This document discusses three cases of tuberculosis (TB). The first case involves a 52-year-old Hispanic female presenting with cough, sputum, fatigue, and blood in her sputum. Examination finds lymph nodes and rales in her left lung. Tests show a positive PPD test and cavitary lesions on her chest X-ray, confirming active pulmonary TB. The second case is about a man referred for cough and fever, with bilateral pneumonia and apical involvement on chest X-ray. Sputum smear confirms acid-fast bacilli, and TB is diagnosed. He refuses admission and treatment. The third case discusses a woman diagnosed with sputum smear-negative pulmonary TB who stops treatment and attending follow

1. T.B. Cases
Dr. Sameh Ahmad Muhamad abdelghany
Lecturer Of Clinical Pharmacology
Mansura Faculty of medicine

2. TUBERCULOSIS

3. CAS(1)

4. CHIEF COMPLAINT
4
 “I have had a cough for a month. Two nights ago I
woke up with a sharp pain in my chest and I coughed
up some blood.”.

5. HISTORY
5
 HS is a 52-year-old Hispanic female who presents to the emergency
department with complaints of cough, productive of small amounts of yellow
sputum within the last month. She has experienced increasing fatigue,
occasional shortness of breath on exertion, and mild chest discomfort. She
has had periodic night sweats; last night her temperature was 38.9°C. Two
nights ago, she noticed streaks of bright-red blood in her sputum without any
particular odor or taste. The only medication she has taken is an over-the-
counter cough preparation. Three months ago, the patient presented to a free
clinic and diagnosis revealed a diagnosis of type 2 diabetes. A purified protein
derivative (ppd) test, required for work clearance, was placed. She was noted
to have a positive ppd test, but because her chest x-ray showed no active
disease, she was cleared to work.

6. HISTORY
6
Past Medical History:
 Type 2 DM diagnosed 3 months ago
 Immunized with BCG
 Allergies/Intolerances/Adverse Drug Events:Penicillin
(rash)

7. PHYSICAL EXAMINATION
7
General
Vital Signs
 BP 144/92 mm Hg, P 82, RR 18, T 37.9°C
Neck and Lymph Nodes
 Few small 2–3-mm non tender, freely movable lymph
nodes in left anterior cervical and axial area

8. PHYSICAL EXAMINATION
8
Chest
 Configuration and expansion symmetrical. Tactile
fremitus, percussion symmetrical bilaterally. Breath
sounds and vocal fremitus are normal. A few rales are
noted at the left apex posteriorly.
 Other areas of examination was normal

9. LABORATORY
9
 Skin Test Results
 PPD (tuberculin) 16 mm at 48 hours

10. Chest X-ray
10
 Bilateral upper lobe
infiltrates with well-defined
cavitating lesion of the left
apex

11. Questions
11
 Q1.What groups are at highest risk for developing TB?
 Q2: In patients with laboratory-confirmed drug-susceptible
active pulmonary Mycobacterium tuberculosis (MTB), what are
the standard medication(s) and duration of treatment?
 Q3: The patient’s liver function tests are slightly elevated. Why
is this important and does it change the management of her TB
infection?
 Q4: How is therapeutic efficacy assessed in the treatment of TB?

12. Questions
12
Four weeks later, the patient returns for follow-up. Her
sputum cultures are positive for AFB and the organism is
identified as M. tuberculosis resistant to isoniazid (INH).
 Q5: How does this information change your recommended drug
combination and duration of drug therapy?
 Q6: How should the close contacts of this patient be treated?

13. Answer of Question 1
13
 Elderly
 Infants
 Low socioeconomic status
 Crowded living conditions
 Disease that weakens immune system like HIV
 Alcoholism
 Recent Tubercular infection (within last 2 years)
Back

14. Answer of Question 2
14
 Initial phase (first 2-4 months): 4 drugs are used (RIPE):
(Rifampin + INH + Pyrazinamide + Ethmabutol).
 Continuation phase (next 4-6 months): at least 2 drugs are
used (INH + rifampin).
Back

15. Answer of Question 3
15
 Most of anti-tuberculous drugs in first line are
hepatotoxic so needs liver functions monitoring
 INH, rifampin, and pyrazinamide are hepatotoxic
but because of their effectiveness, they should be
used depending on monitoring of liver function
tests.
 In severe liver damage, only one drug can be used.
Back

16. Answer of Question 4
16
 Efficacy assessed:
i. Clinical: symptoms & signs of TB dimnished
ii. Lab: sputum smear & Culture
iii. Radiological: chest x-ray
Back

17. Answer of Question 5
17
 Treatment must be individualized
 should seek expert consultation
 6 months intensive treatment (always including an
injectable drug) followed by at least an 18 month
continuation phase
 May proceed to 2nd line of anti-tuberculous drugs:
o Para aminosalicylic
acid ,Ethionamide,Cycloserine,Fluoroquinolones and
Capreomycin
Back

18. Answer of Question 6
18
 Latent TB (i.e. patients with +ve Tuberculin skin test and
had history of contact to a person proved to have TB)
 INH alone for 6-9 months or dual Rifampicin + INH for 3
months.
Back

19. CAS(2)

20. Scenario
20
A man in his 40s is referred to a chest physician with a cough
productive of sputum and a fever. A chest x-ray indicates bilateral
pneumonia with apical involvement. A sputum smear reveals the
presence of acid, alcohol-fast bacilli. His physician considers that
TB is the most likely clinical diagnosis. This is subsequently
confirmed microbiologically. The patient does not comply with
treatment and needs to be admitted to hospital, but refuses. There
are indications he might be disruptive if admitted into hospital.

21. Questions
21
 Q1: What form of TB does this patient have?
 Q2: What can be done to compel his admission to hospital?
 Q3: What treatment should he receive for his TB??

22. Answer of Question 1
22
 This man has sputum smear-positive pulmonary TB, the
infectious form of the disease, and poses a risk of infection to
others.

23. Answer of Question 2
23
 Legal measures should be considered to have the patient
compulsorily admitted to hospital.
 He will need to be admitted to a side room.
Back

24. Answer of Question 3
24
 Initial phase (first 2-4 months): 4 drugs are used (RIPE):
(Rifampin + INH + Pyrazinamide + Ethmabutol).
 Continuation phase (next 4-6 months): at least 2 drugs are
used (INH + rifampin).
Back

25. CAS(3)

26. Scenario
26
A woman in her mid-20s is diagnosed as having sputum smear-
negative pulmonary TB. Although she initially takes her anti-TB
drugs, she does not attend follow-up clinics and her condition
deteriorates. Her primary care doctor collects a sputum sample
from her and persuades her to attend the chest clinic. The sputum
smear is now positive and it is found she has continued to work,
despite being advised not to do so.

27. Questions
27
 Q1:What type of treatment regimen should be offered to this
patient?
 Q2: Should the patient's work contacts be screened?

28. Answer of Question 1
28
 Patients like this should receive supervised treatment
(DOTS) three times a week in a convenient setting, such
as at home.
Back

29. Answer of Question 2
29
 The question of whether work contacts should be
screened must be dealt with on an individual case basis.
 A telephone conversation will provide initial information
on the working environment and should be followed up
by a visit if initial inquiries indicate a possible need to
screen workplace contacts.
Back

30. T H A N K Y O U !
A N Y Q U E S T I O N S ?