A DETAILED CASE STUDY OF A PATIENT WITH HIV-1 INFECTION AND PULMONARY TUBERCULOSIS.

1. AKHIL JOSEPH
REG.NO : 13Q0402

2. DEFINITION
 Tuberculosis is a chronic granulomatous disease
caused by Mycobacterium tuberculosis,which can
produce either a silent ,latent infection or a
progressive,active disease.

3. ETIOLOGY
 Causative Organism:TB is caused by Mycobacterium
species.
 In humans,infection by M.tuberculosis.
 In animals,infection by M.bovis.
 In Africans,infection by M.africanum
 M.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).

4. 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)

5. 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

6. 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

7. 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 lobes
 Cavitation that may show air fluid levels as the infection progresses.

8. 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.

9. 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.

10. 0

11. PATHOPHYSIOLOGY

12. COMMON SIGN & SYMPTOMS
 Severe impairment or suppression of immune system.
 Pneumocystis carinii pneumonia (pcp) is mostly seen.
 Opportunistic infection
 CD4+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
• Headache
 Fever
 Lymphadenopathy

13. DEMOGRAPHIC DETAILS
 PATIENT NAME:ABC
 SEX:M
 DEPT:MEDICINE
 DOA:10-12-2016
 AGE:30yrs
 IP NO:27687
 UNIT:C
 DOD:17-12-2016

14. REASON FOR ADMISSION
 C/O fever with chills since 1 week.
 C/O cough since 1 week.
 generalisedweakness +

15. PAST MEDICAL HISTORY
 Not a k/c/o HTN,DM,TB,epilepsy,anaemia

16. HISTORY OF PRESENT ILLNESS
 Patient was apparently alright but 7 days back he
developed fever with chills,insidious in
onset,intermittent type.
 No H/O rigors
 H/O dry cough since 7 days.
 H/O breathlessness since 7 days.
 H/O generalised weakness +

17. FAMILY HISTORY
 DIET:mixed
 APPETITE:decreased
 SLEEP:normal
 B/B:regular

18. SOCIAL HISTORY
 Chronic Alcoholic
 Tobacco Chewing

19. GENERAL PHYSICAL EXAMINATION
 Patient is moderately built and
nourished,conscious,cooperative,well oriented to
time,place and person.
 O/E,
 PR:90 bpm
 BP:110/70mmHg
 Febrile
1. PICKLE
B/L Pitting pedal edema

20. SYSTEMIC EXAMINATION
 CVS:S1 S2 +
 RS:NVBS+
 CNS:NAD
 P/A:soft,non-tender,no organomegaly

21. INVESTIGATIONS
 CBC with ESR
 RBS
 Serum Creatinine
 LFT
 Chest X-Ray
 RVD
 HBsAg
 ECG
 Urine Routine
 Culture sensitivity test
 USG Abdomen
 MP Antigen

22. PROVISIONAL DIAGNOSIS
CHRONIC ALCOHOLIC CIRRHOSIS OF LIVER ,
SEVERE ANAEMIA ?

23. LABORATORY DATA
11/12 13/12
Hb 3.3gm/dl(13.5-17.5) 6.0gm/dl
WBC 1500cells/µl(4500-10500) 1800cells/µl
POLYMORPHS 65%(40 -75) 53%
BASOPHILS 00(0-1) 00
EOSINOPHILS 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/µl
PLATELETS 60,000cells/µl(1.5-4.5
lakhs)
110000cells/µl
ESR 100mm at the end of the
1st hour

24. 11/12
RBS 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 Reactive
HBs Ag - ve
Albumin 3.1 gm %(3.5-5.2)

25.  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

26. TREATMENT CHART
BRAND
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,nic
otinamide
15mg,
0.15mg,200m
g
im 1-0-0 √ √ √ √ √ √ √ √
IVF DNS 2 pint iv 1-1-1 √ √ √
TAB.Sepmax
DS
Sulphamethoxazole
,trimethoprim
800mg,160m
g
p/o 1-0-0 √ √ √ √ √ √
TAB.Benadon Vit B6 40mg p/o 0-1/2-0 √ √ √ √ √ √
TAB.Akurit 4 INH,rif,pyr,ethamb
utol
75mg,150mg,
400mg,275m
g
p/o 3-0-0 √ √ √ √ √ √

27. FOLLOW UP
 DAY 1
 O/E,
 BP:100/70 mmHg
 PR:90 bpm
 Febrile
 S/E,
 CVS:S1 S2 +
 RS:NVBS+
 CNS:NAD
 P/A:Soft,non-tender

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

29.  DAY 2
 O/E,
 BP:110/70mmHg
 PR:80 bpm
 S/E,
 CVS:S1 S2 +
 RS:NVBS+
 CNS:NAD
 P/A:Soft non-tender

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

31.  DAY 3
 O/E,
 BP:110/60mmHg
 PR:80 bpm
 S/E,
 CVS:S1 S2 +
 RS :NVBS +
 CNS:NAD
 P/A :soft non tender

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

33.  DAY 4
 O/E,
 BP:120/60mmHg
 PR:88bpm
 Afebrile
 S/E
 CVS:S1,S2 +
 RS:NVBS+
 CNS:NAD
 P/A:Soft non tender

34.  Adv:
 APC

35.  DAY 5
 O/E
 BP:110/60mmHg
 PR:88bpm
 Afebrile,
 S/E
 CVS:S1,S2 +
 RS:NVBS+
 CNS:NAD
 P/A:Soft non tender

36.  Adv:
 APC

37.  DAY 6
 O/E:
 BP:110/60mmHg
 PR:80bpm
 Afebrile
 S/E:
 CVS:S1,S2 +
 RS:NVBS+
 CNS:NAD
 P/A:Soft non tender

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

39.  DAY 7
 O/E:
 BP:110/70mmHg
 PR:84bpm
 S/E:
 CVS:S1,S2 +
 RS:NVBS+
 CNS:NAD
 P/A : Soft non tender

40.  Adv:
 APC

41. FINAL DIAGNOSIS
 FROM THE SUBJECTIVE AND OBJECTIVE
EVIDENCES , THE PHYSICIAN DIAGNOSED IT AS
“RVD POSITIVE ,PULMONARY TB ,
PANCYTOPENIA”

42. DISCHARGE MEDICATION
BRAND GENERIC NAME DOSE ROUTE FREQUENC
Y
DURATION
T.AKURIT 4 INH,PYR,EHAMBUTOL,RIFAM
PICIN
75mg,400mg,2
75mg,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,TRIM
ETHOPRIM
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,2
00mg
p/o 1-0-0 10DAYS

43. PHARMACEUTICAL CARE PLAN
 SUBJECTIVE 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%

44. 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.

45.  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.

46. 2. Concurrent use of rifmpin and isoniazid can cause
severe hepatic toxicuty, so monitor LFT.
MONITORING PARAMETER
CBC with ESR
LFT
CD4 COUNT
CLINICAL SYMPTOMS OF LIVER INJURY

47. TREATMENT
PHARMACOLOGICAL 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)

48.  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 DRUGS
 Ciprofloxacin
 Azithromycin
 Rifabutin

49. CATEGORY BASED TREATMENT
 Category I:New positive pulmonary TB patients.
 New severe extra pulmonary tuberculosis patients
 Negative 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 disease
 Multi-drug resistant TB

50. DOTS(Directly Observed Treatment
In Short Strategy)
 H3R3Z3E3/S3 for 2 months +H3R3 for 4 months
 Total therapy:6 months
 DOTS Therapy is directed to following people:
 Homeless people
 History of non-medication adherence patients.
 Chronic alcoholic
 Active TB
 TB with AIDS:2HRZE,Duration:9 months
 Mycobacterium avium complex in AIDS due to immune
suppression.Clarithromycin/Azithromycin+Etm+/-
Rifampin

51. 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

52. STANDARD TREATMENT -First line
drugs
The recommended preferred first-line ARV regimens
For infants and children are:
 Regimen of 2 NRTI plus 1 NNRTI
 AZT* + 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.

53. 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

54. PATIENT COUNSELLING
 About 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.

55. LIFE STYLE MODIFICATION FOR RVD
WITH PTB
 Medication Adherence
 Potential 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 assessment
 Psychological support
 Exercise

56.  Dont spit in the public places
 Avoid irritants (smoke , dust )
 Use mask while coughing
 About the administration of the drugs which the
doctor has prescribed
 Advice patients to report the signs of hepatic
dysfunction such as dark urine , decreased appetite ,
jaundice .