CASE PRESENTATION ON RVD AND PTB

AKHIL JOSEPHREG.NO : 13Q0402

DEFINITIONTuberculosis is a chronic granulomatous

disease caused by Mycobacterium tuberculosis,which can produce either a silent ,latent infection or a progressive,active disease.

ETIOLOGYCausative Organism:TB is caused by

Mycobacterium species.In humans,infection by M.tuberculosis.In animals,infection by M.bovis.In Africans,infection by M.africanumM.tuberculosis is an aerobic,non-spore

forming bacillus that resist decolourization by acid alcohol after staining with basic fuschin....organism is referred to as an acid fast bacilli(AFB).

PATHOPHYSIOLOGY Airborne/droplet ingestion (cough, sneezing,speaking)

Droplet nuclei enter the respiratory tract and reach alveoli(bacteria enter ciliary epithelium)

Initiation of primary infection(organisms multiply)

Activation of alveolar macrophages(phagocytosis of bacilli)

Persistence of organism(few in number)

Rupture of macrophages & release of bacilli

Organisms multiply, transport of bacilli by lymphatic system to other organs

Formation of gra nuloma(cell mediated immunity delayed type of hypersensitivity by activation of CD4+T cells,secretion of INF gamma, IL )

Large number of macrophages surrounds the organism

In high immune people disease may relapse after 2 yrs(latent tb infection)

In immune suppressed people tubercular bacilli appear(rapid multiplication)

Active tb infection

CLINICAL PRESENTATION SIGNS AND SYMPTOMS:Weight loss,fatigue,a productive cough,fever,and night sweats.Frank hemoptysis

PHYSICAL EXAMINATION:Dullness to chest percussion,rales and increased vocal fremitus are

observed frequently on auscultation.

LAB TESTS:Moderate elevations in WBC Count with a lymphocyte predominance.Chest Radiograph:Patchy or nodular infiltrates in the apical areas of

the upper lobes or the superior segment of the lower lobesCavitation that may show air fluid levels as the infection progresses.

Definition

AIDS, the acquired immune deficiency syndrome(some times called as slim disease) is a fatal illness caused by a retrovirus known as the human immunodeficiency virus(HIV) which breaks the body’s immune system, leaving the victim vulnerable to a host of life-threatening opportunistic infections, neurological disorders, or unusual malignancies.

ETIOLOGY

AIDS is caused by HIV, a human retrovirus.Two types- HIV I and HIV II which are genetically

different but has related forms.HIV I is most common type associated with AIDS in US,

Europe and Central Africa.HIV II causes similar disease in West Africa and India.HIV-2 is transmitted less efficiently than HIV-1.

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PATHOPHYSIOLOGY

COMMON SIGN & SYMPTOMSSevere impairment or suppression of immune system.Pneumocystis carinii pneumonia (pcp) is mostly seen.Opportunistic infectionCD4+T- cells count falls below 200 cells/mm3 of

blood.In healthy adult it’s value is 600-1500 cells/mm3 of

blood.• Weight loss• Pharyngitis• Neurological symptoms.• Rash• HeadacheFeverLymphadenopathy

DEMOGRAPHIC DETAILS

PATIENT NAME:ABC

SEX:M

DEPT:MEDICINE

DOA:10-12-2016

AGE:30yrs

IP NO:27687

UNIT:C

DOD:17-12-2016

REASON FOR ADMISSIONC/O fever with chills since 1 week.C/O cough since 1 week.generalisedweakness +

PAST MEDICAL HISTORYNot a k/c/o HTN,DM,TB,epilepsy,anaemia

HISTORY OF PRESENT ILLNESSPatient was apparently alright but 7 days

back he developed fever with chills,insidious in onset,intermittent type.

No H/O rigorsH/O dry cough since 7 days.H/O breathlessness since 7 days.H/O generalised weakness +

FAMILY HISTORYDIET:mixedAPPETITE:decreasedSLEEP:normalB/B:regular

SOCIAL HISTORYChronic AlcoholicTobacco Chewing

GENERAL PHYSICAL EXAMINATIONPatient is moderately built and

nourished,conscious,cooperative,well oriented to time,place and person.

O/E,PR:90 bpmBP:110/70mmHgFebrile1. PICKLE

B/L Pitting pedal edema

SYSTEMIC EXAMINATIONCVS:S1 S2 +RS:NVBS+CNS:NADP/A:soft,non-tender,no organomegaly

INVESTIGATIONSCBC with ESRRBSSerum CreatinineLFTChest X-RayRVDHBsAgECGUrine RoutineCulture sensitivity testUSG AbdomenMP Antigen

PROVISIONAL DIAGNOSIS

CHRONIC ALCOHOLIC CIRRHOSIS OF LIVER , SEVERE ANAEMIA ?

LABORATORY DATA11/12 13/12

Hb 3.3gm/dl(13.5-17.5) 6.0gm/dlWBC 1500cells/µl(4500-

10500)1800cells/µl

POLYMORPHS 65%(40 -75) 53%BASOPHILS 00(0-1) 00EOSINOPHILS 3%(0-5) 2%LYMPHOCYTES 32%(20-40) 45%MONOCYTES 00%(0-7) 0%RBC O.75mill/µ l(4.7-6.1) 1.53mill/µlPLATELETS 60,000cells/µl(1.5-4.5

lakhs)110000cells/µl

ESR 100mm at the end of the 1st hour

11/12RBS 112 mg/dl(60-140)Sr . Urea 18 mg%(10-50)Sr . Creatinine 0.9 mg/dl(0.6-1.2)ALT 22 U/L(6-38)AST 68 U/L(6-40)ALP 122 U/L(35-140)T . Bilirubin 0.8 MG%(0.2-1)D . Bilirubin 0.3 MG %(0.1-0.4)I . Bilirubin 0.5 MG %(0.1-0.6)HIV - 1 ReactiveHBs Ag - veAlbumin 3.1 gm %(3.5-5.2)

SPUTUM CULTURE SENSITIVITY TEST : organisms isolated .

ZN stain : AFB seen

USG abdomen : moderate to gross ascitis.

Pus cells : 1-2/hpf

Epithelial cells : 0-1/hpf

TREATMENT CHARTBRAND NAME

GENERIC NAME

DOSE ROUTE

FREQUENCY

1 2 3 4 5 6 7 8

Blood Transfusion PRBC

PACKAGED CELL VOLUME

3 PINT IV√ √

INJ.Taxim Cefotaxime 1gm iv 1-0-1 √ √ √ √ √ √

INJ.Pantakind

Pantoprazole 40mg iv 1-0-0 √ √ √ √ √ √(t)

√ √

INJ.Vitcofol 2 ml in 100ml NS

folic acid,vitaminB12,

nicotinamide

15mg, 0.15mg,20

0mg

im 1-0-0 √ √ √ √ √ √ √ √

IVF DNS 2 pint iv 1-1-1 √ √ √

TAB.Sepmax DS

Sulphamethoxazole,trimethoprim

800mg,160mg

p/o 1-0-0 √ √ √ √ √ √

TAB.Benadon

Vit B6 40mg p/o 0-1/2-0 √ √ √ √ √ √

TAB.Akurit 4 INH,rif,pyr,ethambutol

75mg,150mg,400mg,

275mg

p/o 3-0-0 √ √ √ √ √ √

FOLLOW UPDAY 1O/E,BP:100/70 mmHgPR:90 bpmFebrileS/E,CVS:S1 S2 +RS:NVBS+CNS:NADP/A:Soft,non-tender

Adv:Blood transfusion 3 pint whole bloodInj.Taxim 1gm iv 1-0-1Inj.Pantakind 40 mg iv 1-0-1Inj.Vitcofol 2amp in 100 ml NS iv 1-0-0IVF DNS 2 pint with mvi

DAY 2O/E,BP:110/70mmHgPR:80 bpmS/E,CVS:S1 S2 +RS:NVBS+CNS:NADP/A:Soft non-tender

Adv:Inj.Taxim 1gm iv 1-0-1Inj.Pantakind 40mg iv 1-0-0Inj.Vitcofol 2 amp in 100 ml NS iv 1-0 -0IVF DNS 2 pint with mviTab.Sepmax DS 1-0-0Tab.Akurit 4 3-0-0Tab.Benadon 40mg 0-1/2-0

DAY 3O/E,BP:110/60mmHgPR:80 bpmS/E,CVS:S1 S2 +RS :NVBS +CNS:NADP/A :soft non tender

Adv:Inj. Taxim 1g iv 1-0-1Inj. Pantakind 40mg iv 1-0-0Inj. Vitcofol 2 amp. In 100 ml NS IV 1-0-0Tab.Sepmax DS 1-0-0Tab. Akurit 4 3-0-0Tab. Benadon 40mg 0-1/2-0

DAY 4O/E,BP:120/60mmHgPR:88bpmAfebrileS/ECVS:S1,S2 +RS:NVBS+CNS:NADP/A:Soft non tender

Adv:APC

DAY 5O/EBP:110/60mmHgPR:88bpmAfebrile,S/ECVS:S1,S2 +RS:NVBS+CNS:NADP/A:Soft non tender

Adv:APC

DAY 6O/E:BP:110/60mmHgPR:80bpmAfebrileS/E:CVS:S1,S2 +RS:NVBS+CNS:NADP/A:Soft non tender

Adv:Tab.pantakind 40 mg 1-0-0Inj. Vitcofol 2cc in 100ml NS iv 1-0-0Tab.Sepmax DS 1-0-0Tab. Akurit 4 3-0-0Tab.Benadon 40mg 0-1/2-0

DAY 7O/E:BP:110/70mmHgPR:84bpmS/E:CVS:S1,S2 +RS:NVBS+CNS:NADP/A : Soft non tender

Adv:APC

FINAL DIAGNOSIS

FROM THE SUBJECTIVE AND OBJECTIVE EVIDENCES , THE PHYSICIAN DIAGNOSED IT AS “RVD POSITIVE ,PULMONARY TB , PANCYTOPENIA”

DISCHARGE MEDICATIONBRAND GENERIC NAME DOSE ROUTE FREQUE

NCYDURATION

T.AKURIT 4 INH,PYR,EHAMBUTOL,RIFAMPICIN

75mg,400mg,275mg,150mg

P/O 3-0-0 90 DAYS

T.BENADONE VIT B6 40 mg P/O 0-1/2-0 90 DAYS

T.SEPMAX DS SULPHAMETHOXAZOLE,TRIMETHOPRIM

800 mg,160 mg

P/O 1-0-0 30DAYS

T.PANTAKIND PANTAPRAZOLE 40 mg P/O 1-0-0 10DAYS

SYP.VICTOFOL

FOLIC ACID,VIT B12,NICOTINAMIDE

15mg,0.15mg,200mg

p/o 1-0-0 10DAYS

PHARMACEUTICAL CARE PLANSUBJECTIVE EVIDENCE : c/o fever with chills

since 1 week , c/o cough since 1 week . Generalized weakness +ve

OBJECTIVE EVIDENCE :

HB : 6gm/dl ↓ WBC : 1500cells/ul ↓ RBC : 1.53mill/ul ↓ PLATELETS : 110000 cells/ul ↓ ESR : 100 mm at the end of the first hour ↑ HIV 1 : REACTIVE CULTURE SENSITIVITY TEST : Organisms isolated ZN stain : AFB seen

USG abdomen : moderate gross ascites ALBUMIN : 3.1 gm%

ASSESSMENT : By observing the subjective and objective evidences , the physician diagnosed it as “ RVD +ve , PTB , PANCYTOPENIA “

PLANNING:GOALS OF THE THERAPY : 1. To decrease the fever , chills and cough .2. To improve patient’s quality of life .3. To make patient adhere to the medication .4. To incease Hb and RBC counts .5. To prevent further oppurtunistic infections.6. To recommend the best ART regimen.

GOALS ACHIEVED 1. Fever, chills and cough reduced 2. patients quality of life is improved 3. Haemoglobin and RBC count is increased. 4. To inform patient caretaker to initiate the ART from GOVT.

Hospital .

PHARMACIST INTERVENTION Anti-TB and ART drugs at same time involves a number of

potential difficulties including - Cumulative drug toxicities Drug – drug interactions, A high pill burden and The Immune Reconstitution Inflammatory Syndrome (IRIS)

1. Concurrent use of pyrazinamide and riampin may result in severe hepatic injury – major – delayed onset.

2. Concurrent use of rifmpin and isoniazid can cause severe hepatic toxicuty, so monitor LFT.

MONITORING PARAMETER CBC with ESRLFTCD4 COUNTCLINICAL SYMPTOMS OF LIVER INJURY

TREATMENTPHARMACOLOGICAL TREATMENT: ANTI-TB DRUGS:Agents that are

therapeutically effective against TB.First Line Drugs:They have high antitubercular

efficacy as well as low toxicity.Isoniazid(H)Rifampin(R)Pyrazinamide(Z)Ethambutol(E)Streptomycin(S)

Second Line Drugs:They have either low Anti-TB efficacy or high toxicity or both.

Thiacetazone(Tzn)Para Amino Salicylic acid(PAS)Ethionamide(Etm)Cycloserine(Cys)NEWER DRUGSCiprofloxacinAzithromycinRifabutin

CATEGORY BASED TREATMENTCategory I:New positive pulmonary TB patients.New severe extra pulmonary tuberculosis patientsNegative for pulmonary TB with extensive paranchymal

involvement.Category II:Treatment failure due to

resistance,inadequate dose,uncompliance,relapse,multi-drug resistant TB

Category III:Less severe extra TB Less negative for PTB with extensive parenchymal

involvement.Category IV:Chronic diseaseMulti-drug resistant TB

DOTS(Directly Observed Treatment In Short Strategy)H3R3Z3E3/S3 for 2 months +H3R3 for 4 monthsTotal therapy:6 monthsDOTS Therapy is directed to following people:Homeless peopleHistory of non-medication adherence patients.Chronic alcoholicActive TBTB with AIDS:2HRZE,Duration:9 monthsMycobacterium avium complex in AIDS due to immune

suppression.Clarithromycin/Azithromycin+Etm+/- Rifampin

According to revised national TB control program [RNTCP]

Category of Treatment

Type of Patient Regimen

Category I New sputum smear-positive Seriously ill** new sputum smear-negative Seriously ill** new extra-pulmonary

2H3R3Z3E3+ 4H3R3

Category II Sputum smear-positive Relapse Sputum smear-positive Failure Sputum smear-positive Treatment After Default Others

2H3R3Z3E3S3 + 1H3R3Z3E3 + 5H3R3E3

Category III New Sputum smear-negative, not seriously ill New Extra-pulmonary, not seriously ill

2H3R3Z3 + 4H3R3

STANDARD TREATMENT -First line drugsThe recommended preferred first-line ARV

regimensFor infants and children are:Regimen of 2 NRTI plus 1 NNRTIAZT* + 3TC + NVP or EFV**D4T + 3TC + NVP or EFV**ABC+ 3TC + NVP or EFV is an alternative

however, in the national programme – ABC is not available and is still costly.

HIV with TB

Anti TB should be started first & ART should be started 2-8 weeks after anti TB for those individuals who have a CD4 count of less than 200mm.

Increased risk of inflammatory immune reconstitution syndrome

Rifampicin lowers NVP drug level by 20-58% and EFV drug level by 25%. In children, there is no information on appropriate dosing of NVP and EFV when used with Rifampicin.

2NRTI + NVP

PATIENT COUNSELLINGAbout disease : TB is a chronic granulomatous

disease caused by mycobacterium tuberculosis.RVD : A disease in which there is severe loss of

body cellular immunity , grately lowering the resistance to infection and malignancy .

About drug : Pantaprazole – taken half an hour before meals

Benadon : taken with meals . Cefotaxim : should Be taken after meals

INH+PYR+RIFAMPICIN – taken on empty stomach one hour before meals.

LIFE STYLE MODIFICATION FOR RVD WITH PTB

Medication AdherencePotential adverse effects from and

interactions with antiretroviral drug therapy and ways to manage adverse effects

Educating the patient about modes of HIV transmission and effective techniques for prevention of transmission

Nutritional assessmentPsychological supportExercise

Dont spit in the public placesAvoid irritants (smoke , dust )Use mask while coughingAbout the administration of the drugs which

the doctor has prescribedAdvice patients to report the signs of hepatic

dysfunction such as dark urine , decreased appetite , jaundice .