered "safe".
My wife had the first 2 boys with C-Section the last one being a premature birth at 35weeks. We are afraid her scar might pop open or become really thin after 30weeks and assuming that it might be another premature birth. That is why we chose a hospital in chine with the best NICU care. But now if we have to take the TB medicine we have to either go to South Korea or Singapore and if we take the TB meds i think we have to give birth in the same country because i understand that my wife needs to be under close monitoring of the TB doctor for her liver conditions.
Please give me more advice.

Thank you very much doctor.
doctor
Answered by Dr. Aarti Abraham (1 hour later)
Brief Answer:
AS BELOW

Detailed Answer:
Hello
Thanks for writing to us with your health concern.
Firstly, can you tell me how was the diagnosis of tuberculous lymph node made ?
Was a needle biopsy done or was it just a clinical diagnosis.
Once you tell me how the diagnosis was made, ( and if you can upload any reports, that would be preferable ) , I would be able to guide you in a better way.
Looking forward to hearing from you.
Take care.
Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Aarti Abraham (12 minutes later)
I will indicate what picture they refer to before each translation..


This one refers to the Acid-Fast Stain lab report (抗酸染色):
1. Ziehl-Nelson Acid-Fast stain: Positive (+)
2. Fluorescent Acid-Fast stain: Positive (+)
3. Suggestive for further Acid-Fast testing specifically entailed for Mycobacterium tuberculosis



This one refers to the “Culture Negative” lab report:

1. General bacterial culture indicates no bacterial growth
2. Culture Negative





This one refers to the ultrasound test ending in "右颈部淋巴结肿大”:

“超声所见” Ultrasound shows…
The right lateral cervical area can see a mixed echo 4.0x1.0cm, irregular morphology with unclear borders, within the structure lacks echoes, fluid. CDFI: signals suggest rich blood flow peripherally and internally

Multiple low echoes can be seen on right lateral cervical area, largest at 2.2x1.2cm, uneven echo within, CDFI: indicates rich vascular flow

Remainder of cervical area and supraclavicular fossa remain uncharacteristic of irregular swollen lymphatics

Indications:
Right cervical area indicates low echoes, consider inflammation
Right cervical lymph node enlargement






This one refers to the ultrasound test ending in "建议治疗后复查”

超声所见 Ultrasounds shows…
Left cervical area and bilateral supraclavicular fossa does not indicate irregular enlargement of lymph nodes

Posterior right ear and superior cervical area to inferior right cervical area shows multiple low echo nodules

Superior cervical area shows the largest 2.4x1.5cm nodule, CDFI: Irregular vascular flow not seen within

Inferior cervical lymph node shows rich vascular supply

超声提示: indication
Posterior right ear and right cervical area shows multiple lymph node enlargement, undetermined nature, recommend additional check-up post-treatment






This one refers to the doctor’s diagnosis:

2014-5-26(?)
Pus culture, general culture no bacterial growth
Acid-Fast stains (+)
PPD (+)
36hrs rash/wheal 1.9x1.5cm
nodule 2.2x2cm
Recommend transfer to specialized TB health care centers

doctor
Answered by Dr. Aarti Abraham (4 hours later)
Brief Answer:
AS BELOW

Detailed Answer:
From what I understand, a needle biopsy of the lymph node was done.
Now, it is very strange that this is positive on staining but negative on culture.
There is some error in the labs here.
I would ask you to get a repeat culture done.
For culture positive TB, treatment should definitely be started, there is no point in being cautious.
ANti TB medications ARE actually quite safe.
So if this is culture positive TB, then treatment needs to be started, irrespective of the other factors.
All the best
Please feel free to discuss further.
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
doctor
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Follow up: Dr. Aarti Abraham (3 days later)
Hi Doctor,

Thank you for your answer. According to your suggestion we went to see a Tb Doctor in Mongolia and my wife was prescribed some meds, I will attach the picture of it, can you please tell me whether these are the right dosage safe to use during pregnancy?
It reads Rifampicin 150 mg, Isoniazid 75mg, Pyrazinamide 400mg and Ethambutol Hydrochloride 275mg. She is supposed to take these for 7 days first until the next checkup.
They tried to do a scoop test again today and the result confirmed it is a TB bacteria but the Surgery Doctor wants to open up the wound further more to take out "more". He said it didn't look good and it needs to be taken out. How does this sound? I think that since she is pregnant we don't want to open up the wound further more.
Can we just proceed to take the Tb Meds for now?
doctor
Answered by Dr. Aarti Abraham (1 hour later)
Brief Answer:
AS BELOW

Detailed Answer:
Hello
Yes, if the result confirmed that tuberculosis is present, then you should start the medication.
You should take the drugs for 2 months, and then reduced number of drugs for another 4 months atleast.
DO NOT STOP TREATMENT MIDWAY - it might lead to resistant tuberculosis.
Yes, if the pus is drained, it will provide her relief.
Take care.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Aarti Abraham (4 minutes later)
Thank you doctor.
What do you mean by drained pus? Should we allow the doctor to perform further surgery to further open up the wound to take out more pus?
doctor
Answered by Dr. Aarti Abraham (8 hours later)
Brief Answer:
AS BELOW

Detailed Answer:
Yes, removal of as much pus and necrotic ( dead ) tissue as possible will provide maximum relief.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Dr. Aarti Abraham

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Suggest treatment for lymph node tuberculosis in pregnancy

Brief Answer: AS BELOW Detailed Answer: Hello Thanks for writing to us with your health concern. Firstly, can you tell me how was the diagnosis of tuberculous lymph node made ? Was a needle biopsy done or was it just a clinical diagnosis. Once you tell me how the diagnosis was made, ( and if you can upload any reports, that would be preferable ) , I would be able to guide you in a better way. Looking forward to hearing from you. Take care.