Transcript 3rd CPG on Management of Tuberculosis

Case Discussion 1 TREATMENT OF TB
IN ADULTS
by
Dr. Razul Md Nazri Md Kassim
1
History
• 30 year-old Malay gentleman, smoker
• Active IVDU - last injection was a week prior to
admission
• 1 week history of fever, chills & rigors,
associated with productive cough, LOA & LOW
2
History (cont.)
• 2 days before admission, patient had
headache & his family members noticed that
his speech was incoherent & he was talking
irrelevantly
• He denied h/o contact with TB patients, no
palpitations, no shortness of breath
3
History (cont.)
• Clinically, patient was conscious & alert. However, he
took time answering questions.
• Mild pallor, no lymphadenopathy
• Weight: 45 kg, height: 165 cm
• BP: 110/70 mm Hg, PR: 90/min, T: 37.6C, RR: 20
• Lungs: Clear
• CVS: S1 S2, no murmurs
• Neurology: Cranial nerves grossly intact,
Power of left side 3/5, right side 4/5
4
Q1
• List the differential diagnoses.
• What are the investigations would you
like to order?
5
A1
• List the differential diagnoses.
1. Infective endocarditis
2. Brain abscess & meningitis
3. Opportunistic infections
• What are the investigations would you like
to perform?
1.
2.
3.
4.
CXR
Blood culture & sensitivity
Echocardiography
CT Brain
6
Q2
• Interpret the
chest
radiograph.
7
A2
• Interpret the chest radiograph.
– Right upper zone opacities with air
bronchogram
Reduced lung volume
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Management of Tuberculosis
(3rd Edition)
9
Q3
• Interpret the CT brain findings.
10
A3
• Interpret the CT brain findings.
1.
2.
3.
4.
5.
Subdural effusion
Brain edema
Tuberculoma
Midline shift
Infarct
Space occupying lesion
11
Initial Investigations
BUSE
Na
140mmol/L
Other Ix
K
3.5mmol/L
Cl
102mmol/L
Urea
8mmol/L
FBC
TWBC
Hb
Platelet
Creat
80mmol/L
LFT
5.14 x 103 T. Protein
10.2 g/dL Albumin
43 x 103
Bilirubin
ALT
ALP
60 g/L
34g/L
35 IU/L
158 U/L
655 U/L
Sputum AFB -ve
12
Management of Tuberculosis
(3rd Edition)
13
Investigations
Investigation
HIV
Hepatitis C
Random Blood Glucose
Results
Non-reactive
Reactive
4.5 mmol/l
14
Management of Tuberculosis
(3rd Edition)
15
Investigations (cont.)
• Echocardiography: Normal,
no vegetation
• Blood C&S: NO GROWTH
Q4. What is your diagnosis?
16
A4
Smear negative PTB with tuberculous meningitis
(Stage II)
17
Q5
• How to treat this patient?
18
A5
AIM
1. Cure
2. Reduce transmission
No
Post-exposure
history
Site of
infection
PTB
Meningitis
Heath education to the patient
& family members/carers
DOT/S
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Management of Tuberculosis
(3rd Edition)
20
Dosages of First-line AntiTB Drugs
21
EPTB
Duration of
treatment
Steroids
22
Patient Had Been Started With:
Isoniazid: 300 mg OD
Rifampicin: 450 mg OD
+
Dexamethasone
12 mg OD
Ethambutol: 1000 mg OD
Pyrazinamide: 1250 mg OD
23
Q6
• What forms need to be filled-up?
24
A6
• TBIS format
Activity
Accessory
Registration
Report
PATIENT
MANAGEMENT
AND CONTACT
TBIS 10A-1,
10A-2,
10B,10C,…..
TBIS 101A,
TBIS 101B
TBIS 201A,
201B,…..
LABORATORY
TBIS 20A,
20B,,,,,,
TBIS 102A,
102B
TBIS 202A,…..
BCG
TBIS 30A, 30B TBIS 103A
TBIS 203A,…..
25
TBIS FORM
TB Registry
Notification TB
TBIS 10B-2
TBIS 10B-1
TBIS 10A-1
TBIS 10E
TBIS 10 I
26
10A-1 / 10B-1
27
10B-2 / 10C-1
28
10G-2 / 10E
29
10F / 10G
30
10J / Notification
31
32
33
Investigations (cont.)
FBC
TWBC
Hb
Platelet
22/1/13 26/1/13 28/1/13 30/1/13 1/2/13 5/2/13
5.14
10.2
43
37
5.07
10.6
14
3.50
8.8
14
2.62
7.6
47
2.52
6.8
91
34
Investigations (cont.)
LFT
22/1/13 26/1/13 28/1/13 30/1/13
1/2/13
3/2/13
T.protein
60
52
50
43
44
46
Albumin
34
20
18
17
19
20
Bilirubin
35
169
91
61
ALT
158
130
120
80
40
38
ALP
655
661
614
427
278
283
35
Take Home Messages
1. High clinical suspicion & prompt diagnosis
are very important in managing PTB & EPTB.
2. Dosage & duration of treatment are
important in TB management.
3. Rifampicin-based regimen is preferred in all
types of TB infection.
4. Ensure all TBIS forms are filled-up.
36
THANK YOU
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