CASE 2

PTB Category IV
MDR-TB

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CLINICAL HISTORY
 @ENERAL DATA

ï N.J.
ï female
ï 39 years old
ï Married
ï Filipino
ï Roman Catholic
ï Born on October 8, 1972 , born and currently residing in
Rosario, Cavite
ï Currently enrolled for Category IV treatment on July 15,
2010 at TB DOTS of DLSHSI.
  !"#$

ï
No subjective complaint at time of consult
 %$&' &%#$!!#%%

ï Patient was apparently well until 16 years PTC when

she experienced °
°° ° 

 

 °     ° 

 .

ï Diagnosed by a private physician to have |


 °.

ï ånderwent treatment for Category I. She was given

Amoxicillin, Rifampicin, Ethambutol and
Pyrazinamide for ‰ 
 %$&' &%#$!!#%%

ï Declared
° after completion of treatment

ï Probable sources of infection were her grandfather,

father and three other siblings who were also
diagnosed with PTB but who did not undergo proper
treatment.
 %$&' &%#$!!#%%

ï Four years prior to consultation, patient presented

with signs and symptoms of °
°° 
° 

 
   °   ° 
  .

ï She had 3x sputum smear (-) and (+) chest x-ray

ï She was enrolled as  °treatment of 

 duration with 4 in 1 medications and
Streptomycin injection for 56 days.
 %$&' &%#$!!#%%

ï Treatment was completed and she was declared to

have °  
  

ï She was exposed again when she took care of her

father and siblings who were confined in a hospital
due to progressive TB
 %$&' &%#$!!#%%

ï In late 2008 or early 2009 she had  

 

   ° 
  .

ï She consulted a private physician and was diagnosed

to have |
 °and underwent an 
 treatment of Fixcom 4.

ï After treatment she was considered
° .

 %$&' &%#$!!#%%

ï Patient experienced again °
°° 
 after 5

months of treatment.

ï She either self-medicated with a mucolytic

medications like carbocisteine for one week or have
antibiotics prescribed by physicians like amoxicillin
or ampicillin

ï Cough relief was only temporary and patient also

had signs and symptoms of 


 
   °      °.
 %$&' &%#$!!#%%

ï After a few months of °
°° ° 


 

 , she decided to seek consultation.

ï She had herself enrolled in the MDR treatment

program in DLSHSI
 %$&' &%#$!!#%%

ï On the day of consultation patient had no subjective

complaints.

ï She is compliant to her medications and had not

noticed any side effects of drugs taken.
 |"%$()"!%$&'

(-) previous accidents, injuries and diseases

(-) diabetes, hypertension, goiter, history of psychiatric

illnesses, renal and cardiac problems

(+) hospitalized thrice when she gave birth to her three

children via normal vaginal delivery.

(+) Patient had irregular intake of ferrous sulfate, one

tablet, OD and unrecalled brand name of imported
multivitamins from Australia and supplements with
minerals and iron, one tablet, OD.
 *%$$&)"#('#)!+)%$&'

ï @3P3 (3-0-0-3)
ï Menarche: 14 years
ï Cycle is regular lasting for 3 to 5 days
ï Consumes 2-3 napkins, not really full, per day
ï (-) history of amenorrhea and dysmenorrhea
ï (-) STDs, dyspareunia
ï (+) withdrawal method
ï (+) previous intake of OCPs for at least one year in
between pregnancies.
 "!'%$&'

†(-) Diabetes Mellitus

(+) Asthma - sibling

†(-) Hypertension

†(-) Allergies

†(+) Cancer ± aunt (distant relative)

 "!'%$&'

(+) Tuberculosis - mother (cured), father (‚), of 10

siblings three siblings (‚) & 4 were treated

†(+) Cardiac problems - mother (cardiomegaly)

†(-) Pulmonary problems

(+) renal problems ± aunt (distant relative)

 |&%#"!"#()"!%$&'

ï born in and is presently residing in Rosario, Cavite

ï lives with her husband and three children in a small

bungalow type house made of concrete

ï currently self- employed

ï previously employed as a cashier at the fish port.

 |&%#"!"#()"!%$&'

ï (-) smoker, (-) alcoholic drinker, (-) drug user

ï Water source is non-boiled water from the faucet,

supplied by NAWASA

ï The family¶s diet consists mostly of vegetables and

fish but is in general not restricted.
 |&%#"!"#()"!%$&'

ï Sanitary toilet with manual flushing.

ï @arbage is collected once a week

ï (-) pets
 Review of Systems

(+) weight gain (+) some difficulty of

(+) blurring of vision breathing when walking
(-) fever (associated with weather)
(-) rashes (-)chest pressure
(-) headache (-) dysphagia
(-) tinnitus (-) abdominal pain
(-) epistaxis (-) any bowel habits change
(-) difficulty swallowing (-) nocturia
(-) hemoptysis (-)polyuria
(-) dyspnea (-) joint pain
(-) anxiety
PHYSICAL EXAMINATION
 @eneral Survey

ï Alert, awake, oriented to three spheres

ï Ambulant

ï (-) cardiopulmonary distress

ï Appears younger than her stated

chronological age of 39.
 VITAL SI@NS

ï | 131/85mmHg after 30 mins: 120/82mmHg

ï  : 105 beats/minute
ï | 98 beats/minute
ï : 18 cycles/minute
ï  &"$,&: 37°C
 Regional Examination

l INTE@åMENT:

l (-) pallor, (-) jaundice, (-) erythema,

(-) edema,
l (-) masses, (-) erythema
l (-) scars
l (+) good skin turgor
l (+) 0.5 x 0.5 brown nevus at right
eyebrow
 Regional Examination

l HEAD & NECK:

l normocephalic

l (-) masses, tenderness, alopecia,

l (+) soft texture of hair

 Regional Examination

l
'%

l Normal relationship of eyelids to the eyeballs

l Visual Acuity: Jaeger: OD: 20/40 +1;
OS: 20/30 -1
l Funduscopy: (-) assessed
l (-) Ptosis
l Tonometry: soft
l Clear and pinkish conjunctiva
l Full EOM movements
l Direct & consensual papillary reflex: 3 to 2 mm
 Regional Examination

l
"&%

l Cerumen scanty
l No masses ulcerations or tenderness on
periauricular and pinna.
l Weber: midline
l Rinne: air conduction > bone conduction
l Schwabach: not assessed
 Regional Examination

l ,$:

l (-) Lesions, Masses

l Tongue in midline, (-) lesions
l Smooth and pink mucosa
l Symmetrical uvula with left sided leaning
l 3 missing molar teeth, recent tooth
extraction
l (+) caries
 Regional Examination

l )-:

l Trachea midline
l Neck supple
l Thyroid isthmus palpable
l (-) nodules palpable
l Thyroid prominence moves with
deglutition
 Regional Examination

l %

l Symmetrical external nose

l Midline Nasal Septum
l Equal size and shape of the external nares

l ' (%

l (-) palpable cervical lymph nodes

 Regional Examination

l %$"#(,#+%

l Inspection: not assessed

l Palpation: not assessed
l Percussion: not assessed
l Auscultation:
(+) soft wheezes during
inspiration breath sounds at
both upper-middle lung fields,

(-)crackles, rhonchi, stridor

 Regional Examination

l .

l Inspection: not assessed

l Palpation: not assessed
l Percussion: not assessed
l Auscultation:
normal rate, regular rhythm,
S1 louder S2 at apex, S2 louder than S1
at the base, no S3, S4, no murmurs
 Regional Examination

ï *(#"!
/"

l Inspection: inverted umbilicus,

(+) striae gravidarum
l Auscultation: (-) assessed

l Palpation: soft,
(-) abdominal guarding upon touch

l Percussion: (-) assessed

 Regional Examination

ï
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ß @ood range of motion on all joints

ß (-) evidence of swelling or deformity
ß (-) nodes on hands
ß Peripheral pulses full and equal
ß (-) tenderness
ß (-) cyanosis, clubbing, bipedal edema
 Neurological Examination

ï Mental status:

ß alert, conscious, coherent

ß (-) cardio-respiratory distress

ß oriented to time, person and place

ß appears younger than her chronological age of 39 years.

 Regional Examination

ï Cranial Nerves:

CN I - not assessed
CN II - (+) direct & consensual light reflex
CN III, IV, VI - full & equal EOMs
CN V ± not assessed
CN VII - full facial expression
CN VIII - good gross hearing
CN IX, X ± @ood speech with no nasal twang
CN XI - good shoulder shrug
CN XII -Tongue in Midline, (-) Atrophy of the tongue
 Regional Examination
ï Motor:

- (-) tremors nor fasiculations

- Deep tendon: not assessed

ï Sensory:

- Patient sense of touch, pain, vibration, position

preserved

ï Cerebellar: not assessed

ï Meningeals: not assessed

ï Higher Cerebral: not assessed

 ASSESSMENT

 
                   
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        0        

 PTB Category IV MDR-TB

ï Tuberculosis (TB) is a bacterial infection caused by

O


 
  .

ï The bacteria usually attack the lungs, but they can

also damage other parts of the body.

ï TB spreads through the air when a person with TB of

the lungs or throat coughs, sneezes or talks.

ï One is more likely to get TB if the person has a weak

immune system.
 Symptoms of TB in the lungs include:

Cough for two or more weeks, with or without:

ï Fever
ï Chest and/or back pains not referable to any MS
disorder
ï Hemoptysis or recurrent blood-streaked sputum
ï Significant weight loss
ï Other symptoms, such as sweating, fatigue, body
malaise, shortness of breath
ï If not treated properly, TB can be deadly.

ï One can usually cure active TB by taking several

medicines for a long period of time.

ï People with latent TB can take medicine so that they

do not develop active TB.
 Ë"$% 1

ï Tuberculosis is completely curable through short-

course chemotherapy.

ï Treating TB cases who are sputum-smear positive

(and who can therefore spread the disease to others)
at the source, it is the most effective means of
eliminating TB from a population.
 Ë"$% 1

ï DOTS or Directly Observed Treatment Short course

is the internationally recommended strategy for TB
control that has been recognized as a highly efficient
and cost-effective strategy.

ï DOTS comprises five components:

5 Components of DOTS

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V TB can be cured and the

epidemic reversed if
adequate resources and
administrative support for
TB control are provided.
5 Components of DOTS

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V Chest symptomatics
examined this way helps
to reliably find infectious
patients.
5 Components of DOTS

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V Helps to ensure the right

drugs are taken at the
right time for the full
duration of treatment.
5 Components of DOTS

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V Ensures that a credible

national TB program does
not have to turn anyone
away.
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V Helps to keep track of

each individual patient
and to monitor overall
program performance.
ï The new global Stop TB Strategy builds on the
DOTS strategy, which remains the fundamental
basis for TB control.

ï The six additional essential elements in the new

strategy are:
The six additional essential elements in the new strategy are:

1. Sustaining, improving and accelerating quality

DOTS expansion

2. Addressing TB-HIV, MDR-TB and other special

challenges

ß TB/HIV collaborative interventions

ß DOTS-Plus for MDR-TB
ß Reaching vulnerable, high risk groups
The six additional essential elements in the new strategy are:

3. Contributing to health system strengthening

ß TB control innovations that strengthen health systems

ß Adaptation of innovations from other TB control programs
ß Practical Approach to Lung Health

4. Engaging all care providers

ß Public-private partnerships
ß Ensuring equitable access to international standards of care for TB
to all
The six additional essential elements in the new strategy are:

5. Empowering patients and communities

ß Advocacy, communication and social mobilization

ß Community-based TB care

6. Enabling and promoting research

ß Program-based operational research

ß Development of new diagnostics, drugs and vaccines
 Pathogenesis of PTB

AFB reach
the alveoli

Not contained by
macrophages
Multiply and
lyse the
macrophages

Disseminate
via regional
lymph nodes
 Pathogenesis of PTB

Delayed-Type hypersensitivity destroys nonactivated

macrophages

@ranuloma formation at site of primary lesion and sites of

dissemination

Lesions heal by fibrosis or undergo further evolution

 Pathogenesis of PTB

Alveolar macrophages secrete cytokines

Manifestation of disease,
granuloma formation,
mycobacterial killing
Classification: |,!#"&'6|7
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Type: !" %

Treatment Regimen: +#.

 CATE@ORY IV

@iven as treatment for:

ï Chronic
V (still smear positive after supervised re-treatment)
 CATE@ORY IV

Drugs used in Treatment:

ï Kanamycin ± 1g OD
ï Ofloxacin ± 2 tabs (400 mg)
ï Prothionamide ± 3 tabs
ï Cycloserine ± 3 tabs
 CATE@ORY IV

ï 5 consecutive (-) sputum smear

ï 4 consecutive (-) culture
ï CXR Jan 12, 2011 compared with CXR July 5, 2010:
Diminution of prev. described fibrohazed
densities in both lung fields, decrease in sizes of
both previously described cavitations
ï Stable physical condition
ï (-) ADR
ï (+) Weight gain from 53.5 kg to 61.7 kg
ï Currently in the Continuation Phase
 CATE@ORY IV

ï Strains of O 
  resistant to both isoniazid

and rifampicin with or without resistance to other
drugs

ï Requires treatment with second-line drugs

 CATE@ORY IV

ï Second-line drugs are not suitable for short course

treatment

ï Require prolonged treatment with drugs that are less

effective and more toxic
 Choice of drugs

ï Add at least 3 new drugs.

ï Preferably have an aminoglycoside
(Streptomycin / Kanamycin / Amikacin/
Capreomycin)
ï One fluoroquinolone
(Ofloxacin / Ciprofloxacin / Levofloxacin).
ï Ethionamide or Prothionamide
ï Any one of the following:
Cycloserine, PAS, Clofazimine or Moxifloxacin
 &%$ #&,+% )#(#&,+%
Essential Other Old New
Isoniazid Pyrazinamide Ethionamide Quinolones
Rifampicin Ethambutol Cycloserine Ofloxacin
Streptomycin Capreomycin Ciprofloxacin
Amikacin Sparfloxacin
Kanamycin Macrolides
PAS Clarithromycin
Thiocetazone Clofazimine
Amoxicillin &
Clavulanic
acid
New rifamycins
Rifabutin
Rifapentine
http://www.hivandhepatitis.com/recent/lipo/tb.html
http://www.niaid.nih.gov/SiteCollectionImages/topics/tuberculosis/tb2.jpg
 @lobal Situation of MDR-TB

ï MDR-TB is present in five continents, a third of the

countries surveyed having levels above 2% among new
patients.
ï In Latvia 30% of all patients for treatment had MDR-TB.
ï Russia when surveyed had 5% with MDR-TB.
ï In the Dominican Republic, 10% had MDR-TB.
ï In Africa, Ivory Coast had also emergence of MDR-TB.
ï Preliminary reports from Asia (India and China) show
high levels of drug resistance as well. In the State of
Delhi, India, 13% of all TB patients had MDR-TB.
 Philippine Setting

ï Data from Makati Medical Center DOTS Clinic

(2003) indicates high incidence of MDR TB.
ï Approximately 30% of isolates tested were resistant
to all five first line drugs, 39.4% to four, 16.8% to
three, 12.1% to two.
ï Fluoroquinolone resistance was noted in 40.9%
isolates.
 Epidemiology

ï MDR-TB afflicts countries with poor health

infrastructure
ï Also likely to break out in industrialized countries
ï During the late 1980s and early 1990s outbreaks of
MDR-TB in North America and Europe killed over
80% of those who contracted it.
ï The major TB outbreak in New York in the early
1990s was primarily a MDR-TB epidemic, with one
in ten cases being drug-resistant.
Key factors for the management of MDR TB:

ï Diagnosis of MDR TB
ï Reliable susceptibility testing
ï Prevention of MDR TB
ï In new cases
ï In old cases
ï Designing an appropriate regimen
ï Essential Drugs
ï Second line Drugs
ï Cross resistance
ï Ranking with respect to Efficacy, Cost, Tolerance
ï Reliable drug supply of second line drugs
Principles to be followed while treating MDR-TB patients:

ï Starting MDR-TB drug regimen

ï Check the history of the patient carefully for previous treatment regimens.
ï Check whether all drugs in the previous regimens have been taken and for
how long.
ï Determine the status of sputum smears at all junctures (in terms of
positivity ,conversions and sensitivities ± if available).

ï Confirmed/ Strongly suspect MDR TB

ï Counsel the Patient and family members

ï Send Tissue / sputum for culture and sensitivity testing (if available)

ï Start MDR Regimen

 Treatment Plan:

ï åse at least 4 ± 5 drugs as long as these include 2

drugs not previously taken.

V Do not add a single drug to a failing regimen to avoid

resistance to the new drug.
V Consider continuing with isoniazid and rifampicin (most
bactericidal) despite resistance.
V Either pyrazinamide or ethambutol may be discontinued.
 Treatment Plan:

ï Continue treatment for 18 months more from the

time the patient¶s sputum becomes AFB and culture
negative.

V @et cultures to check sensitivity of TB organism.

 Treatment Plan:

ï Consider surgery for unilateral cavitary lesions in

whom MDR-TB is established in the laboratory.
 Prevention

1. Vaccination

ß Attenuated strain of O , bacille Calmette-@uerin (BC@)

ß Protects infants and young children below 5 years of age

ß Efficacy unclear in other situations

 Prevention

2. Treatment of latent infection

ß Candidates for chemoprophylaxis are identified by TST

(Tuberculin Skin Testing)

ß (+) ± determined by reaction size and risk group

ß If (+), consider drug treatment

 Reference:

l http://www.nlm.nih.gov/medlineplus/tuberculosis.
htl
l www.who.int/topics/tuberculosis
l www.philhealth.gov.ph/providers/download/Comp
rehensiveånifiedPolicy_.pdf · PDF file
l http://www.tbdots.com/site/en/doctor_section_tb
_mdr.html
l http://www.hivandhepatitis.com/recent/lipo/tb.ht
ml
 Reference:

l http://www.heartlandntbc.org/images/full_mdr_t
b_care_plan.jpg
l http://www.niaid.nih.gov/SiteCollectionImages/to
pics/tuberculosis/tb2.jpg
l j  
 O
 17th ed.
2009
l O 
  
 
  
4th ed. 2005
ï Ong, W. et. al. p O
 3rd
edition 2009
Thank you!