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TUBERCULOSIS

TUBERCULOSIS.

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TUBERCULOSIS

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  1. TUBERCULOSIS • MW, a 36 y/o woman, is admitted to the hospital with a 2 month history of cough, which has recently become productive. She also is experiencing fatigue, night sweats, and has lost 10 pounds. Other medical problems include diabetes mellitus, which is controlled with 10 units of NPH daily, and poor nutritional status secondary to frequent dieting. MW works as a volunteer in a nursing home several days a week. Recently it was discovered that two patients that she had been caring for had undiagnosed TB. Physical exam was normal but MW’s chest X-ray revealed bibasilar infiltrates. A PPD skin test and sputum collection for cultures and sensitivity and a smear for AFB were ordered as part of MW’s diagnostic workup. Initial lab tests were within normal limit • The result of her PPD skin test, read at 48 hours was palpable induration of 14mm. Her sputum smear was positive for AFB, and additional sputum cultures for M. tuberculosis were ordered to confirm a diagnosis of active disease. What subjective and objective findings does MW have that are consistent with TB?

  2. Subjective Findings: • History of cough • Fatigue/general malaise • Night Sweats • Anorexia • Pleuritic pain

  3. Objective Findings: • Fever • Bibasilar infiltrates • Positive sputum for AFB • Positive PPD • Risk factor of diabetes

  4. Question: • Should MW be tested for HIV infection? • Why or why not?

  5. Answer: • Yes! TB may be the first manifestation of HIV infection. Approximately 37% of HIV-infected patients develop TB within five months compared with 5% of exposed persons with intact immune defenses.

  6. Question: • How should treatment be initiated in MW pending the results of the sputum C & S? Her HIV test was negative

  7. Regimen Options for the Initial Treatment of TB Among Children & Adults *All regimens administered 2 or 3 times wk should be monitored by directly observed therapy for the duration of therapy. **The strongest evidence from clinical trials is the effectiveness of all four drugs administered for the full 6 months. There is weaker evidence that SM can be discontinued after 4 months if the isolate is susceptible to all drugs. The evidence for stopping PZA before the end of 6 months is equivocal for the 3 times/wk regimen and there is no evidence on the effectiveness of this regimen with EMB for less than the full 6 months. DOT, directly observed therapy; EMB, ethambutol; HIV, human immunodeficiency virus; INH, isoniazid; PZA, pyrazinamide; RIF, rifampin; SM, streptomycin. Source: Applied Therapeutics: The Clinical Use of Drugs., 7th Edition, 2001, Lippincott, Williams, and Wilkens, Editors

  8. Question: • Can she transmit infection during treatment?

  9. Answer: • She should cease to be infectious about two to four weeks after therapy has been started, at which time the number of organisms in her sputum should be reduced

  10. Question: • Six weeks later MW’s sputum cultures were positive for M. tuberculosis. Sensitivity tests showed that the organism was sensitive to both INH and rifampin. According to the previous table what drug regimen should be used for continued therapy of MW? • How long should treatment be maintained?

  11. Question: • MW who is diabetic and has poor nutritional status should be placed on which vitamin supplement because she may be at a greater risk of developing INH-induced peripheral neuropathy?

  12. Answer: • Pyridoxine 25-100mg daily.

  13. Question: • Why is multiple drug therapy indicated for the treatment of active disease?

  14. Answer: • 1. To prevent the development of resistance. • 2. To sterilize the sputum as quickly as possible

  15. Question: • If MW does not respond to her current therapy should one more drug be added to her regimen? • Why or why not?

  16. Answer: • NO! Adding a single drug to a failing regimen is the most common and devastating mistake in TB therapy. This is essentially the same as monotherapy because one can assume that the organisms are resistant to the medications currently being used. Resistance to the new drug will eventually develop, further reducing the patient’s chance of cure. New susceptibilities should be obtained and treatment adjusted accordingly.

  17. ADVERSE DRUG EFFECTS

  18. INH • Hepatitis • Peripheral neuropathy • Allergic reactions • Drug interactions e.g. phenytoin (Dilantin), carbamazapine (Tegretol), diazepam (Valium)

  19. Rifampin • Flu-like syndrome • Hepatotoxicity • Thrombocytopenia • Nausea and vomiting • Discoloration of bodily fluids • Drug interactions: oral contraceptives, fluconazole, ketoconazole and others

  20. INH-rifampin • Hepatotoxicity

  21. Ethambutol • Optic neuritis

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