A case presentation on Pneumonia and TB by rxpharmedico.in

1. VIGNAN PHARMACY COLLEGE,
VADLAMUDI
A case study
on
PNEUMONIA and TUBERCULOSIS
By
B.NOM KUMAR NAIK,
17AB1T0005.

2. CASE STUDY
● A 77 years old male patient was admitted in hospital with chief
complaints of Cough with Hemoptysis, decreased apatite and known
case of Pulmonary Koch's with Secondary pneumonia
( Fungal - Candida + Klebsiella pneumonia )

3. S O A P NOTES :
Patient details : -
Name : - xxx Age : - 77 years Gender : - Male
Subjective evidences :
Chief complaints :
❑ Cough with Hemoptysis ,
❑ Decreased apatite .

4. Past history :
1. Hypertension,
2. Diabetes mellitus - 2,
3. Diabetic nephropathy with severe proteinuria,
4. Anemia
5. Generalized surgical emphysema
6. Hepatitis ( ATT Induced )
7. Hypokalemia - improved .

5. Past medical history :
1. Inj.Colistin - 1miu ….IV…..TID
2. Inj.Clindamycin - 600mg ….IV….TID
3. Inj.Capsofungin - OD
4. ATT Regimen
5. Tab.Atraconazole - 400mg….IOB
Family history :
● NIL.

6. Allergies :
● Not known
● Ex - Smoker,
● Ex - Alcoholic.
Social / personal history :

7. 1.Vitals :
Objective evidences :
● B.P : - 160/90mm Hg
● R.R : - 15Cycles/min
● P.R : - 106 Beats/min
● Temp : - 98.6 F
● SpO2 : - 82 %
● Height : - 160cm
● Weight : - 90 kg
● BMI : - 35.2 ( Obese )

8. 2.Clinical examinations :
 RS : BAE +
 Abdomen : Soft
 CVS : S1 , S2 +
 CNS : C & C

9. 3.Investigations :
1. COMPLETE BLOOD COUNT ( CBC )
2. SERUM ELECTROLYTES
3. LIVER FUNCTION TEST ( LFT )
4. BED SIDE ECHO
5. CT CHEST PLAIN
6. CHEST X - RAY
7. SPUTUM SAMPLE TEST
8. ECG
9. PLEURAL FLUID FOR LDH
10.RANDOM BLOOD SUGAR
11.C - REACTIVE PROTEIN.

10. COMPLETE BLOOD COUNT : -
Parameters Observed value Normal value
WBC 3,400cells/cumm 4000- 11000cells/cumm
Haemoglobin 8.8g/dL 12.0 - 15.0 g/L
Day : - 1

11. Parameters Observed value Normal value
Sodium 131 mmol/L 135.0 - 145 mmol/ L
Potassium 2.8 mmol/ L 3.5 - 4.5 mmol/L
Serum creatinine 1.0mg/dl 0.7 - 1.2 mg/dl
SERUM ELECTROLYTES: -

12. SERUM ELECTROLYTES : -
Parameters Observed value Normal value
Sodium 131 mmol/L 135.0 - 145 mmol/ L
Day : - 2
LIVER FUNCTION TEST : -
Parameters Observed value Normal value
Total bilirubin 1.9mg/dL 0.2 - 1.3mg / dL

13. BED SIDE ECHO : -
● Very poor echo windo
● Mild concentric LVH
● No obvious RWMA
● Grade - 1 Diastolic dysfunction of LVH
● AV Sclerosis / TriviLAAR
● Mild TR / Moderate PAH
● IVC : 1.39 cm ( Not collapsing )
● No clots.

14. Day : - 3
Parameters Observed value Normal value
Platelets 1.03laksh/cumm 1.5 - 40 laksh/cumm
PLATELETS COUNT : -
CT CHEST PLAIN : -
● History of Cough and Haemoptysis
● Extensive surgical emphymatous changes in chest wall
● Mild pneumomediastinum
● Consolidations in right middle lobe and lingula of left lung
● Mild bacterial pleural effusion with underlying lung collapse
● Large cavity lesion with fluid level and surrounding satellite nodular infiltrate with cavity seen involving
right upper lobe , possible tubular etiology however follow up needed

15. Day : - 4SERUM ELECTROLYTES: -
Parameters Observed value Normal value
Albumin 1.8g/dL 3.5 - 5.0g /dL
C.REACTIVE PROTEIN : -
Parameters Observed value Normal value
C.Reactive protein 200.6mg / dL <10 mg /dL

16. Day : - 5PLEURAL FLUID FOR LDH : -
Parameters Observed value Normal value
Pleural fluid for LDH 334 IU / L Physician co- relates.
SPUTUM SAMPLE TEST : -
● Negative bacilli in single and pair ;few budding yeast
● Manual cell's are observed.
Note : - From day 6, 7and 8 all parameters are observed normal

17. Day : - 9
Parameters Observed value Normal value
Sodium 133mmol/L 135.0 - 145.0 mmol/L
Leukocyte esterase Negative -
Serum creatinine 0.6 0.7 - 12mg/dL
Haemoglobin 9.7g/dL 12.0 - 15.0 g /dL
RANDOM BLOOD SUGAR 174 mg /dL 60 - 140 mg / dL
Nitrates Negative -

18. S.no Parameters Day – 1 Day – 2 Day – 3 Day – 4 Day – 5 Day – 6 Day – 7 Day – 8 Day – 9
1 B.P
(mm of Hg)
130/90 140/90 130/80 140/90 130/80 120/80 130/80 130/90 120/80
2 SpO2 95% 96% 100% 100% 98% 94% 95% 98% 98%
3 R.R 24 20 26 24 20 20 20 20 23
4 PULSE 100 92 100 102 115 90 112 86 97
5 TEMP 99 98.5 98.6 98.6 99.3 99 98.3 98 98.6
Vitals :

19. Assement :
● From subjective and objective evidences and some case relevant
studies an assessment was made and patient was diagnosed with
PULMONARY KOCHS with SECONDARY PNEUMONIA

20. ★ Tuberculosis (TB) is caused by infection with Mycobacterium tuberculosis (MTB), which is part of
a complex of organisms including M. bovis (reservoir cattle) and M. africanum (reservoir humans).
★ The resurgence in TB in the UK observed over the latter part of the last century has finally halted
and notification of TB has fallen by around 1.5% per year since 2000.
Causes : -
● Patient-related
➔ Age (children > young adults < elderly)
➔ First-generation immigrants from high-prevalence countries
➔ Close contacts of patients with smear-positive pulmonary TB
➔ Overcrowding (prisons, collective dormitories); homelessness (doss houses and hostels)
PULMONARY KOCHS (TB)

21. ➔ Chest X-ray evidence of self-healed TB
➔ Primary infection < 1 year previously
➔ Smoking: cigarettes, bidis (Indian cigarettes made of tobacco wrapped in temburini leaves) and
cannabis
● Associated diseases
➔ Immunosuppression: HIV, anti-tumour necrosis factor (TNF) and
other biologic therapies, high-dose glucocorticoids, cytotoxic agents
➔ Malignancy (especially lymphoma and leukaemia)
➔ Diabetes mellitus
➔ Chronic kidney disease
➔ Silicosis
➔ Gastrointestinal disease associated with malnutrition (gastrectomy,
jejuno-ileal bypass, cancer of the pancreas, malabsorption)
➔ Deficiency of vitamin D or A
➔ Recent measles in children.

22. Signs and symptoms : -
➢ Chronic cough, often with haemoptysis
➢ Pyrexia of unknown origin
➢ Unresolved pneumonia
➢ Exudative pleural effusion
➢ Asymptomatic (diagnosis on chest X-ray)
➢ Weight loss, general debility
➢ Spontaneous pneumothorax.
Diagnosis : - Specimens required
Pulmonary
● Sputum* (induced with nebulised hypertonic saline if patient not
expectorating)
● Bronchoscopy with washings or BAL(BAL = bronchoalveolar lavage)
● Gastric washing* (mainly used for children)

23. Extrapulmonary
● Fluid examination (cerebrospinal, ascitic, pleural, pericardial, joint): yield classically very low
● Tissue biopsy (from affected site): bone marrow/liver may be diagnostic in disseminated disease
Diagnostic tests
● Tuberculin skin test: low sensitivity/specificity; useful only in primary or deep-seated infection
● Stain
1. Ziehl–Neelsen
2. Auramine fluorescence
● Nucleic acid amplification
● Culture
1. Solid media (Löwenstein–Jensen, Middlebrook)
2. Liquid media (e.g.MGIT = mycobacteria growth indicator tube)
● Pleural fluid: adenosine deaminase
● Response to empirical antituberculous drugs (usually seen after 5–10 days)
Baseline blood tests
● Full blood count, C-reactive protein, erythrocyte sedimentation rate, urea and electrolytes, liver function tests
Note : - *At least two but preferably three, including an early morning sample.

24. ➢ Pneumonia is as an acute respiratory illness associated with recently developed radiological pulmonary
shadowing that may besegmental, lobar or multilobar.
➢ The context in which pneumonia develops is highly suggestive of the likely organism(s) involved; therefore,
pneumonias are usually classified as community- or hospital-acquired, or those occurring in
immunocompromised hosts.
➢ ‘Lobar pneumonia’ is a radiological and pathological term referring to homogeneous consolidation of one or
more lung lobes, often with associated pleural inflammation; bronchopneumonia refers to more patchy
alveolar consolidation associated with bronchial and bronchiolar inflammation, often affecting both lower
lobes.
Causes : -
★ Cigarette smoking
★ Upper respiratory tract infections
★ Alcohol
★ Glucocorticoid therapy
★ Old age
SECONDARY PNEUMONIA

25. ★ Recent influenza infection
★ Pre-existing lung disease
★ HIV
★ Indoor air pollution.
Organisms causing pneumonia : -
Bacterias
1. Streptococcus pneumoniae
2. Mycoplasma pneumoniae
3. Legionella pneumophila
4. Chlamydia pneumoniae
5. Haemophilus influenzae
6. Staphylococcus aureus
7. Chlamydia psittaci
8. Coxiella burnetii (Q fever)
9. Klebsiella pneumonia (Freidländer’s bacillus)

26. Viruses
1. Influenza, parainfluenza
2. Measles
3. Herpes simplex
4. Varicella
5. Adenovirus
6. Cytomegalovirus
7. Coronaviruses (SARS-CoV and MERS-CoV)(MERS = Middle East respiratory syndrome;
SARS = severe acute respiratory syndrome).
Signs and symptoms : -
● Cough with large amounts of sputum, sometimes fetid and blood-stained
● Pleural pain common
● Sudden expectoration of copious amounts of foul sputum if abscess ruptures into a bronchus
● High remittent pyrexia
● Profound systemic upset

27. ● Digital clubbing may develop quickly (10–14 days)
● Consolidation on chest examination; signs of cavitation rarely found
● Pleural rub common
● Rapid deterioration in general health, with marked weight loss if not adequately treated.
Diagnosis : -
★ Pulmonary infarction
★ Pulmonary/pleural tuberculosis
★ Pulmonary oedema (can be unilateral)
★ Pulmonary eosinophilia.
★ Malignancy: bronchoalveolar cell carcinoma
★ Cryptogenic organising pneumonia/bronchiolitis obliterans organising pneumonia (COP/BOOP)

28. Full blood count
★ Very high (> 20 × 109/L) or low (< 4 × 109/L) white cell count: marker of severity
★ Neutrophil leucocytosis > 15 × 109/L: suggests bacterial aetiology
★ Haemolytic anaemia: occasional complication of Mycoplasma
Urea and electrolytes
★ Urea > 7 mmol/L (~20 mg/dL): marker of severity
★ Hyponatraemia: marker of severity
Liver function tests
★ Abnormal if basal pneumonia inflames liver
★ Hypoalbuminaemia: marker of severityErythrocyte sedimentation rate/C-reactive protein
★ Non-specifically elevated
Blood culture
★ Bacteraemia: marker of severity
Cold agglutinins
★ Positive in 50% of patients with Mycoplasma
Atrial blood gases
★ Measure when SaO2 < 93% or when clinical features are severe, to assess ventilatory failure or acidosis
Blood

29. Lobar pneumonia
➔ Patchy opacification evolves into homogeneous consolidation of affected lobe
➔ Air bronchogram (air-filled bronchi appear lucent againsconsolidated lung tissue) may be present
Bronchopneumonia
➔ Typically patchy and segmental shadowing
Complications
➔ Para-pneumonic effusion, intrapulmonary abscess or empyema
Staphylococcus aureus
➔ Suggested by multilobar shadowing, cavitation, pneumatoceles and abscesses.
Sputum samples
➔ Gram stain, culture and antimicrobial sensitivity testing.
Chest X-ray
SPUTUM

30. ➔ Gram stain, culture and antimicrobial sensitivity testing
➔ Polymerase chain reaction for Mycoplasma pneumoniae and other atypical pathogens.
➔ Pneumococcal and/or Legionella antigen
Plural fluid
Oropharynx swab
Urine

31. Goals : -
● Comply with therapeutic regimen,
● No recurrence of disease,
● To have normal pulmonary function,
● To take appropriate measures to prevent disease spread,
● Measures to assist in effective coughing, maintain a patent airway,
decreasing viscosity and tenaciousness of secretions, and assist in
suctioning.
Treatment / Plan

32. Medications :
Drugs Generic name Dose Route Frequency Duration
Tab.Asporin + Clopidogrel
+ Atorvastatin
Tab.Asporin + Clopidogrel +
Atorvastatin
75mg /
75mg /
10mg
Po OD From day 1 to 9
Tab.Itraconazole Itraconazole - Po OD From day 1 to 9
Tab.Diltiazem Diltiazem 30mg Po TID From day 1 to 9
Tab.Bendon Vit.B6 40mg Po OD Give if required # Not given untill
Tab.Vibact DS lactobacillus - Po BID From day 1 to 9
Cap.Rabeprazole DSR Rebeprazole sodium and
domperidone
- Po OD From day 1 to 9
Inj.Human Actrapid Insulin - SC TID From day 1 to 9
Syp.Kcl Potassium chloride 10ml Po TID From day 1 to 9

33. Drugs Generic names Dose Route Frequency Duration
Neb with Duolin Levosalbutamol Tartarat - 50 mcg
Ipratropium Bromide - 20 mcg
- Nasal TID From day 1 to 9
Neb with Budecort Budesonide 0.5 mg / 1 mg - Nasal BID From day 1 to 9
Inj.Meropenam Meropenem Trihydrate and
Sterile Sodium Carbonate (Sodium 90.2
mg)
1gm I.V Q8H From day 2nd to 9th
Inj.Clindomycin clindamycin phosphate 60mg I.V Q8H From day 3rd to 9th
Neb.Mucomix Acetylcysteine - Nasal Q8H From day 2nd to 9th
Inj.Vit.C Vit.c 1.5gm I.V Q8H From day 2nd to 9th
Inj.Optineuron B - complex with vitamin.B12 1Amp I.V Q24H From day 2nd to 9th
Inj.Pantoprazole Pantoprazole I.V OD Give if requird.
Albumin care Proteins, Glutamine, BCAA 's Po Q12H Given on 9th day

34. Drugs Indication Standard dose
Tab.Asporin + Clopidogrel + Atorvastatin Anti platelet effect 81 – 325 mg + 75 – 325 mg + 10 –
80 mg / day
Itraconazole Anti – fungal 200 – 400 mg / day
Diltiazem Anti hypertensive 0.25 mg – 20 mg / day
Vit.B6 Vitamin supplement ---------
lactobacillus Probiotic 1 – 2 capsules / day
Rebeprazole sodium and domperidone GERD (Gastroesophageal reflux disease ) 60mg / OD + 10 - 20 mg / day
Insulin Hyper glycemia ( Harmonal supplement ) 0.5 – 1 unit/kg
Potassium chloride Hypokalemia 40 – 100 meq

35. Drugs Indication Standard dose
Levosalbutamol Tartarat - 50 mcg
Ipratropium Bromide - 20 mcg
bronchodilators 4mg + 500mcg / day
Budesonide Anti asthamatic 180 – 600 mcg / day
Meropenem Trihydrate and
Sterile Sodium Carbonate
Antibiotic 500mg + 90.2mg / day
clindamycin phosphate Antibiotic 150 – 300 mg for every 6 hrs
Acetylcysteine Mucociliary clearance 200 - 600mg / day
Vit.c Vitamin supplement -------------
B - complex with vitamin.B12 Vitamin supplement -----------
Pantoprazole Anti ulcer 40 mg / OD
Proteins, Glutamine, BCAA 's Proteins and amino acids
supplements
--------------

36. Patient counseling :
• Avoid eating fatty food.
• Maintain an ideal body weight.
• Do exercise daily for 30 mins.
• Avoid taking Cola beverages.
• Maintain healthy diet.
• Avoid taking Banana.
• Avoid taking Grape fruit juice and Grape fruits.
• Avoid exposure to second-hand smoke.

37. Pharmacist intervention :
1) Usually 2 antacids are not preferable because they cause therapeutic duplication.
2) Usually 4 vitamin supplements are not preferred because they can cause therapeutic duplication.
3) Should not take Diltiazem and Insulin at a time because they can cause severe hypoglycemia.
4) Should not take Itraconazole and budesonide simultaneously bcz they can cause Raise in B.P.
5) Should not take Itraconazole and Rabeprazole simultaneously Bcz they can cause less effective
against fungal species.
6) Insulin and syp.Kcl are not used together bcz they can cause increased hypoglycemia.
7) Should not take Diltiazem and Budesonide together Bcz they can cause Sever asthma attack.