5-54
Follow-up Actions
Evacuation/Consultation Criteria: Refer to tropical medicine/infectious disease specialist when possible.
Zoonotic Disease Considerations
Principal Animal Hosts: Dogs, cats, rodents
Clinical Disease in Animals: Intermittent fever, anemia, weight loss; may be asymptomatic
Probable Mode of Transmission: Contaminated bite wounds or contact with fecal matter of Reduviidae
family of insects (kissing bugs).
Known Distribution: Western Hemisphere; Texas, Mexico, Central and South America
Mycobacterial Infections
ID: Tuberculosis
LTC Duane Hospenthal, MC, USAIntroduction: Mycobacterium tuberculosis, M. Bovis and others cause tuberculosis (TB), a chronic pulmonary
infection that is seen worldwide. Infection is spread by airborne particles. Clinical disease (TB) develops in
only about 10% of those infected. Others have latent tuberculosis infection (LTBI), since they do not have
evidence of active disease. Disease in adults usually occurs secondary to reactivation of past infection.
Disease occurs more frequently in children, and in adults with immunocompromised, including secondary to
HIV infection, malignancy, chronic steroid therapy, uncontrolled diabetes, malnutrition, silicosis, or who are
smokers. Extrapulmonary disease occurs in approximately 15% of infected persons and can affect virtually
any organ system (see Skin: Cutaneous Tuberculosis) and can disseminate throughout the body. Purified
protein derivative (PPD) skin testing can be used to document tuberculosis infection (active) or screen for
exposure (LTBI). Many countries immunize infants and children with BCG (Bacillus Calmette-Guerin) vaccine,
which may cause falsely positive reactions to PPD testing. These reactions wane with time, so a positive
reaction to PPD testing in adults should not be dismissed as a reaction to BCG given as a child.
Subjective: Symptoms
Chronic productive cough (bloody), chest pain, fever, chills, night sweats, anorexia, weight loss, fatigue.
Focused History: Do you cough up blood? (other causes of chronic cough not usually associated with
hemoptysis) Do your night sweats drench your bedding or bedclothes? (sweating in bed is normal; having
“drenching” sweats is not) How long have you been coughing? (A cough lasting longer than 2-3 weeks is
unlikely from bacterial or viral infection.)
Objective: Signs
Using Basic Tools: Vital Signs: Normal to low-grade fever, weight loss
Percussion: Unilateral, localized dullness over the upper lung fields
Auscultation: Decreased breath sounds or rales corresponding to percussed dullness (upper lung fields)
Using Advanced Tools CXR: consolidation or cavitary lesion in upper lung fields; purified protein derivative
(PPD) skin testing to document tuberculosis infection.
NOTE: PPD may be negative in persons with active infections.
Assessment:
Differential Diagnosis
Chronic cough - chronic bronchitis or COPD not associated with progressive weight loss or night sweats
Lung cancer - usually seen in patient with smoking history
Fungal pneumonias (histoplasmosis, blastomycosis, paracoccidioidomycosis) - chronic pulmonary symptoms
are rare and usually seen in smokers in endemic areas.
Plan:
Treatment