Case 2 Tbdots-mdr

PRESENTED BY:JI NAOMI JO ANASTACIO & MARIA MARISSA

GOLLA MAY 13, 2011

TB DOTS CENTER OF DLSHSI

CASE 2PTB Category IV

MDR-TB

CLINICAL HISTORY

GENERAL DATA

N.J. female39 years oldMarried Filipino Roman Catholic Born on October 8, 1972 , born and currently

residing in Rosario, Cavite Currently enrolled for Category IV treatment on

July 15, 2010 at TB DOTS of DLSHSI.

Chief Complaint

No subjective complaint at time of consult

History of present Illness

Patient was apparently well until 16 years PTC when she experienced recurrent non-productive cough of more than 2 weeks, fever and weight loss.

Diagnosed by a private physician to have PTB,

Category I .

Underwent treatment for Category I. She was given Amoxicillin, Rifampicin, Ethambutol and Pyrazinamide for 6 months


Declared cured after completion of treatment

Probable sources of infection were her grandfather, father and three other siblings who were also diagnosed with PTB but who did not undergo proper treatment.


Four years prior to consultation, patient presented with signs and symptoms of recurrent non-productive cough, fever and general body weakness.

She had 3x sputum smear (-) and (+) chest x-ray

She was enrolled as Category II treatment of 8 months duration with 4 in 1 medications and Streptomycin injection for 56 days.


Treatment was completed and she was declared to have treatment completed.

She was exposed again when she took care of her father and siblings who were confined in a hospital due to progressive TB


In late 2008 or early 2009 she had on and off cough, back pain and general body weakness.

She consulted a private physician and was diagnosed to have PTB, Category III and underwent an 8-month treatment of Fixcom 4.

After treatment she was considered cured.


Patient experienced again recurrent cough after 5 months of treatment.

She either self-medicated with a mucolytic medications like carbocisteine for one week or have antibiotics prescribed by physicians like amoxicillin or ampicillin

Cough relief was only temporary and patient also had signs and symptoms of back pain, loss of appetite, general body weakness and fever.


After a few months of recurrent productive cough, she decided to seek consultation.

She had herself enrolled in the MDR treatment program in DLSHSI


On the day of consultation patient had no subjective complaints.

She is compliant to her medications and had not noticed any side effects of drugs taken.

Past Medical History

(-) previous accidents, injuries and diseases

(-) diabetes, hypertension, goiter, history of psychiatric illnesses, renal and cardiac problems

(+) hospitalized thrice when she gave birth to her three

children via normal vaginal delivery.

(+) Patient had irregular intake of ferrous sulfate, one tablet, OD and unrecalled brand name of imported multivitamins from Australia and supplements with minerals and iron, one tablet, OD.

Obstetric and Gynecologic History

G3P3 (3-0-0-3) Menarche: 14 years Cycle is regular lasting for 3 to 5 daysConsumes 2-3 napkins, not really full, per day(-) history of amenorrhea and dysmenorrhea(-) STDs, dyspareunia (+) withdrawal method(+) previous intake of OCPs for at least one

year in between pregnancies.

Family History

(-) Diabetes Mellitus

(+) Asthma - sibling

(-) Hypertension

(-) Allergies

(+) Cancer – aunt (distant relative)

Family History

(+) Tuberculosis - mother (cured), father (†), of 10 siblings three siblings (†) & 4 were

treated

(+) Cardiac problems - mother (cardiomegaly)

(-) Pulmonary problems

(+) renal problems – aunt (distant relative)

Personal and Social History

born in and is presently residing in Rosario, Cavite

lives with her husband and three children in a small bungalow type house made of concrete

currently self- employed

previously employed as a cashier at the fish port.


(-) smoker, (-) alcoholic drinker, (-) drug user

Water source is non-boiled water from the faucet, supplied by NAWASA

The family’s diet consists mostly of vegetables and fish but is in general not restricted.


Sanitary toilet with manual flushing.

Garbage is collected once a week (-) pets

Review of Systems

(+) weight gain

(+) blurring of vision

(-) fever

(-) rashes

(-) headache

(-) tinnitus

(-) epistaxis

(-) difficulty swallowing

(-) hemoptysis

(-) dyspnea

(+) some difficulty of breathing when walking (associated with weather)

(-)chest pressure

(-) dysphagia

(-) abdominal pain

(-) any bowel habits change

(-) nocturia

(-)polyuria

(-) joint pain

(-) anxiety

PHYSICAL EXAMINATION

General Survey

Alert, awake, oriented to three spheres

Ambulant

(-) cardiopulmonary distress

Appears younger than her stated chronological age of 39.

VITAL SIGNS

BP: 131/85mmHg after 30 mins: 120/82mmHg

HR: 105 beats/minutePR: 98 beats/minuteRR: 18 cycles/minuteTemperature: 37°C

• INTEGUMENT:

• (-) pallor, (-) jaundice, (-) erythema, (-) edema,

• (-) masses, (-) erythema• (-) scars • (+) good skin turgor• (+) 0.5 x 0.5 brown nevus at

right eyebrow

Regional Examination

• HEAD & NECK:

• normocephalic

• (-) masses, tenderness, alopecia,

• (+) soft texture of hair


• Eyes:

• Normal relationship of eyelids to the eyeballs

• Visual Acuity: Jaeger: OD: 20/40 +1; OS: 20/30 -1

• Funduscopy: (-) assessed • (-) Ptosis• Tonometry: soft• Clear and pinkish conjunctiva• Full EOM movements• Direct & consensual papillary reflex: 3 to 2

mm


• Ears:

• Cerumen scanty• No masses ulcerations or tenderness

on periauricular and pinna.

• Weber: midline• Rinne: air conduction > bone

conduction• Schwabach: not assessed


• Mouth:

• (-) Lesions, Masses• Tongue in midline, (-) lesions • Smooth and pink mucosa• Symmetrical uvula with left sided

leaning• 3 missing molar teeth, recent tooth

extraction• (+) caries


• Neck:

• Trachea midline• Neck supple• Thyroid isthmus palpable• (-) nodules palpable• Thyroid prominence moves with

deglutition


• Nose:

• Symmetrical external nose• Midline Nasal Septum• Equal size and shape of the external

nares • Lymph Nodes:

• (-) palpable cervical lymph nodes


• Chest and Lungs

• Inspection: not assessed• Palpation: not assessed• Percussion: not assessed• Auscultation:

(+) soft wheezes during inspiration breath sounds at both upper-middle lung

fields,

(-)crackles, rhonchi, stridor


• CVS

• Inspection: not assessed• Palpation: not assessed• Percussion: not assessed• Auscultation:

normal rate, regular rhythm, S1 louder S2 at apex, S2 louder than S1 at the base, no S3, S4, no murmurs


Abdominal Exam:

• Inspection: inverted umbilicus, (+) striae gravidarum

• Auscultation: (-) assessed

• Palpation: soft, (-) abdominal guarding upon

touch• Percussion: (-) assessed



Extremities

Good range of motion on all joints (-) evidence of swelling or deformity (-) nodes on hands Peripheral pulses full and equal (-) tenderness (-) cyanosis, clubbing, bipedal edema

Neurological E xamination

Mental status:

alert, conscious, coherent

(-) cardio-respiratory distress

oriented to time, person and place

appears younger than her chronological age of 39 years.


Cranial Nerves:

CN I - not assessedCN II - (+) direct & consensual light reflexCN III, IV, VI - full & equal EOMsCN V – not assessed CN VII - full facial expressionCN VIII - good gross hearing CN IX, X – Good speech with no nasal twangCN XI - good shoulder shrugCN XII -Tongue in Midline, (-) Atrophy of the tongue


Motor:

- (-) tremors nor fasiculations- Deep tendon: not assessed

Sensory:

- Patient sense of touch, pain, vibration, position preserved

Cerebellar: not assessed

Meningeals: not assessed

Higher Cerebral: not assessed

ESSENTIALLY NORMAL FINDINGS,SUSPECTED PARENCHYMAL LUNG DAMAGE

ASSESSMENT

Tuberculosis (TB) is a bacterial infection caused by Mycobacterium tuberculosis.

The bacteria usually attack the lungs, but they can also damage other parts of the body.

TB spreads through the air when a person with TB of the lungs or throat coughs, sneezes or talks.

One is more likely to get TB if the person has a weak immune system.

PTB Category IV MDR-TB

Symptoms of TB in the lungs include:

Cough for two or more weeks, with or without:

FeverChest and/or back pains not referable to any

MS disorderHemoptysis or recurrent blood-streaked

sputumSignificant weight lossOther symptoms, such as sweating, fatigue,

body malaise, shortness of breath

If not treated properly, TB can be deadly.

One can usually cure active TB by taking several medicines for a long period of time.

People with latent TB can take medicine so that they do not develop active TB.

What is DOTS?

Tuberculosis is completely curable through short-course chemotherapy.

Treating TB cases who are sputum-smear positive (and who can therefore spread the disease to others) at the source, it is the most effective means of eliminating TB from a population.

What is DOTS?

DOTS or Directly Observed Treatment Short course is the internationally recommended strategy for TB control that has been recognized as a highly efficient and cost-effective strategy.

DOTS comprises five components:

5 Components of DOTS

1. Sustained political and financial committment.

TB can be cured and the epidemic reversed if adequate resources and administrative support for TB control are provided.


2. Diagnosis by quality ensured sputum-smear microscopy.

Chest symptomatics examined this way helps to reliably find infectious patients.


3. Standardized short-course anti-TB treatment (SCC) given under direct and supportive observation (DOT).

Helps to ensure the

right drugs are taken at the right time for the full duration of treatment.


4. A regular, uninterrupted supply of high quality anti-TB drugs.

Ensures that a credible national TB program does not have to turn anyone away.


5. Standardized recording and reporting

Helps to keep track of each individual patient and to monitor overall program performance.

The new global Stop TB Strategy builds on the DOTS strategy, which remains the fundamental basis for TB control.

The six additional essential elements in the new strategy are:


1. Sustaining, improving and accelerating quality DOTS expansion

2. Addressing TB-HIV, MDR-TB and other special challenges

TB/HIV collaborative interventions DOTS-Plus for MDR-TB Reaching vulnerable, high risk groups


3. Contributing to health system strengthening

TB control innovations that strengthen health systems Adaptation of innovations from other TB control

programs Practical Approach to Lung Health

4. Engaging all care providers

Public-private partnerships Ensuring equitable access to international standards of

care for TB to all


5. Empowering patients and communities

Advocacy, communication and social mobilization Community-based TB care

6. Enabling and promoting research

Program-based operational research Development of new diagnostics, drugs and vaccines

Pathogenesis of PTB

AFB reach the alveoli

Multiply and lyse the macrophag

es

Disseminate via

regional lymph nodes

Not contained by macrophages

Pathogenesis of PTB

Delayed-Type hypersensitivity destroys nonactivated macrophages

Granuloma formation at site of primary lesion and sites of dissemination

Lesions heal by fibrosis or undergo further evolution

Pathogenesis of PTB

Alveolar macrophages secrete cytokines

Manifestation of disease, granuloma formation, mycobacterial killing

Classification: Pulmonary TB (PTB)Smear Positive

Type: Relapse

Treatment Regimen: Regimen IV

CATEGORY IV

Given as treatment for:

Chronic (still smear positive after supervised re-treatment)

CATEGORY IV

Drugs used in Treatment:

Kanamycin – 1g ODOfloxacin – 2 tabs (400 mg)Prothionamide – 3 tabsCycloserine – 3 tabs

CATEGORY IV

5 consecutive (-) sputum smear4 consecutive (-) cultureCXR Jan 12, 2011 compared with CXR July 5,

2010:Diminution of prev. described fibrohazed

densities in both lung fields, decrease in sizes of both previously described cavitations

Stable physical condition(-) ADR(+) Weight gain from 53.5 kg to 61.7 kgCurrently in the Continuation Phase

CATEGORY IV

Strains of M. tuberculosis resistant to both isoniazid and rifampicin with or without resistance to other drugs

Requires treatment with second-line drugs

CATEGORY IV

Second-line drugs are not suitable for short course treatment

Require prolonged treatment with drugs that are less effective and more toxic

Choice of drugs

Add at least 3 new drugs. Preferably have an aminoglycoside

(Streptomycin / Kanamycin / Amikacin/ Capreomycin) One fluoroquinolone

(Ofloxacin / Ciprofloxacin / Levofloxacin). Ethionamide or Prothionamide Any one of the following:

Cycloserine, PAS, Clofazimine or Moxifloxacin

First Line Drugs Second Line Drugs

Essential Other Old New

IsoniazidRifampicin

PyrazinamideEthambutolStreptomycin

EthionamideCycloserineCapreomycinAmikacinKanamycinPASThiocetazone

Quinolones

Macrolides

ClofazimineAmoxicillin &Clavulanic acid

Ofloxacin CiprofloxacinSparfloxacin

Clarithromycin

New rifamycins Rifabutin Rifapentine

http://www.hivandhepatitis.com/recent/lipo/tb.html

http://www.niaid.nih.gov/SiteCollectionImages/topics/tuberculosis/tb2.jpg

Global Situation of MDR-TB

MDR-TB is present in five continents, a third of the countries surveyed having levels above 2% among new patients.

In Latvia 30% of all patients for treatment had MDR-TB.

Russia when surveyed had 5% with MDR-TB. In the Dominican Republic, 10% had MDR-TB. In Africa, Ivory Coast had also emergence of

MDR-TB.Preliminary reports from Asia (India and China)

show high levels of drug resistance as well. In the State of Delhi, India, 13% of all TB patients had MDR-TB.

Philippine Setting

Data from Makati Medical Center DOTS Clinic (2003) indicates high incidence of MDR TB.

Approximately 30% of isolates tested were resistant to all five first line drugs, 39.4% to four, 16.8% to three, 12.1% to two.

Fluoroquinolone resistance was noted in 40.9% isolates.

Epidemiology

MDR-TB afflicts countries with poor health infrastructure

Also likely to break out in industrialized countries

During the late 1980s and early 1990s outbreaks of MDR-TB in North America and Europe killed over 80% of those who contracted it.

The major TB outbreak in New York in the early 1990s was primarily a MDR-TB epidemic, with one in ten cases being drug-resistant.

Key factors for the management of MDR TB:

Diagnosis of MDR TB Reliable susceptibility testing Prevention of MDR TB In new cases In old cases Designing an appropriate regimen Essential Drugs Second line Drugs Cross resistance Ranking with respect to Efficacy, Cost, Tolerance Reliable drug supply of second line drugs

Principles to be followed while treating MDR-TB patients:

Starting MDR-TB drug regimen Check the history of the patient carefully for previous treatment regimens. Check whether all drugs in the previous regimens have been taken and for

how long. Determine the status of sputum smears at all junctures (in terms of

positivity ,conversions and sensitivities – if available).

Confirmed/ Strongly suspect MDR TB

Counsel the Patient and family members

Send Tissue / sputum for culture and sensitivity testing (if available)

Start MDR Regimen

Treatment Plan:

Use at least 4 – 5 drugs as long as these include 2 drugs not previously taken.

Do not add a single drug to a failing regimen to avoid resistance to the new drug.

Consider continuing with isoniazid and rifampicin (most bactericidal) despite resistance.

Either pyrazinamide or ethambutol may be discontinued.

Treatment Plan:

Continue treatment for 18 months more from the time the patient’s sputum becomes AFB and culture negative.

Get cultures to check sensitivity of TB organism.

Treatment Plan:

Consider surgery for unilateral cavitary lesions in whom MDR-TB is established in the laboratory.

Prevention

1. Vaccination

Attenuated strain of M. bovis, bacille Calmette-Guerin (BCG)

Protects infants and young children below 5 years of age

Efficacy unclear in other situations

Prevention

2. Treatment of latent infection

Candidates for chemoprophylaxis are identified by TST (Tuberculin Skin Testing)

(+) – determined by reaction size and risk group

If (+), consider drug treatment

Reference:

• http://www.nlm.nih.gov/medlineplus/tuberculosis.htl

• www.who.int/topics/tuberculosis• www.philhealth.gov.ph/providers/download/

ComprehensiveUnifiedPolicy_TB.pdf · PDF file• http://www.tbdots.com/site/en/

doctor_section_tb_mdr.html• http://www.hivandhepatitis.com/recent/lipo/

tb.html

Reference:

• http://www.heartlandntbc.org/images/full_mdr_tb_care_plan.jpg

• http://www.niaid.nih.gov/SiteCollectionImages/topics/tuberculosis/tb2.jpg

• Harrison’s Principles of Internal Medicine 17th ed. 2009

• Manual of Procedures for the National Tuberculosis Control Program 4th ed. 2005

Ong, W. et. al. Expanded Medicine Blue Book 3rd edition 2009

Thank you!

Case 2 Tbdots-mdr

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