PRESENTED BY: JI NAOMI JO ANASTACIO & MARIA MARISSA GOLLA MAY 13, 2011 TB DOTS CENTER OF DLSHSI CASE 2 PTB Category IV MDR-TB
Nov 26, 2014
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
History of present Illness
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.
History of present Illness
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.
History of present Illness
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
History of present Illness
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.
History of present Illness
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.
History of present Illness
After a few months of recurrent productive cough, she decided to seek consultation.
She had herself enrolled in the MDR treatment program in DLSHSI
History of present Illness
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.
Personal and Social History
(-) 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.
Personal and Social History
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
Regional Examination
• 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
Regional Examination
• Ears:
• Cerumen scanty• No masses ulcerations or tenderness
on periauricular and pinna.
• Weber: midline• Rinne: air conduction > bone
conduction• Schwabach: not assessed
Regional Examination
• 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
Regional Examination
• Neck:
• Trachea midline• Neck supple• Thyroid isthmus palpable• (-) nodules palpable• Thyroid prominence moves with
deglutition
Regional Examination
• Nose:
• Symmetrical external nose• Midline Nasal Septum• Equal size and shape of the external
nares • Lymph Nodes:
• (-) palpable cervical lymph nodes
Regional Examination
• 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
Regional Examination
• 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
Regional Examination
Abdominal Exam:
• Inspection: inverted umbilicus, (+) striae gravidarum
• Auscultation: (-) assessed
• Palpation: soft, (-) abdominal guarding upon
touch• Percussion: (-) assessed
Regional Examination
Regional Examination
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.
Regional Examination
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
Regional Examination
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.
5 Components of DOTS
2. Diagnosis by quality ensured sputum-smear microscopy.
Chest symptomatics examined this way helps to reliably find infectious patients.
5 Components of DOTS
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.
5 Components of DOTS
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 Components of DOTS
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:
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
The six additional essential elements in the new strategy are:
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
The six additional essential elements in the new strategy are:
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!