Post Graduate Student in M.D. (General Medicine)

Place: Bellary

From: Date: 13/11/08

DR. DHANARAJ GURANNA D.

Post Graduate Student in M.D. (General Medicine)

Department of Medicine,

Vijayanagara Institute of Medical Sciences, Bellary.

To

The Principal,

Vijayanagara Institute of Medical Sciences,

Bellary.

THROUGH PROPER CHANNEL

Respected Sir,

Subject : Acceptance of registration and forwarding of my dissertation topic.

With reference to the above subject, I, the undersigned studying Post Graduate Course in M.D General Medicine has been allotted the dissertation topic “CLINICAL PROFILE OF MILIARY TUBERCULOSIS AT VIMS COMBINED HOSPITALS BELLARY”, under the guidance of DR.SHASHIBHUSHAN Professor, Department of Medicine, VIMS, Bellary.

I request you to kindly forward the dissertation topic in the prescribed form to the University for approval.

Thanking you,

Yours sincerely,

Signature of the guide: (DR. DHANARAJ GURANNA D.)

PG in General Medicine

(DR.SHASHIBHUSHAN) VIMS, Bellary.

Professor of Medicine,

Department of Medicine,

VIMS, Bellary

From: Date : 15.11.2008.

The Professor and Head of the Department, Bellary

Department of Medicine,

Vijayanagara Institute of Medical Sciences, Bellary.

To

The Registrar,

RajivGandhiUniversity of Health Sciences,

Bangalore.

THROUGH PROPER CHANNEL

Respected Sir,

As per the regulations of the University for registration of Dissertation topic, the following Post Graduate Student in MD General Medicine has been allotted the dissertation topic as follows by the Official Registration Committee of all qualified and eligible guides of the Department of Medicine.

NAME / TOPIC / GUIDE
DR. DHANARAJ GURANNA D
Post Graduate Student in M.D.
General Medicine,
VIMS, Bellary. / “ CLINICAL PROFILE OF MILIARY TUBERCULOSIS AT VIMS COMBINED HOSPITALS BELLARY”, / DR.SHASHIBHUSHAN
Professor of Medicine Department of Medicine, VIMS, Bellary.

Therefore, I kindly request you to communicate the acceptance of the dissertation topic allotted to the PG student at an early date.

Thanking you,

Yours faithfully,

Signature of the guide: ( DR. VISHNU HAYAGREEV)

Professor and HOD

Department of Medicine

(DR.SHASHIBHUSHAN) VIMS , Bellary.

Professor of Medicine,

Department of Medicine

VIMS, Bellary.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

ANNEXURE – II

SYNOPSIS FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 / Name of the candidate and Address
( In Block letters ) / DR. DHANARAJ GURANNA D
POST GRADUATE STUDENT IN M.D .GENERAL MEDICINE
VIMS, BELLARY – 583104.
2 / Name of the Institution / VIJAYANAGAR INSTITUTE OF MEDICAL SCIENCES, BELLARY
3 / Course of study and subject / M.D. in MEDICINE
4 / Date of admission to the course / 09-04- 2008
5 / Title of Topic:
“CLINICAL PROFILE OF MILIARY TUBERCULOSIS AT VIMS COMBINED HOSPITALS BELLARY ”,
6 / Brief resume of the intended work:
6.1 Need for the Study:

In the pre-chemotherapy era, the Miliary Tuberculosis was fatal, and was most often an early complication of primary TB in children. In the past three decades,the presentation of miliary TB has changed radically. Numerous reports have indicated an ever increasing number of adults and elderly patients afflicted by this kind of TB.HIV infection has significantly influenced the clinical presentation and caused resurgence of miliary TB.As the clinical features of the disease are nonspecific ,if it goes unrecognised ,Miliary TB is lethal.

Hence the present study is taken up to study the demographic,clinical , radiographic and laboratory features,method of diagnosis and prognostic variables in patients with miliary tuberculosis prospectively.
6.2 Review of Literature:
Miliary Tuberculosis refers to clinical disese resulting from the uncontrolled hematogenous dissemination of Mycobacterium Tuberculosis bacilli.(1) Lesions are usually yellowish granulomas 1to 2 mm in diameter that resembles millet seeds(14).
Several large retrospective series provide much of the data on clinical features of Miliary Tuberculosis.(2-7) Most common symptoms and signs in patients with Miliary Tuberculosis are fever and or night sweats,anorexia,weightloss,weakness,malaise,cough,dyspnoea,pleuritic chestpain,abdomenpain,nausea,vomiting,diarrhea,headache,pulmonary(rales,rhonchi,rubs,signs of effusion),Hepatomegaly,splenomegaly,altered mental status,meningismus,ascites,jaundice,
Lymphadenopathy (2-7).Eye examination may reveal choroidal tubercles which are pathogmonic of military tuberculosis in upto 30%of cases(14).
The clinical presentation of miliary tuberculosis is highly variable.When it develops during primary infection ,the disease has more acute onset and more rapid clinical course.Acute disease may be fulminant,including multiorgan failure(8),a syndrome of septic shock(9) and acute respiratorydistress syndrome(10,11).Late military tuberculosis can be acute but is more likely to be subacute or chronic.At the chronic end of spectrum patients may present with failure to thrive without fever(6),with fever of unknown origin(3)or with dysfunction of one organ system (12). Rigors are unusual but have been described(13,14).The mean duration of illness reported was two months(3).
Chest radiography reveals miliary reticulonodular pattern .A sputum smear for AFB is negative in 80% of cases.The PPD test may be negative in half of cases.Anemia with leucopenia or leucocytosis with neutrophilia,DIC,elevated alkaline phosphates levels and other abnormalities in liver function tests(14).
Age>65yrs,lymphopenia,thrombocytopenia,hypoalbuminia,elevated transaminase,treatment delay are associated with increased mortality(2).
6.3 Objectives of the study:
The present study is taken up to study the patients with miliary tuberculosis prospectively, at VIMS Combined Hospitals with respect to -
1.Clinical presentation at first visit.
2.Radiographic & Laboratory findings , method of diagnosis and prognostic variables.
7 / Materials and methods:
7.1 Source of data: All patients visiting VIMS Combined Hospitals Bellary ,who fulfils the inclusion criteria for diagnosis of miliary tuberculosis will be studied prospectively.The study will be done during the study period.
7.2 Method of collection of data (including samling procedure if any)
A detailed clinical evaluation (history and examination ) and relevant radiographic,laboratory investigations will be done for all subjects as per the proforma.
Inclusion criteria:
Only those patients with following diagnostic criteria for military tuberculosis will be included in the study.
Miliary pattern on chest X-ray and one or more :
1.Sputum smear AFB positive.
2. Histopathological evidence of TB on FNAC/Bone marrow biopsy.
3. Clinical presentation and response consistant with TB.
Exclusion criteria:
1.Pregnant women.
2.Children <14 years of age
7.3 Does the study requires any investigations or interventions to be conducted on patients or other humans or animals ? If so please describe briefly.
YES The study requires the following investigations which are routinely done in our hospital. No interventions are done.
Investigations to be done :
Mandatory investigations:
1.Chest X-Ray PA view
2.Sputum for AFB
3.Complete Hemogram
4.Tuberculin skin test(PPD test)
5.Liver function tests
6. Blood Urea and serum creatinine.
Optional investigations
1.FNAC
2.Bone marrow biopsy
3.CT Scan Brain
4.CSF Analysis
5.Serum electrolytes
6. HIV
7.4 Has ethical clearance been obtained from your Institution in case of 7.3 ?
YES, Ethical clearance has been obtained from VIMS INSTITUTIONAL ETHICS COMMITTEE, Bellary.
8 / List of References:
I. Text books references :
1.Sharma, SK, Mohan, A, Sharma, A, Mitra, DK. Miliary tuberculosis: new insights into an old disease. Lancet Infect Dis 2005;
2.Maartens, G, Willcox, PA, Benatar, SR. Miliary tuberculosis: Rapid diagnosis, hematologic abnormalities, and outcome in 109 treated adults. Am J Med 1990
3.Kim, JH, Langston, AA, Gallis, HA. Miliary tuberculosis: epidemiology, clinical manifestations, diagnosis, and outcome [see comments]. Rev Infect Dis 1990
4. Gelb, AF, Leffler, C, Brewin, A, et al. Miliary tuberculosis. Am Rev Respir Dis 1973;
5. Munt, PW. Miliary tuberculosis in the chemotherapy era: with a clinical review in 69 American adults. Medicine (Baltimore) 1972;
6. Proudfoot, AT, Akhtar, AJ, Douglas, AC et al. Miliary tuberculosis in adults. Br Med J 1969;
7. BIEHL, JP. Miliary tuberculosis; a review of sixty-eight adult patients admitted to a municipal general hospital. Am Rev Tuberc 1958
8.Sydow, M, Schauer, A, Crozier, TA, Burchardi, H. Multiple organ failure in generalized disseminated tuberculosis. Respir Med 1992;
9.Ahuja, SS, Ahuja, SK, Phelps, KR, et al. Hemodynamic confirmation of septic shock in disseminated tuberculosis. Crit Care Med 1992
10.Piqueras, AR, Marruecos, L, Artigas, A, Rodriguez, C. Miliary tuberculosis and adult respiratory distress syndrome. Intensive Care Med 1987;
11.Mohan, A, Sharma, SK, Pande, JN. Acute respiratory distress syndrome (ARDS) in miliary tuberculosis: A twelve year experience. Indian J Chest Dis Allied Sci 1996;
12.Asada, Y, Hayashi, T, Sumiyoshi, A, et al. Miliary tuberculosis presenting as fever and jaundice with hepatic failure. Hum Pathol 1991;
13.Asada, Y, Hayashi, T, Sumiyoshi, A, et al. Miliary tuberculosis presenting as fever and jaundice with hepatic failure. Hum Pathol 1991;
14. Harrisons Principles of Internal Medicine 17th Edition.
9 / Signature of the candidate :
10 / Remarks of the guide :
11 / Name and Designation of :
( In Block Letters)
11.1 Guide: / DR.SHASHIBHUSHAN
Professor of Medicine,
Department of Medicine,
VIMS, Bellary.
11.2 Signature
11.3 Co – Guide, if any
11.4 Signature
11.5 Head of the Department / DR.VISHNU HYAGRIV
Professor and Head of the Department,
Department of Medicine,
VIMS, Bellary.
11.6 Signature
12 / 12.1 Remarks of Chairman and Principal
12.2 Signature