Case Study On A Patient With Pulmonary Tuberculosis

Case Study On A Patient With pneumonic TuberculosisThe case that is about to be discussed here revolves somewhat a uncomplaining diagnosed with pulmonary terabit. The enduring that was clerked, Mrs A, was a 61 year old woman. She was a Malay housewife. Her Body Mass Index value of 26.0 kg/m2 ground on her height of 1.58 m and weight of 65 kg indicated that she fell into the sound figure.The patient was admitted to the Accident Emergency mode transferred in from another hospital via an ambulance. She flummoxed symptoms such as shortness of breath(SOB) and her respiratory rate was 20 breaths per minute. She appeared pale and unclouded and her descent glucose aims were low (2.1 mmol/l) and her channel pressure values indicated she was hypertensive with a value of 152/93 mmHg. Upon physical examination, mild leg swelling was sight.Based on her past medical muniment, patient was diagnosed with pulmonary terabyte for the past 3 months, hypertension for the past 5 solar officereal days, diabetes for the past 5 years and advanced renal failure for the past 6 months.Upon enquiry, she was seen to be a non-smoker and a non alcoholic. Patient lived with her daughter.Several investigations were performed to evaluate the patients condition. A dictatorial indifference smear rivulet indicated that the patients tuberculosis was exempt active. Upon renal function assessment, creatinine clearance was calculated and a value of 5.5 ml/min indicated set 5 renal failure. Her yard and urea levels were similarly above range based on Table 1. Upon haematology assessment, her low blood sugar levels indicated hypoglycaemia and patients haemoglobin count was also low signifying anemia. breast X ray was conducted on this patient and minor lesions at the apical segments of the upper lobe were seen. This is a typical radiographic representation of patients with tuberculosis.Table 1 Results of the investigations performed research lab TestReadingsNormal range unem otionality Smear TestPositive nephritic FunctionCreatinine, CrUreaPotassium, K+912 mol/l37.8 mmol/l5.5 mmol/l44-80 mol/l1.7 8.5 mmol/l3.5 5.0 mmol/lHaematology AssessmentBlood Sugar LevelHaemoglobin2.1 mmol/l9.8 g/dl4.5 6.0 mmol/l13.5 18 g/dlTable 2 provides details about patients drug history giving information about patients drugs and their respective doses. Upon interview, patient apprised that she had not been purchasing every over the counter medications. She also has no known drug everyergy.Table 2 Drug History and their respective doses and their reading materialDrugDoseDurationIndicationRifampicin300 mg OD2 monthsAnti TBIsoniazid200 mg OD2 monthsAnti TBPyrazinamide750 mg OD2 monthsAnti TBEthambutol600 mg OD2 monthsAnti TBPyridoxine20 mg OD2 monthsTreatment of neuropathyGliclazide40 mg OD5 yearsAnti diabeticPrazosin2 mg TDS5 yearsAnti HypertensiveFurosemide80 mg OD5 yearsAnti Hypertensivenifedipine20 mg TDS5 yearsAnti HypertensiveBased on the investigations performed, the patient was diagnosed to be suffering from pulmonary tuberculosis and diabetes mellitus.Patients daily condition was monitored and appropriate management was under stooln to control the patients condition. Patients boilers suit progress is tabulated in the table 3 and the observation is recorded.Table 3 Patients clinical progress and managementdayClinical ProgressManagement1hypoglycemia = 2.1 mmol/LAFB seek positiveChest X ray performedSOBHyperkalaemia ( 5.5 mol/L)Anemic ( 9.8 g/dL)BP 152/93 mmHgStrict fluid economic consumptionIV Dextrose 10%/24 hoursRefer to chest physicianLesions at upper lobesNPO2 to resolve SOB depress on Calcium polystyrene jut out ferrous (IV) sulphateStart antihypertensivesMonitor input output2AFB test +veBlood Sugar Level = 3.0 mmol/LBP 140/90 mmHgStart TB forage (EHRZ)Continue IV Dextrose 10% Monitor Blood GlucoseContinue antihypertensives3Blood Sugar level = 3.2 mmol/Llife-threatening renal impairment ( CrCl =5.6 ml/min )Chest X ray done ti me to timeBP 130/70 mmHgContinue dextrose selectionSend patient for dialysisLesions still presentContinue antihypertensives4No SOBHypoglycaemia resolved = 5.5 mmol/LAFB +veBP 130/75 mmHgRemove adenoidal prongsStop Dextrose. Monitor blood glucoseContinue TB sustenance6K+ level in conventionalism range ( 4.5 mmol/L)Blood Sugar level = 6.0 mmol/LCrCl = 7.7 ml/minBP 130/65 mmHgStop Calcium polystyrene.Monitor blood glucoseSend patient for dialysis8Hyperglycemia = 11.1 mmol/LBP one hundred twenty-five/75 mmHgStart on InsulinDM counselling13AFB -veDXT = 10.2 mmol/LBP 120/70 mmHgTransfer out of isolationContinue insulin. Monitor blood glucoseBased on patients presentation and dissolving agents from investigations performed on day 1, patient was started on dextrose and her blood glucose levels were regularly monitored. Based on patients previous history, a phlegm smear test was ordered and two consecutive positive results resulted in the patient being referred to the chest physic ian. A chest X ray was performed and lesions in the apical segment were present. To resolve patients SOB, patient was started on Nasal Prongs at 3L/min. To control her hyperkalemia, patient was give calcium polystyrene sulphonate powder. Patient was also started on ferric sulphate infusion to help her cope with her anaemia. A strict fluid intake was imposed on patient to resolve her leg swelling and this was monitored finished an input output chart. Her blood pressure (BP) levels were also elevated and patient was given antihypertensives such as nifedipine, prazosin and furosemide to control her BP.On day 2, her sputum smear remained positive and patient was commenced on the intial material body therapy for tuberculosis which consists of isoniazid, rifampicin, pyrazinamide and ethambutol. there was not much improvement in her blood glucose levels and patient was remained on the dextrose infusion. Moving on to day 3, not much improvement was observed and out-of-pocket to patien ts deteriorating renal function, patient was sent for peritoneal dialysis.By day 4, patient could breath normally and no shortness of breath was seen. Nasal prongs were removed. When her blood glucose levels were monitored, the results indicated patient was deep down the normal range and dextrose was withheld. Blood glucose levels were still monitored to pr regular(a)t sudden drops and ontogeny in blood glucose. Her potassium levels were within range by day 6 and calcium polystyrene sulphonate was stopped and potassium levels were monitored as well.Patient suffered from a hyperglycemia episode on day 8 and the patient was given biphasic insulin to treat this condition. By this day, her BP was also in the normal range but the antihypertensives were still continued. On day 13, patient was transferred out of the isolation ward as her sputum smear test produced nix results. Patients condition for tuberculosis was still being monitored. Her blood glucose levels were still in the high range and patient was to be continued on insulin.To summarize this case, patients active tuberculosis tell should be managed well to ensure patient does not suffer from further complications that might arise in the future. Patients history was well noted and this helped in treating the patient in early stages. Adequate investigations were performed to assist the healthcare professional team to diagnose the patient and also to manage the patient. Patient was admitted for a yearn terminus but the appropriate management that was undertaken resulted in improvement in patients condition. Further care for the patient would improve the patients quality of life in the futurePathophysiology and incidenceTuberculosis (TB) is an infectious disease that has plagued many nations across the world. Based on the report by World Health Organization (WHO), almost 9.4 million cases of TB were reported 3. It is highly common of those with TB to contract the Human Immunodeficiency Virus (HIV) and a p revalence of almost 1.7 million deaths from TB among HIV-negative people was recorded around the globe 3. In the United Kingdom, an increasing trend in TB incidence has been reported and this is shown in Figure 1. In 2008, a rate of 14 per one C 000 population in the UK were reported to be suffering from TB 4. Malaysia on the other hand has a higher record of TB cases with 103 per 100 000 population being reported in 2007. Table 1 summarizes some of the data obtained from World Health Organization 3.Figure 1 Number of TB cases reported in the UK from 2000 to 2008 4Table 1 Statistics displaying number of TB cases in Malaysia in 2007 3AllIn HIV + people relative incidenceAll forms of TB (per 100 000 population)10317MortalityAll forms of TB (per 100 000 population)1218.3Multi-drug Resistant TB (MDR-TB)MDR-TB among youthful cases (%)0.1Notified relapse cases (per 100 000 pop/yr)61The bacteria that is responsible for this disease is the acid spendthrift bacilli aerobic bacterium Mycob acterium tuberculosis 1. A key feature that enables this bacterium to survive would be its unique jail cellphone skirt. Mycolic acids are linked covalently to arabinogalactan that provides a barrier to host defense mechanism. Antigens such as lipoarabinomannan present on the exterior of the cell wall facilitate the survival of the organism within macrophages 1. Tuberculosis is spread ordinarily spread within droplets containing the microorganism that are produced when an infected person coughs, sneezes or even talks 1,2. Figure 1 gives a schematic impression of the progression of the disease. The inhaled droplets are initially trapped by dendritic cells that act to expel any foreign particles out. Most mycobacteria are able to surpass this defense mechanism and travels further to the alveoli where it gets ingested by macrophages 1. It then undergoes intracellular replication that might take duration of 4 to 6 hebdomads. Cytokines are further released during this period and this attracts T lymphocytes that are involved in mediating a cell immune response. The next vivid defense system step would be the formation of granuloma that contains the activated T lymphocytes and macrophages. These nodular lesions disable further spread of the disease as the environment within restricts the growth of the bacilli and a latent period occurs 1. For less immunocompetent individuals, the granuloma will not be able to contain the bacilli and the active disease takes form 1.Figure 1 Image depicting the progress of tuberculosis 2The diagnostic tests available are summarized in Table 2. TB offer be divided to latent and active and to diagnose each different test has been recommended. For latent TB, Mantoux test can be carried out and those with positive results can be considered for QuantiFERON TB test 5. To diagnose active pulmonary TB, a chest X-ray would be taken followed by multiple sputum samples that are sent for smear test 5.Table 2 Diagnostic tests available for tub erculosis 1VariablePurposeTime required for resultsSputum smearDetect acid fast bacilliSputum cultureIdentify M tuberculosis3-6 weeks with solidmedia, 4-14 days withhigh-pressureliquid chromatographyTuberculin skin test/ MantouxDetect exposure to mycobacteria48 72 hoursQuantiFERON TB-testMeasure immune reactivity to M tuberculosis12 24 hoursChest radiographyVisualize lobar infiltrates with cavitationMinutesThe drugs that are usually used in tuberculosis are isoniazid, rifampicin, pyrazinamide and ethambutol. Rifampicin is a bactericidal agent that inhibits RNA synthesis by binding to the subunit of RNA polymerase. It can be given via oral administration and can even be distributed to the central nervous system due to its lipophilicity. Metabolism of this drug occurs in the liver and it is usually excreted in the urine. Isoniazid is a bactericidal pro-drug that inhibits ketoenoylreductase enzyme, InhA, that is responsible in synthesizing mycolic acids. Isoniazid can be administer ed orally, intramuscularly or intravenously and is acetylated in the liver and later excreted in the urine. Pyridoxine 10 mg is given concurrently to minimize this risk. Pyrazinamide is another prodrug that is activated by nicotinamidase to pyrazinoic acid. This component at low pH carries proton into the cell and collapses the proton motive force present in the mycobacterium which results in cell death. It is only bactericidal against non growing bacilli forms.. Ethambutol works by binding to arabinosyl transferase enzyme and inhibits the polymerization of the cell wall arabinan component. Table 3 gives the details of the dose and side make reported with the administration of the tuberculosis drugs.Table 3 Tuberculosis drugs with their respective doses and side effects 6,7DrugDoseSide effectsIsoniazid5 -8 mg/kg (max 300 mg)Peripheral neuropathy, hepatotoxictyRifampicin10 15 mg/kg (max 600 mg)Nausea, vomiting, thrombocytopenia, orange discolouration of urinePyrazinamide20 40 mg/ kg ( max 1.5 g 50 kg)Nausea , vomitting, hyperuricemiaEthambutol15 25 mg/kgNeuropathy, red green color blindnessEvidence based medication reviewTreatment for TuberculosisIn the past three decades, no new drugs have been discovered in fighting TB. The 4 drugs have been the gold standard in treating TB The chemotherapy regimen available for tuberculosis therapy can be divided to the initial phase and the continuation phase. In the initial phase, drugs such as rifampicin, isoniazid, pyrazinamide and ethambutol are used 6. These drugs act to decrease the amount of bacteria present and also prevent resistance from emerging from the strains. This regimen is usually for 2 months. The continuation phase would consist of drugs such as isoniazid and rifampicin.Isoniazid was the commencement drug to be introduced into combating tuberculosis back in the 1950s. Rifampicin , an antibiotic, was later added to the market and was added to the isoniazid regimen in 1967. This resulted in shortening the duration of treatment from 12 months to a 6 to 9 month treatment 9. Addition of pyrazinamide to the regimen decreased the chemotherapy duration further. Clinical studies have indicated that a pyrazinamide containing short course regimen had a sputum negative conversion rate of 70-95% in the first two months compared to the treatment without pyrazinamide 11. The relapse rates recorded from these studies also were only 4%.A clinical study conducted in East Africa compared the four 6-month daily regimens that comprised of Streptomycin, Isoniazid and Rifampicin (SHR), Streptomycin, Isoniazid and Pyrazinamide (SHZ) Streptomycin, Isoniazid and thiacetazone (SHZ) and Streptomycin and Isoniazid (SH) 10. The SHZ regimen that was the most effective amongst all the regimens and the SHR regimen had the lowest relapse rate of 2% 30 months post treatment 10. No significant difference results were obtained from the treatment regimen that was carried out for 18 months 10. This study gives an im pression of the might of the isoniazid, rifampicin and pyrazinamide regimen when used togetherIn a Poland study, the efficacy of the 4 different drug regimens containing rifampicin, isoniazid and ethambutol were assessed. During the initial phase, patients were given isoniazid 300 mg, rifampicin 600 mg and ethambutol 25 mg/kg 8. In the continuation phase the regimens given to patients comprised of rifampicin 600 mg, isoniazid 15mg/kg(Regimen A), isoniazid 15 mg/kg rifampicin 600 mg twice a week (Regimen B), Isoniazid 15kg/mg, rifampicin 600 mg ethambutol 50mg/kg once a week (Regimen C) and Isoniazid 15mg/kg, rifampicin 600 mg, ethambutol 50mg/kg twice a week (Regimen D) 8. The result of this study demonstrated that Regimen D had 47% of its patients displaying a significant change in their sputum result to a negative result compared to the other regimens. There were no significant differences in rates between all regimens by the end of the fifth month as all patients had their sputu m converted to negative. This study had the limitation of not including pyrazinamide in its regimen but it can be seen that to achieve a quicker rate of sputum negative cultures a regimen containing ethambutol could be used in the continuation phase.A trial conducted by Jindani et al. assessed the effectiveness of daily dosing of the intial phase drugs compared to the intermittent thrice every week dosing. The drugs that were assessed were isoniazid, rifampicin, pyrazinamide and ethambutol. The doses that were given to the patients were based on WHO recommendations. The outcome measured afterward 2 months had 77% of the patients with negative sputum cultures after their 2 month stint (p=0.001) 13. A similar study was conducted in Hong Kong with the difference being a 12 month follow up period. By the end of the second month, 94% of patient receiving the daily regimen had improved. 90% of those under the intermittent regimen also had improved by the second month. Over the long term follow up, much relapse cases were recorded but the values were not significant 14.Hypoglycemia TreatmentPatient was hypoglycemic upon arrival and dextrose infusion was provided to restore the patients normal blood glucose range. Two forms of treatment are usually available for hypoglycemic attacks namely glucagon and dextrose infusion. A study compared the efficacy between both the options and it was observed that both were capable of treating hypoglycemia effectively. The only disparity observed was the recovery. Patients on dextrose infusion are capable of regaining consciousness by 4 minutes compared to 6 minutes for patients that were on glucagon ( pTable 4 Results of 51 hypoglycemic patients inured with dextrose 10% and dextrose 50% 27Dextrose 10%Dextrose 50%Median time needed to attain recovery (minutes)88Median total dose administered10g ( p25g (pMedian post treatment blood sugar levels6.2 mmol/l (p=0.003)9.4 mmol/l (p=0.003)Diabetes TreatmentOral antidiabetic agents suc h as gliclazide in the patients drug history would not be sufficient for her to have proper control over her glycemic levels. It was reported that tuberculosis affects the hormonal secretion by interfering with endocrinal organs such as pancreas 15. Rifampicin reduces the concentration of gliclazide by inducing liver microsomal enzymes CYP 2C9 that rapidly eliminates gliclazide from circulating in the system 15,16,17. In a study by Park et al., patients given with 80 mg gliclazide had the concentration of the drug present in the body reduced by 70% on day 7. The excretory product half life of the drug also increase 3 fold 17. All these contribute to the inability of the sulfonyluea to reduce the glucose levels in this patient.According to the stepwise address in NICE guide credit lines, the next step to manage this patient would be to start the insulin regimen18. The type of insulin that was given was biphasic Mixtard insulin line of latitude that consists of a short acting analo gue and also a long acting analogue. P.V. Rao reported that, due to the insulin resistance present in patients started on anti Tb therapy, the doses of insulin needed to manage these patients increase 15. It is well proven that insulin can achieve better HbA1c levels as a clinical trial by United Kingdom Prospective Diabetes Study (UKPDS) revealed that after 9 years monotherapy with insulin, 28% of patients achieved HbA1c levels downstairs 7% and 42% patients achieved fasting plasma glucose levels below 7.8 mmol/l 19.Hypertension TreatmentPatient was suffering from Stage 5 renal disease and the target for blood pressure in this patient would be 125/75 mm Hg 20. First line treatment for this patient would be loop diuretic, furosemide 20. They act by inhibiting the Na+/K+/2Cl- transporter on the ascending limb of loop of Henle which results in natriuresis and hence a fall in blood volume 21. This loop diuretic also performs its vasodilator actions via prostaglandin (PGE2 and prostacy clin) formation. This results in an increased blood flow in the medulla 21. In accordance to SIGN guidelines as well, long acting dihyrdopyridines such as nifedipine and blockers can be added as supplementary therapy 20. Nifedipine, a calcium antagonist acts by causing vasodilatation due to reduction in peripheral resistance. blockers such as prazosin block 1 receptors and this results in vasodilation.A study by Vadasz displayed that Furosemide doses at 40 mg did not display any significant changes in systolic blood pressure. However, when the dose was increased to 60 mg, there was a significant reduction in blood pressure 21,22. A combined dose of 40 mg and 60 mg were effective in reducing the diastolic blood pressure. Based on this take the stand, it is clear that furosemide on its own is not capable of decreasing blood pressure. When nifedipine was combined with diuretics it was observed that a statistically significant lower risk of cardiovascular events was observed compared to the non-statistically significant difference that was noted with nifedipine monotherapy 22. In another study by Psaty et al, nifedipine did not demonstrate an increase of risk in myocardial infarction compared to the other calcium channel blockers 25.Prazosins efficacy in lowering blood pressure was studied and the lowest effective dose that is capable of reducing blood pressure was noted to be 10mg 26. Doses below 10 mg per day did not significantly reduce the blood pressure compared to the placebo arm.Treatment of AnaemiaPatient had very low haemoglobin levels and this was indicative mood of anaemia. NICE guidelines have recommended that in order to manage anemia, patients are usually given eryhtropoetin stimulating agents and also iron supplements to help produce haemoglobin 23. There has been no evidence in the use of iron supplements in patients with chronic kidney disease prior to treatment with erythropoietin. But it is recommended that the erythropoietin therapy should not be commenced in conditions of thoroughgoing(a) iron absence 23. In some conditions, where patients were in Stage 5 renal failure also diagnosed with other co-morbidities, treatment with erythropoietin stimulating agents is decided based on clinical judgment by the professional team if the patient were to benefit from the treatment 23.Treatment of HyperkalaemiaPatient was suffering from mild hyperkalemia and it was necessary that this was be treated before it progresses to severe hyperkalemia that might lead to adverse events such as cardiac arrest. A study compared the effectiveness between sodium polystyrene sulfonate and calcium polysterene sulfonate and it is noted that treatement with sodium increases sodium concentration in the body and this escalates the risk of hypertension 24. Treatment with calcium polystyrene sulfonate resulted in 50% decrease in potassium content and an additional advantage of increase in calcium concentration was observed as well 24.ConclusionBased on all the evidence provided for the patients condition, it is clear that the guidelines were adhered in treating the patients individual disease with some minor differences. Tuberculosis treatment for the initial phase was extended for more than 2 months due to the positive result obtained from sputum smear. Patient eventually achieved negative sputum smear and the patient was to be monitored before the patient was commenced on the continuous phase drugs. powerful treatment was undertaken to treat patients hypoglycemia condition, and based on the evidence gathered, dextrose 10% is the suitable treatment option for the patient. The antihypertensive regimen that was chosen was due to the patients renal failure. Nifedipine, prazosin and furosemide collectively controlled the blood pressure of the patient. Ferrous sulphate was chosen as her treatment compared to erythropoietin and this was based on the doctors clinical judgement. Her hyperkalemia which was treated with calcium sulfona te did benefit the patient as her potassium levels were within the normal range at the end of the treatment.PATIENT MEDICATION PROFILEPATIENT detailsNameMrs AConsultantGeneral PractitionerAddressKuala LumpurGenderFemaleWeight65Height158Community PharmacistDate of return (Age)61Known SensitivitiesNoneSocial HistoryNon smoker Non AlcoholicPATIENT HOSPITAL STAYPresenting complaint in primary care / savvy for admissionAdmission dateAprilLow Sugar Level 2.1 mmol/LDischarge Date Discharged toNot KnownShortness of breath pertinent MEDICAL HISTORYrelevant DRUG HISTORYDateProblem DescriptionDateMedicationCommentsFebPulmonary TuberculosisFebRifampicin6 monthsAdvanced Renal FailureFebIsoniazid5 yearsHypertensionFebPyrazinamide5 yearsDiabetes MellitusFebEthambutolFebPyridoxine6 monthsPrazosin6 monthsNifedipine6 monthsFurosemideGliclazideRELEVANT NON DRUG TREATMENTPeritoneal DialysisPrescribed MedicationStartStopClinical/Laboratory TestsDate Result1RifampicinDay 1Sputum Smear TestDay 1Posit ive2IsoniazidDay 1CreatinineDay 1912 mol3PyrazinamideDay 1UreaDay 137.8 mmol/l4EthambutolDay 1PotassiumDay 15.5 mmol/l5PyridoxineDay 1Blood GlucoseDay 12.1 mmol/l6PrazosinDay 1Blood PressureDay 1152/937NifedipineDay 1HaemoglobinDay 19.8 g/dl8FurosemideDay 1Chest XrayDay 1Lesions in the apical segment9Dextrose SolutionDay 1Day 4Blood GlucoseDay 811.1 mmol/l10Ferrous sulphateDay 1Sputum SmearDay 13Negative11Calcium polystyrene sulphate powderDay 1Day 612Insulin MixtardDay 8CLINCIAL MANAGEMENTDiagnosisPharmaceutical NeedPulmonary TuberculosisContinue patient on intial phase drugsHypoglycemiaStart patient on dextroseHypertensionContinue antihypertensive treatmentHyperkalaemiaStart calcium polystyrene sulphonate powderAnaemiaStart ferrous sulphateAdvanced Renal FailureSend patient for peritoneal dialysisPHARMACEUTICAL CARE PLANDateCare Issue/Desired Output workOutputSub therapeutic dosesFor Anti TB drugsDiscussed with the pharmacist and patients diabetic condition was the reason for the dose regimenDoses were not changedDrug sensitivity examenwas not performedPatient is diabetic and is more susceptible for MDR-TBNo test was performedManagement of patients compliance towards anti tuberculosis drugs-Patient might be hospitalised for a long period of time due to renal failure-DOTS scheme to be implemented upon discharge-Adequate patient education on the importance of completing the regimen is importantHospitalisation or DOTS schemeRenal failureEthambutol excreted by kidney. Suggest change of medication to 2 Isoniazid + Rifampicin + Pyrazinamide-If treatment continued, monitoring all-important(a)Continue treatment as before and patient being monitoredAFB testAnother 2 samples should be taken for AFB tests before switching to the continuous phaseAction yet to be takenMonitor drug toxicityLab investigations on full blood count, liver function, blood serum uric acid, serum bilirubin, should be done to ensure no toxicity Eye examination for ethambutol side effectsSchedu led appointments for patientEducation on side effects of drugsTo inform patient about anti Tb drugs side effect and advise patient not to stop the drug and side effects can be controlled ( PZA and arthralgia )Counseling by pharm