Unit 10 Treating the Dually Infected Patient: B Family Case Botswana National Tuberculosis Programme Manual Training for Medical Officers

Unit 10 Treating the Dually Infected Unit 10 Treating the Dually Infected Patient: B Family CasePatient: B Family Case

Botswana National Tuberculosis Programme Manual Training for Medical Officers

Slide 2Unit 10: Case Studies

B Family Case: Question 1B Family Case: Question 1

• Mr. B is on TB retreatment and ART

• Mr. B returns with nausea, vomiting, and jaundice

What do you do for Mr. B?


B Family Case: B Family Case: Answer 1Answer 1

• Take a detailed history• Do a physical examination• Make sure to assess Mr. B’s liver• Take blood for liver function, electrolytes, full blood

count• Bilirubin (100), AST (400 range), ALT (500 range)

• Admit Mr. B to the hospital for observation• Stop all TB and HIV medications, but maintain

cotrimoxazole


B Family Case: Question 2B Family Case: Question 2

1 week later, Mr. B’s LFTs have

decreased to less than 2 x ULN

What do you do for Mr. B now?



• Reintroduce TB drugs

• Monitor liver function tests


B Family Case: B Family Case: Question 3Question 3

After a 16 day re-introduction, the patient’s LFTs remain < 2x ULN and Mr. B is without jaundice

1. When do you consider starting ART again?

2. Which drugs should Mr. B take?


B Family Case: Answer 3B Family Case: Answer 3

1. 2-4 weeks after re-starting full doses of anti-tuberculosis drugs

2. Medications• Alluvia, 2 tabs BD• Ritonavir, 3 capsules BD• Combivir, 1 tab BD

*Alluvia is now available in Botswana – it is a tablet form of Kaletra and does not need to be refrigerated


B Family Case: B Family Case: Question 5Question 5

Why should Mr. B take Alluvia + Ritonvir

instead of restarting EFV?



• EFV can cause heptatotoxicity

• Since Mr. B is tolerating the ATT, you assume it was the efavirenz that caused the deviation in liver function and jaundice

Unit 10 Treating the Dually Infected Unit 10 Treating the Dually Infected Patient: CasePatient: Case

Botswana National Tuberculosis Programme Manual Training for Medical Officers


Additional CaseAdditional Case

• A 45 year old female named TT with fever for 4 weeks, cough with bloody sputum, sweats and weight loss of 7 kg

• Sputum is AFB+• Her HIV test is positive

and CD4 is 20 cell/cu mm

Chest X-ray shows right paratracheal adenopathy


Additional Case: Question 1Additional Case: Question 1

1. What questions do you ask her?

2. What medications do you start her on?


Additional Case: Answer 1Additional Case: Answer 1

1. Ask her if she is still menstruating• TT reports that her menses stopped at 43 years

of age

2. Start patient on rifampicin, isoniazid, pyrazinamide and ethambutol plus cotrimoxazole



• TT is started on a four drug TB therapy and is discharged

• She returns after 1 month• Her fevers, night sweats and

cough have stopped and she has gained 5kg

• She is tolerating the TB drugs • TB therapy is continued• She is started on ARVs

including zidovudine, lamivudine and efavirenz

Why is she taking efavirenz instead of nevirapine?

X-ray shows improvement



TT is taking efavirenz instead of nevirapine because she is beyond child bearing age and because efavirenz is the preferred NNRTI for use in patients taking rifampin



• She comes back to your facility 2 weeks after starting ARVs

• She says that her fever, cough and night sweats have come back

• She has taken her ARTs as prescribed, but thinks they are making her more sick and she would like to stop them

1. What other information do you want from her history?

2. How would you assess her?



1. You want to know whether or not she was adherent to all her medications

2. Assessing TT• Check for other signs/symptoms: nausea, vomiting and

diarrhoea, which may indicate other infections or malabsorption

• Check blood pressure, heart rate, temperature, respiratory rate and oxygen saturation

• Perform labs: sputum smear for AFB, sputum culture, FBC, liver tests, CD4 count, viral load

• Perform a chest x-ray



1. What is your differential diagnosis?

2. What do you look for on physical exam?


Additional Case: Answer 4 (1)Additional Case: Answer 4 (1)

1. Differential diagnosis• TB IRIS• Drug-resistant TB• Failure of TB therapy due to poor adherence or

malabsorption of medications• Bacterial pneumonia • PCP• Drug toxicity


Additional Case: Answer 4 (2)Additional Case: Answer 4 (2)

2. Physical examination• Close evaluation of the chest

• Listen for adventitious sounds, symmetrical excursion

• Check for enlarged lymph nodes• Assess for body swelling (oedema) • Assess for abdominal distention• Asses for jaundice • Complete neurologic exam


Additional Case: Question 5 (1)Additional Case: Question 5 (1)

• TT reports excellent adherence and denies nausea, vomiting or diarrhoea

• Oxygen saturation is 96% on room air

• Heart rate, respiratory rate and other vital signs are normal

• Remainder of physical exam is normal

• Sputum smear negative Diffuse bilateral infiltrates


Additional Case: Question 5 (2)Additional Case: Question 5 (2)

1. What condition(s) do you suspect now?

2. What is your management plan now?



1. Narrowed differential diagnosis• TB IRIS• PCP• Bacterial pneumonia

2. Management• Advise her to continue ART and the TB continuation regimen

• Educate her, using a caring, respectful attitude

• Ask questions and listen• Ensure she understands the benefit of remaining on both

treatments• Encouragement

• Schedule her to come back in 1-2 weeks, or sooner if she gets worse



• 2 weeks later her symptoms are worse

• Sputum culture from last visit shows no growth to date

• Sputum smear is AFB negative

• Respiratory rate is 28• Oxygen saturation is 90%

on room air• Crackles heard bilaterally What is your diagnosis?

X-ray shows no improvement



• TB IRIS: Occurs in 10-40% of patients• The immune system is likely reacting to dead mycobacteria

in the system• The inflammation is worsening as her immune system

reconstitutes itself on ART• Risk factors

• Starting ARVs within 6 weeks of TB treatment• Disseminated, extra-pulmonary disease• Low baseline CD4 count• Rise in CD4 %• Fall in viral load• High bacillary burden Source: www.who.int/entity/tb/events/tbiris.ppt


Additional Additional Case: Question 7Case: Question 7

How do you manage TT now?



• Admit her to hospital• Give oxygen• FBC, chemistry panel• Administer corticosteroids to reduce inflammation

• If she continues to worsen despite steroid treatment: • Stop ART until she has clinically improved (resolution of chest x-

ray, respiratory distress)• Restart ART once clinically stable

• Continue TB treatment regimen throughout • If a culture turns positive:

• Suspect drug resistance• Do sensitivity testing



• 1 week later, TT remains on ART and TB treatment + steroids

• T.T. reports feeling much better

• Lungs sound normal• Sputum culture is still

negativeChest x-ray shows improvement

How long should steroids be continued?



• Consider a 4 week taper

• May need to restart if IRIS recurs

Documents

Unit 10 Treating the Dually Infected Patient: B Family Case Botswana National Tuberculosis Programme Manual Training for Medical Officers