Unit 7 Treatment of TB:Unit 7 Treatment of TB:B Family CaseB Family Case

Botswana National Tuberculosis Programme Manual Training for Medical Officers

Slide 2Unit 7: Case Study

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

B Family BackgroundB Family Background

Slide 3Unit 7: Case Study

B Family Case (1)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

Slide 4Unit 7: Case Study

B Family B Family Case (2)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)

Slide 5Unit 7: Case Study

B Family B Family Case: Question 1Case: Question 1

1. How do you manage Mr. B’s case?

2. Does Mr. B qualify for HIV treatment?

Slide 6Unit 7: Case Study

B Family B Family Case: Case: Answer 1 (1)Answer 1 (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

Slide 7Unit 7: Case Study

B Family B Family Case: Answer 1 (2)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

Slide 8Unit 7: Case Study

B Family B Family Case: Answer 1 (3)Case: Answer 1 (3)

2. All HIV positive TB patients qualify for HIV treatment

• Treatment start time is variable• Review BNTP manual

Slide 9Unit 7: Case Study

B Family B Family Case: Case: Question 2 (1)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

Slide 10Unit 7: Case Study

B Family B Family Case: Case: Question 2 (2)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?

Slide 11Unit 7: Case Study

B Family B Family Case: Case: Answer 2 Answer 2

• Obtain a sputum specimen on the spot and send it for microscopy

Slide 12Unit 7: Case Study

B Family B Family Case: Case: Question 3Question 3

What other tests should the

medical officer order?

Slide 13Unit 7: Case Study

B Family B Family Case: Case: Answer 3Answer 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

Slide 14Unit 7: Case Study

B Family B Family Case: Case: Question 4Question 4

• Wt 52kg• T 38.2• RR 26• HR 118• White patches on

soft palate

• Cervical lymphadenopathy

• Course lung sounds• Enlarged liver

• CXR shows reticular nodular pattern• Examination shows:

Based on these results, what should be the next step of Mr. B’s treatment?

Slide 15Unit 7: Case Study

B Family B Family Case: Answer 4Case: Answer 4

• Admit Mr. B

• Start him on:• Crystalline penicillin & cotrimoxazole, 4SS tabs • Fluconazole, 200mg daily x 14• Paracetamol, 500mg TDS-PRN• IV fluids

Slide 16Unit 7: Case Study

B Family B Family Case: Question 5Case: Question 5

What is Mr. B being presumptively treated for?

Slide 17Unit 7: Case Study

B Family B Family Case: Answer 5Case: 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

Slide 18Unit 7: Case Study

B Family B Family Case: Case: Question 6Question 6

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

How do you manage Mr. B’s case?

Slide 19Unit 7: Case Study

B Family B Family Case: Case: Answer 6 (1)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

Slide 20Unit 7: Case Study

B Family Case: B Family Case: Answer 6 (2)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

Slide 21Unit 7: Case Study

B Family B Family Case: Question 7 (1)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

Slide 22Unit 7: Case Study

B Family B Family Case: Case: Question 7 (2)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

Slide 23Unit 7: Case Study

B Family B Family Case: Case: Question 7 (3)Question 7 (3)

1. What ART regimen is he started on and when does he begin treatment?

2. What lab test is important in choosing an ART regimen?

Slide 24Unit 7: Case Study

B Family B Family Case: Case: Answer 7Answer 7

1. Combivir + Efavirenz• 2 weeks after initiating ATT

2. 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)