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Unit 7 Treatment of TB: B Family Case

Unit 7 Treatment of TB: B Family Case. Botswana National Tuberculosis Programme Manual Training for Medical Officers. B Family Background. You’ll remember that… Mrs. B has HIV and starts on IPT

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Unit 7 Treatment of TB: B Family Case

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  1. Unit 7 Treatment of TB:B Family Case Botswana National Tuberculosis Programme Manual Training for Medical Officers

  2. B Family Background You’ll remember that… • Mrs. B has HIV and starts on IPT • Her husband, Mr. B, presents at the clinic with a cough, and has recently had contact with his uncle who has TB • Though his exam is mostly normal, he gives a spot sputum sample and is told to come back the next day Unit 7: Case Study

  3. B Family Case (1) • Mr. B weighs 58kg • After you examine Mr. B and take an initial spot sputum sample, Mr. B returns the next day (day 2) with his morning specimen • You obtain another spot sample and all 3 samples are sent to the lab for acid-fast staining (direct microscopy) • You ask Mr. B to return in 3 days Unit 7: Case Study

  4. B Family Case (2) • When he returns (day 5), Mr. B is feeling worse • He reports loss of appetite and seeing blood in his sputum • His results are: • Sputum AFB positive (scanty) x 1 • 2 sputum negative • HIV positive • Mr. B is TB positive • With the new BNTP manual, ONE positive sputum specimen is adequate for the diagnosis of TB (previously, 2 positives were needed) Unit 7: Case Study

  5. B Family Case: Question 1 • How do you manage Mr. B’s case? • Does Mr. B qualify for HIV treatment? Unit 7: Case Study

  6. B Family Case: Answer 1 (1) • Start Category I treatment • FDC • 4 tablets (R150/H75/Z400/E275) daily • Make sure all patients are weighed at initiation of treatment • Single drugs • Isoniazid (INH) 300mg daily, Rifampicin (R) 600mg daily, Pyrazinamide (Z) 2000mg daily, Ethambutol (E) 1200mg daily Unit 7: Case Study

  7. B Family Case: Answer 1 (2) • Educate the patient • Provide counselling • Start cotrimoxazole, 400/80mg, 2 tabs daily • Take blood for CD4 • Take baseline bloods: FBC, Chemistry (renal function, electrolytes, LFT) • Refer him to the nearest HIV site 35 km away • Ask him to return for ART assessment and to review results Unit 7: Case Study

  8. B Family Case: Answer 1 (3) 2. All HIV positive TB patients qualify for HIV treatment • Treatment start time is variable • Review BNTP manual Unit 7: Case Study

  9. B Family Case: Question 2 (1) • 2 weeks later, Mr. B returns to the clinic • Haemoglobin is 8.0 • CD4 is 300 • You provide him with iron supplements and continue to monitor him until completion of TB treatment 6 months later • At completion of treatment, he is considered cured Unit 7: Case Study

  10. B Family Case: Question 2 (2) • 5 months after completing TB treatment (month 11), Mr. B. returns to the clinic complaining of cough, difficulty swallowing and pain in his feet • He looks moderately ill • He says he never followed up with the HIV clinic because the hospital is too far for him to travel and he doesn’t have the taxi fare What should you do now for Mr. B? Unit 7: Case Study

  11. B Family Case: Answer 2 • Obtain a sputum specimen on the spot and send it for microscopy Unit 7: Case Study

  12. B Family Case: Question 3 What other tests should the medical officer order? Unit 7: Case Study

  13. B Family Case: Answer 3 • Other tests ordered by the MO • 2 more sputum specimens • Sputum for culture • FBC • Repeat CD4 • Chemistry : LFTs, creatinine, BUN, electrolytes • Chest X-ray • NOTE: ESR is not helpful in diagnosis and is not recommended Unit 7: Case Study

  14. Wt 52kg T 38.2 RR 26 HR 118 White patches on soft palate Cervical lymphadenopathy Course lung sounds Enlarged liver B Family Case: Question 4 • CXR shows reticular nodular pattern • Examination shows: Based on these results, what should be the next step of Mr. B’s treatment? Unit 7: Case Study

  15. B Family Case: Answer 4 • Admit Mr. B • Start him on: • Crystalline penicillin & cotrimoxazole, 4SS tabs • Fluconazole, 200mg daily x 14 • Paracetamol, 500mg TDS-PRN • IV fluids Unit 7: Case Study

  16. B Family Case: Question 5 What is Mr. B being presumptively treated for? Unit 7: Case Study

  17. B Family Case: Answer 5 • PCN and cotrimoxazole are to treat bacterial pneumonia and as a prevention for PCP • Fluconazole, at 200mg daily x 14, is to treat oesophageal candidiasis • NOTE: It is not appropriate to use fluconazole for oral candidiasis Unit 7: Case Study

  18. Tests show: 1 sputum smear positive 2 sputum smear negative CD4 50 ALT 75 AST 77 Alk Phos 150 Total bili – O/S Hb 7.6 WBC 3.0 Platelets 75 Na 125 B Family Case: Question 6 How do you manage Mr. B’s case? Unit 7: Case Study

  19. B Family Case: Answer 6 (1) • Continue X-PCN x 10 days • For bacterial pneumonia coverage • Change cotrimoxazole dose to 2 tabs daily for prophylaxis • CXR was not indicative of PCP, so cotrimoxazole treatment dosage was stopped Unit 7: Case Study

  20. B Family Case: Answer 6 (2) Send a sputum specimen for culture and drug susceptibility testing Start TB treatment immediately • FDC • 4 tablets (R150/H75/Z400/E275) daily + Streptomycin, 1g IM daily • Single drugs • Streptomycin, 1g IM daily, Isoniazid, 300mg daily, Rifampicin, 600mg daily, Pyrazinamide, 2000mg daily, Ethambutol, 1200mg daily Unit 7: Case Study

  21. B Family Case: Question 7 (1) Botswana National HIV Programme states: • If CD4 <100, start 1-2 weeks after initiating TB treatment • If CD4 100-200, start 2-3 weeks after initiating TB treatment • If CD4 >200, start treatment after completion of ATT • HAART • AZT/3TC (Combivir) + Efavirenz Unit 7: Case Study

  22. B Family Case: Question 7 (2) • Mr. B is discharged after 5 days and is referred to IDCC for HIV management and a local clinic for DOT • Mr. B. presents to the IDCC with laboratory results from the hospital the following week • He attends a counselling session with DOTS supporter • He is started on ART Unit 7: Case Study

  23. B Family Case: Question 7 (3) • What ART regimen is he started on and when does he begin treatment? • What lab test is important in choosing an ART regimen? Unit 7: Case Study

  24. B Family Case: Answer 7 • Combivir + Efavirenz • 2 weeks after initiating ATT • Haemaglobin • If Mr. B’s Hb is <7.5, he will be started on d4T instead of AZT (AZT causes bone marrow suppression, which leads to anaemia) Unit 7: Case Study

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