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 !"#$%| &$!$ % '"%()
%*#"&+*$"%
‡ Tuberculosis is an infectious
disease caused in most cases by
organism called |



 
  •
‡ The microorganisms usually enter the
body by inhalation through the lungs• They
spread from the initial location in the lungs
to others parts of the body via the blood
stream, the lymphatic system, the airways
or by direct extension to the other organs•
 ,- (".+/ #+!"($(
) +!0"%#,*+/ #+!"($( is the 0"(*
.# 1+ %*( form of the disease, usually
comprising "2 #3".( (• It is the
form if tuberculosis that can be
"%*4$"+(•
/) 5*#
-+!0"%#,*+/ #+!"($(affecting
organs other than the lungs; most
frequently pleura, lymph nodes, spine and
other bones and joints, genitourinary tract,
nervous system, abdomen or virtually any
organ•
 %&+/ #+!"($(
‡ Infection with HIV progressively lead to
extensive destruction of the immune defense
mechanism of the body• Person become
susceptible to opportunistic infection such as TB•
‡ When the protection provided by the immune
system is reduced by HIV infection, the
tuberculosis microorganisms (new or latent)
begin to multiply causing tuberculosis•
‡ This means that the development of tuberculosis
can be a warning sign indicating co-infection
with HIV•
‡ Tuberculosis patient infected with HIV disease
will develop rapidly and become seriously ill and
"6 &$.. #($% #!,%&
!* $%. *$"%
 /7 *$2 ".*+&,
 % #!/7 *$2
‡ To study the common management of
pulmonary tuberculosis in specialized health
institution such as Institute of Respiratory
Medicine, Hospital Kuala Lumpur; focusing on
the investigation, treatment and other plan of
action upon patient admission•
- $.$/7 *$2
1• To study the plan of investigation of smear-
negative patient with multiple co-morbidity•
• To study the priority of treatment plan for
smear-negative pulmonary tuberculosis in HIV
patient•
 | *"&"!"4,
1• History Taking
• Physical Examination
3•
iagnostic Test
a) Chest X-Ray
b) Mantoux / TST / PP
test
c) AFB Sputum
irect Smear
d) Culture & Sensitivity Test
4• Other Test ± CBC, LFT, Retic Count, L
H•
 (+!*8$(+(($"%
‡ Miss SY is a 34 years old Indonesian lady,
a widow and permanent Malaysian citizen•
She claimed to work as storekeeper and
live in Setapak with an education up to
standard six•
‡ She was admitted to Ward 5, Institute of
Respiratory Medicine (IPR) on 9th

ecember 9 and occupying Bed 4•
She was clerked by me on 15th
ecember
9 at 15 hour•
‡ She was referred from medical ward,
Hospital Kuala Lumpur (HKL) for further
investigation and management•
‡ She has known case of recently
diagnosed HIV; presented upon admission
to IPR with generalized lymphadenopathy,
multiple splenic abscess and ulcerated
buttocks due to infected dicubitus ulcer•
‡ She is under follow up with Orthopedic

epartment HKL after underwent minor
surgery to remove her gluteal abscess•
 $(*"#,9$%4
‡ # ( %*$%4"0-!$%- persistent cough
‡ $(*"#,". # ( %*$%4"0-!$%
- Coughing for the past two weeks•
- Persistent and worsening•
- Productive with yellow sputum but no
hemoptysis•
- Fever and night sweat•
- LOA and LOW from 54kg to 48kg•
- Severity 8•
ue to her expulsive cough,
she often suffered from general body
weakness•
 - Cough exacerbated at night and temporarily
relieved by resting, taking cough medication
and expelling her sputum•
- She claimed has no TB contact either from
family or friends•
‡ (*| &$!8+#4$!$(*"#,
- Intensive Care Unit (ICU) of HKL on October
9•
-
iagnosed as HIV positive, HAART not
started•
- PTB treatment started since 6th November
9 with EHRZ•
- Minor surgery to remove abscess from
infected decubitus ulcer
‡ 0$!,$(*"#,
- No history of TB contact•
- Mother passed away from heart disease•
‡ "$!$(*"#,
- No vices
- Used to live with her boyfriend and had sexual
contact
- WAKE
‡ ,(* 0$ 2$ 6
‡ CVS, GUS, MS, End no significant finding
‡ Nervous - Fine Tremor
‡ GIS - Loss of appetite
‡ Resp - cough with yellow sputum and etc•
 ,($!50$%*$"%
 % #!"%&$*$"% ‡  &%&
‡ Alert, distress, - No significant finding
tachypneic - Whitish deposition on
‡ Cachexic, medium build her tongue, whitish
‡ Rashes all over her lesion on her left buccal
body• mucosa and ulcer in her
right buccal•
 % #!50$%*$"%
‡ Hand ‡
9
- No cynosis, clubbing, - Multiple lymph nodes
anemia enlargement particularly
in submandibular,
- Fine tremor cervical and
- Radial pulse 91 per supraclavicular nodes•
minute

  
%(- *$"%
‡ Rashes over his chest and
body
(-$#*"#,
‡ Normal chest movement
and symmetrical
50$%*$"%
‡ No accessory muscle
utilization
‡ Tachypnoeic, RR 34 per #+(($"%
minute ‡ Equal resonance

!-*$"% +(+!**$"%
‡ Normal breath sound
‡ Normal and equal TVF
‡ No added sound
‡ Apex beat 5th IC MCL
‡ Normal chest expansion
‡ Multiple axillae nodes
enlargement
   
%(- *$"% #+(($"%
‡ Rash ‡ Equal resonance
‡ Vertebrae alignment
normal +(+!**$"%
‡ Normal breath sound•
!-*$"% no addded sound
‡ Normal TVF and
breathing expansion
 $.. # %*$!$4%"($(
‡ Bronchiectasis
- coughing large amounts of purulent
sputum
‡ Bacterial pneumonia
- usually shorter history, febrile, response
to antibiotic
‡ Lung abscess
- cough with large amounts of purulent
sputum
‡ Tuberculosis
 %2 (*$4*$"%
|%*"+5 (*'+/ #+!$%9$% (*)
‡ Patients induration result is 5mm•
-+*+0 $&
(*$!!$' )$# *
0 #
‡ 1th
ecember 9 ± negative for AFB,
/3 Line
‡ 4th
ecember 9 ± negative for AFB,
/3 Line
 (*:
#,
3rd November 9
a) The position of the patient
‡ Slight rotation• Postero-anterior film in erect position•
b) The outline of the heart and the mediastinum
‡ Normal in size, shape and position•
c) The position of the trachea
‡ Centrally placed•
d) The diaphragm
‡ Sharp cardiophrenic and costophrenic angles•
e) The lung fields
i• The mid-zone shows some patchy fibrosis•
ii• The lower zone extends shows patchy fibrosis•
f)The bony skeleton
‡ Chest is symmetry, no scoliosis, All ribs present no
erosion•
+!!!""&"+%* - 9th
ecember 9
!""&"+%*  (* %$* . # % 
8$.. # %*$! %4
WBC 7•4 x 13/µL 4• ± 1•
RBC Ĺ9•37 x 16/µL 3•8 ± 5•4
HGB Ļ9• g/dL 1 • ± 16•
HCT Ļ 7•9 % (38• ± 5 •)
MCV 85•6 fL (77 ± 91)
MCH Ļ 7•6 pg ( 8±3 )
MCHC 3 •3 g/dL (3 ± 36)
PLT 36 x 13/µL 15 - 4
NEUT % 51•1 % 4 ± 7
LYMP % 36•4 %  ± 4
NEUT # 3•8 x 13/µL • - 7•
LYMP # •7 x 13/µL 1•5 ± 4•
ESR Ĺ43 mm/hr <  mm/hr
 %! #".$! 
3th
ecember 9

 * #0$%*$"%  (* . # % 
%4
Blood Urea 3• mmol/L •5 - 6•4 mmol/L
Nitrogen (BUN)
Sodium (Na) Ļ133 mmol/L 135 - 145
mmol/L
Potassium (K) Ĺ5• mmol/L 3•5 - 4•5 mmol/L

Chloride (Cl) 1 mmol/L 1 - 18

mmol/L
Creatinine Ļ51 µmol/L 53 - 115 µmol/L
$2 #+%*$"% (*- 7th
ecember 9

 * #0$%*$"%  (* . # % 
%4
Total Protein 73 g/L 64 ± 8 g/L
Globulin Ĺ51• g/L 3 - 3 g/L
Albumin Ļ • g/L 34 - 5 g/L
Albumin/Globulin ratio Ļ•4 1•1 - 1•6
Total Bilirubin Ĺ18 µmol/L  - 17 µmol/L
Alakaline Phosphatase Ĺ 17 U/L 5 ± 136 U/L
(ALP)
Alanine Aminotransferase 14 U/L  - 65 U/L
(ALT)
 *$"+%*- 3rd
ecember 9
‡ Retic Count: 1•3 % (Normal Value: •5 ±
•5%)
‡ Reticulocyte Haemoglobin Content (CHr):
3•8 pg (Normal Value: 5•±3•pg)

**  ,&#"4 %( 

3rd
ecember
9
‡ L
H: 831 U/L (Normal: 4 - 48 U/L)
# *0 %*
 | 
 
|"& ".
#+4( "(4 &0$%$(*#*$"% * $2 % ,- ".#+4(
For treatment of
Meropenem 5mg T
S Intravenous 9th to 1st
ecember 9 skin infection;
under
Carbopenem
class
Tramal 5mg B
Oral - Capsule 9th to 1th
ecember Opioid Analgesic
3mg O
9th to 11th
ecember,
÷ ÷  



Isoniazid Oral ± Tablet 17th
ecember 9 Anti-TB agent
3mg O
 

18 to 31st
ecember 9,
nd January 1

6mg O
9th to 1th
ecember

÷ ÷  
 Antibiotic;

 Anti-TB agent
Rifampicin 15mg O
Oral - Capsule 3th
ecember 9
 

3mg O
31st
ecember 9
6mg O
1st January 1
1mg O
9th to 11th
ecember 9, Vitamin B6
Pyridoxine Oral - Tablet 31
ecember
 1 5mg O
9th
ecember 9
÷ ÷  



Pyrazinamide 4th
ecember 9
5mg O
Oral - Tablet  
 Anti-TB agent

5mg O
5th
ecember 9

75mg O
6th
ecember 9
1 5mg O
3th to 31st
ecember 9
BVC 1:4 B
Topical ± Cream 11th
ecember 9
Aqueous cream as 1% B
Topical - Cream 11th
ecember 9
E
Allergy treatment•
Piriton 4mg T
S Oral - Tablet 11th to 31st
ecember 9 Sedating
antihistamine
Oral - Syrup 1 th to 31st
ecember 9;
Nystatin 5  u QI
nd January 1 Antifungal

1 thto19th
ecember 9; Non-Opioid Analgesic

Paracetamol 1g QI
/PRN Oral - Tablet nd to 9th
ecember 9 & Antipyretic

Clotrimazole B
Topical - Cream nd
ecember 9 Anti-infective,

Antifungal
Lamisil 5mg O
Oral - Tablet nd to 31st
ecember 9 Antifungal
Corticosteroid
Prednisolone 4mg 9th to 3th
ecember 9 Hormone; Allergy
treatment
Oral Rehydration 8th to 3th
ecember 9 Electrolyte
Salt replacement
Purgative 8th to 3th
ecember 9
 "%!+($"%
‡ In an individual infected with HIV, the presence
of other infections, including TB, may allow HIV
to multiply more quickly• This may result in more
rapid progression of HIV disease•
‡ Because HIV is so closeley linked to
tuberculosis, patient should be routinely offered
testing and counselling for HIV, and those HIV
infection should be routinely screened for
tuberculosis•
‡ The philospohy of care must be "two disease,
one patient, one system"•
 . # %
‡ WHO,  • Strategic framework to decrease the burden
of TB/HIV• p19•
‡ International Union Against Tuberculosis and Lung

isease (IUATL
) or The Union• 1• Management of
Tuberculosis, A Guide to The Essentials of Good
Practice• Sixth Edition• p5•
‡ Merck Manual for Medical Proffesional
‡ WHO• 4• TB/HIV a Clinical Manual• Second edition•
‡ WHO• 7• Improving the diagnosis and treatment of
smear-negative pulmonary and extrapulmonary
tuberculosis among adults and adolescents•
Recommendations for HIV-prevalent andresource-
constrained settings•