A 45-year-old male presented with a 2-month history of dry cough and 1-week history of shortness of breath. He was diagnosed with disseminated tuberculosis involving the lungs and massive pericardial effusion. He was started on anti-tuberculosis medications and steroids. He developed lower limb deep vein thrombosis and was started on anticoagulation. He underwent pericardial drainage and window procedure. His treatment plan includes continuing anti-TB medications, increasing warfarin dose, and educating the patient about medication adherence and side effect monitoring.

1. 1
Addis Ababa University
School of Pharmacy
Department of Pharmacology and
Clinical Pharmacy
Disseminated tuberculosis
(lung +pericardium
Arega Gashaw
December 12, 2014

2. Patient Presentation
▫ Card no : 31968
▫ bed No: 812/3
▫ Ward : C 8
▫ Age : 45 years
▫ Sex: M
▫ weight: NA
• CC
▫ Dry Cough for 2 month
▫ Shortness of breath for 1 week
▫ Non trauma
HPI
disseminated TB with massive pericardial effusion with
cardiac tamponed secondary to DTV

3. • PMH : pneumonia
• Medications prior to admission…. NA
• drug allergies ….NKDA
• ADR… NA

4. Physical examination
• Vital sign
▫ PR= 90
▫ RR= 27
▫ BP =90/60 mm Hg
▫ T 36.5°C
▫ Sa O2= 91 %
• HEENT:
▫ Eye: pink conjunctivitis
▫ Distended neck vein
• Leg : lymphatic adenopathy
• Abdominal – liver: smooth, tender, SD+
• MS - grade II pedal edema

5. • Chest: clear and good air entry over the right
side
▫ decrease air entry over the left side
▫ Several pericurdium effusion with tamponda
▫ Chest tube insitu over the left side for drainage of
fluid
• CVS : distant heart sound
• Respiratory: dry cough, SOB
• CNS: conscious
pertinent laboratory findings
• CBC
▫ WBC---- 6.69 × 103/mm3
▫ RBC----- 5.1 × 103/mm3
▫ Platelet--- 2.97 × 103/mm3
▫ Hg ---12.7 g/dL (12-18)

6. Investigation ……
• Coagulation profile
 PT 20.1sec
▫ INR 1.65 sec
▫ PTT 31.7 sec
• AFB 3x negative
• No gram stain
• Pleural fluid analysis
▫ Cell count 200 (ref. < 5 cell/ cc)???
 N-20%
 L-80 %
▫ Cytology : reactive infusion

7. Investigation……
• Total protein 5.8 g/dL…….. (6.6-8.7)
▫ Albumin 3.5 g/dL……….. (3.8-4.65)
▫ Uric acid 9.5 mg/dL…………(3.4-7.1)
▫ LDH 601U/L …………(230-430)…..5951
Serum electrolyte
▫ K 3.8 mEq/L
▫ Na 131 mEq/L
▫ Ca 4.4 mEq/L

8. Investigation……
• Organ function test
▫ BUN 39 mg/dL
▫ Cr 1 mg/dL
▫ ALT(SGPT) -166 U/L….(<40)
▫ AST(SGOT)- 287U/L ….(<40)
▫ ALP- 240 U/L….(44-147)
▫ Bl T- 1.4 mg/dL
▫ D -1mg/dL

9. Other investigation
• Echo examination revels that several
pericardium effusion are present
• CT(chest) : metastasis to the lung with moderate
bilateral plural effusion and pericardial effusion
• Abd U/S: hepatomegally, ascities, right renal
cortical cyst
• Abd CT: requested

10. Hospital Course
• On 10/3/07 He was started anti TB.
RHZE (150+75+ 400+275 mg)4 tab/day
Steroid (prednisolone 60 mg PO/d after
cardiologic side was consulted.
• On 12/3/07
• He develop lower limb acute distal
DVT(doppler proved) and start
anticoagulant
▫ Heparin 17,500 U SC Bid and
▫ Warfarin 5 mg PO/d

11. On 23/3/07
He was preparing for surgery(window opening for
Pericardial fluid drainage
▫ Warfarin discontinue
▫ Heparin continue
On 24/3/07
Pericardial fluid drainage was done and sample sent
for analysis and cytology.
On the same day pericardial window is done by
cardio thoracic gird

12. On 25/3/07
Chest tube is inserted for massive left side.
Drain about 1 L of fluid up on insertion
Currently ;He is complaining of the surgical site pain

13. Currently he is on
Anti TB-RHZE/150+75+400+275mg 4 tab/day
Prednisolone 60 mg PO/d
Pyridoxine 50 mg PO /d
Heparin 17500 U sc
Planned to resume warfarin after
coagulation profile is updated and
discontinue heparin.
Analgesics : petidine 25 mg iv tid
tramadole ……….

14. Discussion and critique of current
treatment
• Use of prednisolone for TB ???
• Prolonged anti coagulant bridge therapy?
• Dose of warfarin ?
• Drug interaction
▫ Ref Vs warfarin
▫ Ref Vs predinsolone
▫ INH Vs warfarin
Pyridoxine + warfarin ( increase or decrease INR b/c
of clotting factor metabolism may alter

15. desired therapeutic outcome
• Achievement of a noninfectious state
• Adherence to the treatment regimen
• Cure as quickly as possible (generally with at least
6 months of treatment)
• Reduction or elimination of symptoms
• Not complicating or aggravating other existing
disease states.
• Avoiding or minimizing adverse effects of treatment.
• Providing cost-effective therapy.
• Maintaining the patient’s quality of life.

16. • Therapeutic Alternatives
▫ LMWH is available for patient with cancer
associated DVT
▫ And where warfarin is contraindicated for long
term treatment
▫ LMWH is either cost saving or cost effective
compare with UFH
▫ Restriction of sodium and fluid
▫ Compression therapy
▫ anti-embolism stockings
▫ Regular exercise
▫ Elevate limbs while seated

17. Design of an optimal individualized
pharmaco-therapeutic plan
▫ Assess and reinforce adherence/concordance with
recommended therapy.
▫ Continue both the anti TB drug, pyridoxine
▫ Suggest discontinuation of prednisolone and
heparin and increasing warfarin to 7.5 mg PO until
to the target INR
▫ Educate on purpose of each medication

18. parameters to evaluate the outcome
1. Clinical evaluation
2. Bacteriological examination
3. Chest radiograph
• Clinical Evaluation
▫ Patients should have clinical evaluations at least
monthly to
▫ Assess adherence; and
▫ Determine treatment efficacy
▫ Identify possible adverse reactions to medications

19. • For any drugs : Allergic reaction ,Skin rash
• For EMB
▫ Eye damage (Blurred or changed vision
• INH, PZA, RIF: Hepatic toxicity
• For INH
▫ Nervous system damage
• Dizziness; tingling or numbness, around the mouth
▫ Peripheral neuropathy • Tingling sensation in hands and
feet
• For PZA
▫ Stomach upset Serious, gout
• For RIF
 Bleeding problems
 discoloration of body fluids
Sensitivity to the sun • Frequent sunburn Minor

20. For warfarin
• Red or dark brown urine and stool
• Bleeding
• Severe headache or stomach pain or upset
• Weakness, faintness, or dizziness
• Skin rash or irritation
• Unusual fever
• Joint or back pain
• Swelling or pain at an injection site

21. Steroids
• salt and water retention
• extracellular fluid volume expansion
• Hypertension
• potassium depletion, and
• metabolic alkalosis
• Immunodeficiency

22. Bacteriological examination
▫ Patients whose cultures have not become negative
after 3 months of
▫ therapy should be reevaluated for potential drug-
resistant disease,
▫ as well as for potential failure to adhere to the
regimen.
▫ AFB ???
▫ AFB cultures?
 Drug susceptibility studies NEVER ADD 1 DRUG IF SUSPECT
RESISTANCE
▫ CXR: Baseline, 2-3 months and after completion

23. General Approach
• Clinical Evaluations at 2 (with PZA), 4 and 8
weeks, then monthly:
▫ PE: Signs/symptoms of hepatitis
▫ Lab Exam
 CBC/platelets
 Liver function tests (ALT, AST, Bili, ALP) at baseline
and monthly
 D/C INH if:
▫ Patient develops symptomatic hepatitis
▫ LFTs > 5 times normal or > 3-5 times baseline
 Renal function tests (Scr, BUN, U/A)
▫ Review of Medication Profile (drug interactions)

24. Monitoring Toxicity
• Hepatotoxicity Plan
• Clinical or Laboratory Evidence
▫ S/S hepatitis, jaundice
▫ AST, ALT > 350 or Bili > 3 D/C INH, Rifampin
and Pyrazinamide
 3x baseline or 5 x normal
Monitorng parameter for heparin and warfarin
PT/INR at the base line, hg, Hct, plt,

25. Provision of patient education including
discharge medication counseling
▫ Take your drug at the same time at each day
▫ Your dose may be adjusted several times based on
the lab. Test
▫ Do not stop taking your medication with our your
doctor approval
▫ Inform your doctor or the pharmacist for any unusual
bleeding from any site,
▫ the symptoms of warfarin toxicity early
▫ Notify your doctors if develop chills, fever, skin rash

26. Other issue …..
• When to seek necessary medical attention
• Consequences of not taking their medicine
correctly
• Name and description of the medication (which
may include the indication).
• Dosage, dosage form, route of administration,
and duration of therapy.
• Action to be taken in the event of missed
doses.

27. 1/25/2016
Presentation on internal medicine ward
Attachment
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