Overview Case Presentation Diagnosis Treatment – Induction phase Treatment – Continuation Phase Treatment Monitoring Assessment of Transmission Outcome.

Overview

• Case Presentation• Diagnosis• Treatment – Induction phase• Treatment – Continuation Phase• Treatment Monitoring• Assessment of Transmission• Outcome• References

Case Presentation

18 y.o Hispanic female presents with 2 day hx of postpartum normal vaginal delivery and abnormal CXR.

No cough, mild fever, no unexpected weight loss

PPD 25 mm by history.

Case Presentation - 2

• PMH: Pt is G1P1, otherwise unremarkable

• FMH: Mother alive and well living in El Salvador; father unknown health status. 1 sib living in El Salvador A/W.

• Social: Lives alone in bedroom room apt in 3-family house. Rents apartment.Works as babysitter. Marital status is single though does have BF. Medical coverage is Medicaid. Immigration status undocumented

Case Presentation - 3

• Meds: Tylenol 1gm PRN pain

• Substance Abuse: Denies smoking, ETOH, and IVDU

• Allergies: none known

Physical Exam Pt sitting in bed in precaution room. In NAD, breathing

comfortably.

VS: WT 108 lbs, T 99.5 (F) HR 98-Pulse Reg--Resp18 BP 104/60

Resp: Symmetric chest wall motion. Neg for retractions or use of accessory muscles. No dullness noted on percussion. No palpable tenderness on palpation. BS with normal air movement, neg for rales and wheezes

Labs

• Hematocrit 40.8• MCV 84• WBC 6.0• Platelets 453• AST 22• Alk Phos 180

• Creat 0.6• Serum Ca 9.9

• PCO2 36.9

• O2 sat 100

• Sputum smear – x3 pending

Chest Radiograph and CT

• CXR suggestive of cavity lesion in LUL and RUL otherwise heart normal size. Diaphragm slightly elevated secondary to heightend uteral placement. Film suggestive of active process of pulmonary tuberculosis.

• CT confirms cavity opacity in RUL

Differential Diagnosis

• Tuberculosis

• Bacterial Pneumonia

• Carcinoma

Diagnosis

• CXR abnormal but not necessarily diagnostic.• Sputum smears may be – or + depending on the

level of infectiousness• May need bronchoscopy with bronchial washings

or lavage• Biopsy may be warranted to confirm

Diagnosis - 2

• Culture is gold standard but takes 3-6 weeks to grow in solid media, 12-28 days with liquid media

• Smear is strongly suggestive but could be due to nontuberculous mycobacteria

• Nucleic acid amplification can rule TB in but not out

• TB skin test not sensitive or specific• In-vitro interferon gamma-based tests similar to

TB skin test

Case Presentation - 4

• Smears: 2+/1+/neg

• HIV serology - negative

Treatment - Induction Phase

Because of the relatively high proportion of adult patients with tuberculosis caused by organisms that are resistant to isoniazid, four drugs are used in the induction phase for the 6-month regimen to be maximally effective.

– Isoniazid 5-10 mg/kg day

– Ethambutol 15-20 mg/kg day

– Rifampin 10 mg/kg day

– Pyrazinamide 20-25 mg/kg/day

Case Presentation - 5

Our patient: Daily therapy with

– Isoniazid 300 mg p.o. (1 pill)– Ethambutol 800 mg p.o. (2 pills)– Rifampin 600 mg p.o. (2 pills)– Pyrazinamide 1000 mg p.o. (2 pills)

Other issues: intermittent regimens, combination pills

Management

• DOT- directly observed therapy

• Self- Administered therapy

• Case Management

• Mandatory Confinement?

Assessment of Transmission

• How long to isolate the patient?

• Source case?

• Transmission to household contacts?

• Transmission in the workplace?

Case Presentation - 6

Initial sputum culture results from our patient:

“M. tuberculosis”

Isoniazid Sensitive

Ethambutol Sensitive

Rifampin Sensitive

Pyrazinamide Sensitive

Treatment – Continuation PhaseBecause of the relatively small number of organisms remaining after 2 months of intensive phase treatment, most patients with tuberculosis can be placed on continuation phase treatment after 8 weeks of induction.

Induction Phase usually lasts 4 months (18 weeks) and can be give daily or twice weekly – Isoniazid 5-10 mg/kg day– Rifampin 10 mg/kg day

Treatment Monitoring• Visit Schedule:

q 2wk during inductionq month during continuation

• Adherence monitoring • Efficacy monitoring

Weight, temperature2 month and 6 month filmsmonthly smear and culture

• Toxicity monitoring Skin rash, LFTs, Nausea, Color vision

Case Presentation - 7

Sputum culture results from our patient after 2 months of induction phase therapy:

“No Growth”

Outcome

• Patient received induction and continuation therapy (2+4=6 months) and was cured

• All household members received TST and chest radiograph if TST+. There we no active cases, but the 2 persons with TST+ received INH for treatment of LTBI

• Baby received INH until follow-up TST 3months later was negative

References

1. Horsburgh CR, Burman WJ. Tuberculosis Treatment: Theory and Practice. In: Therapy of Infectious Diseases, ed Baddour L, Gorbach SL. Philadelphia PA; Saunders, 2003: 529-46.

2. Centers for Disease Control and Prevention. Treatment of Tuberculosis, American Thoracic Society, CDC, and Infectious Diseases Society of America. MMWR 2003;52(no. RR-11):1-80.

3. Horsburgh CR, Feldman S, Ridzon R. Quality standards for the treatment of tuberculosis. Clin Infect Dis 2000;31:633-9.