CLINICAL CASE

SECTION A - GROUP 8

Odosis - Ogania - Omana - Orbase - Orcales - Oriane - Ortiguero - Ortiz - Pablo - Pagteilan
 OBJECTIVES
● To identify the clinical impression and basis.
● To enumerate the differential diagnosis and basis.
● To discuss the pathophysiology and pathogenesis.
● To enumerate the laboratory & diagnostic procedures.
● To interpret the laboratory results, final diagnosis & management.
● To discuss the complications & prognosis.
GENERAL DATA
● L.G, 19 years old
● Male
● Student
● Single
● Roman Catholic
● Born in Bacolod
● Presently residing in Caloocan City
● Consult for the 1st time
CHIEF COMPLAINT

COUGH
HISTORY OF PRESENT
3 weeks PTA
ILLNESS
7 weeks PTA ● Cough persisted and the amount of sputum also
increased to about 100-150 ml per day but without any
● Non-productive cough
any change in the character of the sputum.
● Not accompanied by sore throat, fever or
● At this time, patient started to loss appetite.
nasal obstruction or discharge
10 days PTA
5 weeks PTA
● Still with the above mentioned symptoms of productive
● Cough becomes productive, sputum is
cough and loss of appetite, febrile, low grade and
describe as whitish & mucoid amounting
intermittent fever occur in late afternoon or early
to about 60 ml per day
evening.
● Still do not have any other accompanied
● Relieved by intake of Paracetamol 500mg
symptoms.
● Patient sought consultation due to persistent of cough &
fever.
 Past Medical History

❏ Patient received childhood immunization against Polio, Tetanus and

Pertussis.
❏ (+) Chicken pox & Rubella during elementary days.
❏ (-) Allergy
❏ (-) Previous hospitalization or accident
 Family History

● (+) Hypertension (Father, 52 years old, accountant)

● Healthy (Mother, 50 years old, grade school teacher)

● (+) Diabetes Mellitus Type 2 (Paternal Grandmother)

● No other heredofamilial diseases like asthma, arthritis, gout, cancer, hyperlipidemia,

kidney disease, psychiatric problem, seizures disorder, thyroid disease and

tuberculosis.
 Personal & Social History

● They live in a 2 bedroom flat with good ventilation.

● Located along 6th avenue, 3rd floor of a 5 storey building.
● Non-smoker
● Non-Alcoholic beverage drinker
● Patient plays basketball during weekends with his friends.
● Patient eat regularly and sleep about 6-7 hours per day.
● Garbage are collected twice a week.
 Review of Systems
General/Integumentary
General: (-) weakness, (-) fatigue,
(+) weight loss (noted as loosening of pants about ½ inch in 3 weeks)
Integumentary: (-) rashes, (-) itching, (-) dryness, (-) changes in color,
(-) increase hair fall
HEENT
Head: No headache, No dizziness
Eyes: No redness, No excessive tearing, No double or blurred vision, No pain,
No uses of glasses
Ears: No hearing loss, No tinnitus, No vertigo, No earaches, No discharge
Nose & Sinuses: No nasal stuffiness, No discharge, No itching, No nose bleeding
Throat: No sore throat, No itching, No hoarseness
Teeth & Gums: No dentures, No bleeding but has dental caries
 Review of Systems
Neck: No lump, No pain, No stiffness
Respiratory: No hemoptysis, No dyspnea, No pain
Cardiovascular: No chest pain, No edema, No orthopnea, No dyspnea,
No paroxysmal nocturnal dyspnea, No claudication
Gastrointestinal: No heartburn, No dysphagia, No nausea & vomiting,
No change in bowel movement, No change in character of
stool, No pain on defecation, No abdominal pain
Genitourinary: No frequency, No polyuria, No nocturia, No urgency,
No dysuria, No flank pain, No force of urinary stream,
No hesitancy, dribbling
Musculoskeletal: No muscles or joint pain, No stiffness, No arthritis,
No low back pain
 Review of Systems
Psychiatric: No nervousness, No tension, No memory change,
No suicide attempts

Neurologic: No changes in mood, No headache, No numbness,

No loss of sensation, No tremors, No seizures,
No weakness, No fainting

Hematologic: No anemia, No easy bruising, No bleeding, No transfusion,

No heat or cold intolerance, No excessive sweating,
No polydipsia, No polyphagia, No polyuria
PHYSICAL
EXAMINATION
General Survey: Conscious, cooperative, well-developed, medium build,
well-nourished, with good grooming, ambulatory & cardiopulmonary not
in distress.

Vital Signs:
Blood Pressure : 110/70 mmHg
Respiratory Rate: 19/min
Pulse Rate: 76 beats per min
Temperature: 37.3 degrees celsius
 PHYSICAL
EXAMINATION
Skin: Brown, Smooth, No active lesions with good skin turgor
HEENT
Head: Normocephalic, fine black hair, no scalp lesion
Face: No asymmetry, with good facial expression
Eyes: eyebrow evenly distributed, no active lesions, Eyelashes of the upper
eyelids are directed outward and upward while the lower eyelids are
directed outward and downward, No signs of irritation, erythema or
change in color of the eyelids, palpebral conjunctiva is reddish, bulbar
conjunctiva is white, No dilated blood vessels, Iris is brown, pupils are
round, equal and about 4mm reactive to accommodation, direct and
indirect light stimulation, Cornea is clear, (-) arcus senilis, intact
extraocular muscles
 PHYSICAL
EXAMINATION
Ear: Normal set of ears, No abnormality of the pinna, No tenderness,
No discharge, Auditory canals are clean not skin lesion seen, both tympanic membranes are
shiny, pearly gray, able to visualize the cone of light

Nose: Nasal septum is in midline, No perforation, No discharge, turbinates are

moist and pink, vibrissae seen in the anterior nares, frontal and maxillary
sinuses are not tender, with normal transillumination test.

Mouth: Lips are moist and pink, (-) cheilosis, tongue is symmetrical, No lesion
seen and midline upon protrusion, complete sets of teeth, with some
dental caries seen in 1st molar on right and 2nd molar on the left side
both on the lower sets of teeth, No gum bleeding, uvula is midline,
tonsils not enlarged or inflamed, posterior pharyngeal wall is smooth &
pinkish
 PHYSICAL
EXAMINATION
Neck: No distended neck veins, trachea is at midline, thyroid glands not
palpable, No palpable mass or enlarged lymph nodes.

Chest & Lungs: Elliptical in shape, symmetrical, No dilated superficial blood

vessels, No skin lesion, No abnormal hair growth, No widening or
narrowing of the intercostals spaces, No retractions; normal
tactile fremitus; resonance on percussion of both lung fields;
crackles heard over the right upper chest both posterior and
anterior chest wall.
 PHYSICAL
EXAMINATION
Cardiovascular: Adynamic precordium JVP is 3 cm with the chest elevated at 30˚ angle; apex beat
,

felt the 5th ICS left midclavicular line, No heaves, No lifts, No thrills; S1 better heard at the apex and
S2 louder at the base, no splitting of S2, No murmur appreciated, (-) S3 & S4. Carotid pulses are
strong, equal, with a rapid upstroke and a gradual down stroke, both brachial, radial, popliteal,
pretibial and dorsalis pedis are equal and pulse strength of 2+

Abdomen: Flat, umbilicus is inverted, No dilated blood vessels seen, No visible peristalsis;
normoactive bowel sounds on auscultation of the 4 quadrant, 17 to 25 bowel sounds/min., (-) bruits
over the liver area, abdominal aorta and renal arteries area; abdomen is soft, non tender, no palpable
mass, both liver and spleen are not palpable; Traube’s space is intact, liver span is 7 cm along the
right midclavicular line; negative for kidney punch; (-) Murphy’s sign, Obturator sign, Psoas sign
and Rovsing sign.
 PHYSICAL
EXAMINATION
Extremities:
Hands: No enlargement, No swelling, No erythema and tenderness of the
interphalangeal joints, No atrophy of the thenar and hypothenar,
No clubbing of the fingers, Normal range of motions of the joints
including the wrist.
Upper extremities: No swelling redness or tenderness of the elbow and
shoulder joints with normal range of motions, forearm
circumferences – right 23 cm and left 22.5 cm, upper arm
circumferences – right 28 cm and left 27.8 cm.
 PHYSICAL
EXAMINATION
Lower extremities: No swelling, No erythema and tenderness of the ankle,
knee and hip joints; normal range of motion of the ankles,
knees and hips; Thigh circumferences – right 47 cm. left
47.5cm; calf circumferences – right 36 cm., left 36 cm.,
(-) Anvil sign, Patrick sign and Straight-leg raising sign.
No swelling, No erythema or tenderness of the toes.
Normal gait.

Spine: No abnormal curvatures of the spine, No tenderness,

Normal mobility of the spine
 PHYSICAL
NeuroEXAMINATION
Exam:

Cerebrum: Conscious, coherent, oriented to time, place, and person, shows

good rode, recent and remote memories, speak with ease and
fluently, show good judgment and calculation ability, able to
follow simple command.

Cerebellum: Can do finger to nose test, heel to shin test, rapid pronation
supination movement, (-) Romberg’s sign, normal gait and can
do tandem walking.
Cranial Nerves:

CN I (Olfactory): Able to identify smell of coffee

CN II (Optic): Normal visual acuity, and normal confrontation test

CN III (Oculomotor) IV (Trochlear) VI (Abducens): Intact extraocular muscle

movement, normal pupillary light reflex.

CN V (Trigeminal): Can clench teeth, can move jaw side to side, can feel light
touch on the lower, middle and upper portion of the face,
normal corneal reflex.

CN VII (Facial): Can smile, frown and elevate the eyebrows equally, can close
eyes against resistance, able to taste sweet and salty solution in
the anterior part of the tongue.
CN VIII (Vestibulo-Cochlear): Able to hear ticking of the watch in a distance of
3 inches, normal Rinne test and Weber test.

CN XI (Glossopharyngeal): (+) Gag reflex

CN X (Vagus): Normal gag reflex, uvula in the midline, (-) hoarseness

CN XI (Spinal-accessory): able to shrug shoulder against pressure, able to turn

head side to side against pressure.

CN XII (Hypoglossal): (-) fasciculation of the tongue, tongue is midline on

protrusion, able to push cheek out using the tongue
against pressure
Muscle strength: 5/5 on all extremities
Sensory: Can feel light touch on all exposed part of the body, intact position and vibration sense,
intact 2 point discrimination in the hand, positive for stereognosis.

Reflexes:
Bicep, Tricep, Brachioradialis, knee and ankle reflexes on both right and left 2+

Negative for Babinski’s sign, Chaddock’s sign and Oppenheim

Meningeal sign:
No nuchal rigidity, Brudzinski’s sign and Kernig’s sign
 CLINICAL IMPRESSION

Pulmonary Tuberculosis
Basis:

● Productive cough and whitish mucoid sputum

● Loss of appetite and weight loss
● Fever occurring at afternoon and at night
● Crackles heard at upper posterior and anterior chest
● No childhood immunization for Tuberculosis
 Salient Features
● 19 y/o male
● Non-productive cough to productive cough in 7 weeks
● Increased sputum production, whitish and mucoid
● Fever occurring at afternoon and night
● Loss of appetite
● Weight loss
● (-) Family history of TB
● Crackles heard in right upper anterior and posterior chest wall
DIFFERENTIAL DIAGNOSIS
CHRONIC BRONCHITIS COMMUNITY ACQUIRED
PNEUMONIA

RULE IN (+) weight loss (+) Chronic persistent cough

(+) Productive cough with white mucoid (+) crackles over right upper chest
sputum (+) weight loss

RULE OUT (-)digital clubbing (-) Dyspnea

(-)hemoptysis (-) chest pain
(-)purulent sputum (-) Tachycardia
(-)history of smoking (-) High Grade Fever
(-)exertional dyspnea
Pathogenesis of tuberculosis
Pathogenesis of tuberculosis
Pathogenesis of tuberculosis
Pathophysiology of Pulmonary Tuberculosis
LABORATORY
WORKUPS
 Different Diagnostic Tests
For TB infection

● Basic diagnostic tests ● Additional work ups

○ Radiographic Procedures ○ Xpert MTB/RIF Assay
○ AFB Smear ○ Drug Susceptibility Testing
○ Mycobacterial culture
○ Mantoux Tuberculin Skin Test /
IGRA
Screening and Diagnosis of TB Disease
 Tests to be requested
● Routine tests
○ CBC with Differentials
○ Blood Chemistry
○ Urinalysis

● Diagnostic Tests
○ Chest X-ray
○ AFB Smear and Culture
○ Drug Susceptibility Testing
○ Mantoux Tuberculin Skin Testing / IGRA
 Laboratory Workups
● CHEST X-RAY
○ Primary radiologic evaluation of suspected or proven pulmonary tuberculosis
○ Findings may include nodular lesions, patchy infiltrates (mainly in the upper lobes), cavity
formation, scar tissue, and calcium deposits
○ Not specific for diagnosing pulmonary tuberculosis
■ Has low specificity
○ May appear normal even in the presence of the disease
○ Usual findings in TB cases:
■ Upper lobe infiltrates
■ Presence of cavities
■ Lymphadenopathies
■ Presence of calcifications
 Laboratory Workups
● AFB smear and culture
○ This is still considered as the most efficient way of identifying PTB
■ Provides definitive diagnosis of PTB
■ Simple and economical
■ Can be done in remote areas
○ Patients suspected for pulmonary tuberculosis are recommended at least 3 consecutive sputum
specimens for acid-fast bacilli , preferably collected in 8-24 hour intervals with at least one
being an early morning specimen.
○ Detection of acid-fast bacilli in stained and acid-washed smears examined microscopically
may provide the initial bacteriologic evidence of the presence of mycobacteria in a clinical
specimen
○ Negative smears do not exclude TB disease
 Sputum Collection Guidelines
To collect sputum, follow these steps:

1. Collect your sputum in the early morning

2. Do not eat, drink, smoke, brush your teeth or use mouthwash before collecting your sputum
3. Make sure your first name, last name and date of birth are on the label of the sputum bottles
4. Collect your sputum away from other people. If possible, go outside or open a window while you collect your sputum
5. Open a sputum bottle. Do not touch inside the sputum bottle or inside the cap
6. Take a deep breath. Hold the air for a few seconds. Breathe out slowly. Take another deep breath. Cough hard until sputum comes up in
your mouth
7. Spit the sputum into the sputum bottle. Do this until there is enough sputum to cover the bottom of the bottle
8. Screw the cap on the sputum bottle tightly so it does not leak
9. Write the date and time you collected the sputum on the label of the sputum bottle
10. Seal the sputum bottle in the plastic bag it came with. Do not put more than 1 sputum bottle in each plastic bag
11. Make sure to put the paper lab form in the pouch on the outside of the plastic bag (not inside with the sputum bottle)
12. After you finish collecting your sputum, wash your hands.
 AFB Smear Classification Results
Smear Result Smear Interpretation Infectiousness of Patient

4+ Strongly positive Probably very infectious

3+ Strongly positive Probably very infectious

2+ Moderately positive Probably infectious

1+ Moderately positive Probably infectious

+/- Weakly positive Probably infectious

No acid fast bacilli seen Negative Probably not infectious

 Laboratory Workups
● TUBERCULIN SKIN TEST
○ Mantoux test; Intradermal inoculation of mycobacterial purified protein derivative
○ False-positive result can be caused by infection with nontuberculous mycobacteria or previous BCG
vaccination
○ False negative test can result from immunosuppression
○ Should not be relied upon as test for active TB infection, because a negative result does not rule out
active disease

● INTERFERON GAMMA RELEASE ASSAY (IGRA)

○ Whole-blood test that can be used to diagnose M. tuberculosis infection
○ May be used in most instances in place of TST
○ Preferred in persons who received BCG vaccine because IGRA is not shared with any other BCG
strain
○ Previous BCG vaccination will not cause a false-positive IGRA
○ As with TST, should not be relied upon as test for active TB infection
○ Negative result does not rule out active TB
 Criteria for Positive Tuberculin Skin Test
> 5 mm > 10 mm > 15 mm
● HIV infection ● Recent immigrants (<5 years) from a ● People with no known risk
● Recent contacts of patient with high prevalence country factors for TB
● Injection drug users/abusers
active tuberculosis
● Residents or employees of high risk
● Fibrotic changes on chest congregate settings
radiograph consistent with ● Persons with medical conditions that
previous TB put them at risk
● Immunosuppression, including ● People with a low body weight (<90%
organ transplant or use of of ideal body weight)
corticosteroids > 15 mg/day and ● Children younger than 5 years of age
TNF-a antagonists ● Infants, children, and adolescents
exposed to adults in high-risk
categories
 LABORATORY RESULTS
CBC Sputum AFB:
● Hgb: 11 g/dl (13.2-15.2 g/L) No Acid Fast Bacilli found
● Hct: .33 (0.37 - 0.42)
● WBC: 7.2 (5-10) Na: 140 mmol/L (135-145 mmol/L)
● Neutrophils: 0.55 (0.40 - 0.60) K: 3.9 mmol/L (3.5 - 5.1 mmol/L)
● Lymphocytes: 0.30 (0.20-0.40) BUN: 4.8 umol/L (2.14-7.14 umol/L)
● Monocytes: 0.03 (0.02-0.08) Creatinine: 48 umol/L (45-84 umol/L)
● Eosinophils: 0.02 (0.01-0.03) FBS: 87g/dl
SGOT: 22 (0-35 U/L)
SGPT: 20 U/L (0-33 U/L)
 AFB Smear Result
Smear Result Smear Interpretation Infectiousness of Patient

No acid fast bacilli seen Negative Probably not infectious

Criteria for Patients to Be Considered Non-infectious

Patients can be considered noninfectious when they meet all of the following three criteria:

1. They have three consecutive negative AFB sputum smears collected in 8- to 24-hour
intervals (at least one being an early morning specimen);
2. Their symptoms have improved clinically (for example, they are coughing less and they
no longer have a fever); and
3. They are compliant with an adequate treatment regimen for 2 weeks or longer.
CHEST X-RAY FINDINGS

Multifocal patchy opacities in the right upper

lobe with thickening and upward shift of the
minor fissure.
 Additional Laboratory Workups
● Drug Susceptibility Testing
○ For all patients, the initial M. tuberculosis isolate should be tested for drug resistance
■ This is important to ensure effective treatment
○ Drug Susceptibility patterns should be repeated for patients who do not respond adequately to
treatment or who have positive culture results despite 3 months of therapy
○ It is primarily recommended to all patients who are at risk for drug resistance
■ All cases of retreatment
■ All cases of treatment failure
■ All other cases of smear (+) patients suspected to have one- or multi-drug resistant TB
■ All household contacts of patients with MDR-TB
■ In patients who may be infected with HIV
 Additional Laboratory Workups
Since AFB smear is negative and CXR is suggestive of TB, we can request for NAA in the form of Xpert MTB/RIF
assay

● Xpert MTB/RIF assay

○ Xpert MTB/RIF assay can simultaneously detect TB and rifampicin resistance in <2 hours and has a
minimal biosafety and training requirements
○ Has high sensitivity
○ Can be housed in non-conventional laboratory settings as long as a stable and uninterrupted power
supply can be assured
○ WHO recommends its use worldwide as the first-line diagnostic test in all adults and children with
signs or symptoms of active TB
Interpretation of Xpert MTB/RIF Assay Results and Treatment Decisions
 DIAGNOSIS

Pulmonary Tuberculosis
Basis:

● Patient’s signs and symptoms

● Presence of multifocal patchy opacities in the right upper lobe in chest x-ray
○ Accompanied by thickening and upward shift of the minor fissure
 Prevalence
● Press Release/21 July 2020 - CDC
○ The Department of Health (DOH) reported that although the number of tuberculosis (TB) cases
reported in the country in the first 3 months of 2020 has drastically decrease, this does not mean
good news
○ January to March - 88,662 new and relapse TB cases (20% decline) between February (30,728)
and March (24,782) - DOH-NTP
○ In 2019 - The Philippines had the highest TB incidence in Asia with 554 cases per 100,000 people,
according to a World Health Organization (WHO) report
○ Approximately, 74 Filipinos die of TB every day and is among the top 10 causes of death in the
country
 Prevalence
● All Causes of Mortality (Top
20), Philippines: January to
June, 2020 & 2021

Reference : https://psa.gov.ph/content/causes-deaths-
philippines-preliminary-january-june-2021
MANAGEMENT
 PHARMACOLOGICAL MANAGEMENT
Aims of TB Treatment:
1. To interrupt transmission by rendering patient noninfectious
2. To prevent morbidity and death by curing patients with TB while
preventing the emergence of drug resistance
 PHARMACOLOGICAL MANAGEMENT
Treatment Regimens
Treatment of all patients with new, previously untreated TB should consist of a
● 2-month initial or bactericidal phase
○ The majority of the tubercle bacilli are killed, symptoms resolved and
usually the patient becomes noninfectious
● 4- to 7-month continuation or sterilizing phase
○ It is required to eliminate persisting mycobacteria and prevent relapse
 PHARMACOLOGICAL MANAGEMENT
Initial or Bactericidal Phase:
● Isoniazid (INH)
● Rifampin (RIF)
● Pyrazinamide (PZA)
● Ethambutol (EMB)
 PHARMACOLOGICAL MANAGEMENT
Continuation-phase treatment depends on
● Results of drug susceptibility testing of initial isolates (where available)
● The presence or absence of a cavitary lesion on the initial chest x-ray
● Results of cultures taken at 2 months

4- to 7-month Continuation or Sterilizing Phase

● Isoniazid
● Rifampin
 TREATMENT COMPLETION
Treatment completion is defined primarily as the ingestion of the total
number of doses prescribed within the specified time frame. The duration of
therapy depends on the drugs used, the drug susceptibility test results of the
isolate, and the patient’s response to therapy. Most patients with previously
untreated pulmonary TB disease can be treated with either a 6-month or a 9-
month regimen, although the 6-month regimen is used for the majority of
patients. All 6-month regimens must contain INH, RIF, and initially, PZA. The
goal is to complete all doses within 1 year
 PHARMACOLOGICAL
MANAGEMENT
Regimen Dose Adverse Events
Isoniazid alone for 6 or Adults: 5 mg/kg (max, 300 Drug-induced liver injury, nausea, vomiting,
9 months mg) per day abdominal pain, skin rash, peripheral neuropathy,
dizziness, drowsiness, seizure, drowsiness, seizure
Children: 10 mg/kg per day

Rifampin alone for 3-4 Adults: 10 mg/kg per day Flu-like syndrome, skin rash, drug-induced
months liver injury, anorexia, nausea, abdominal
Children: 10 mg/kg (max: pain, neutropenia, thrombocytopenia, renal
<45 kg, 450 mg; ≥45 kg, 600 reactions (e.g., acute tubular necrosis and
mg) per day interstitial nephritis)
 PHARMACOLOGICAL
MANAGEMENT
Regimen Dose Adverse Events
Isoniazid plus rifampin As above As above
for 3-4 months

Rifapentine plus Adults and children: Hypersensitivity reactions, petechial skin rash,
isoniazid for 3 months drug-induced liver injury
Isoniazid: 15 mg/kg
(900 mg) weekly Anorexia, nausea, abdominal pain

Rifapentine: 15-30 mg/ Hypotensive reactions

kg (900 mg) weekly
TREATMENT OUTCOME
Outcome Description

Cured A sputum smear positive patient who has completed treatment and is sputum smear negative in the
last month of treatment and on at least one previous occasion

Treatment A patient who has completed treatment, but does not meet the criteria to be classified as "cured" or
completed "failure"

Died A patient who dies for any reason during the course of the treatment

Treatment Patient who is sputum smear positive at five months O later during treatment
failure A sputum smear negative patient initially who turned out to be positive during treatment

Lost to Patient whose treatment was interrupted for two consecutive months or more
follow-up

Transfer out Patient who has been transferred to another facility with proper referral/transfer slip for continuation
of treatment
 TREATMENT OUTCOME FOR EXTENSIVELY DRUG-
RESISTANT TUBERCULOSIS (XDR-TB)
Outcome Definition

Cure Completion of at least 24 months of XDR-TB treatment, with 10

negative cultures in the final 12 months of treatment

Completion Completion of treatment on the advice of a physician, without

other criteria to categorize the treatment as cure

Loss to follow-up Interruption of treatment ≥30 days

Failure to achieve sputum conversion by the 6th month of
treatment (two consecutive cultures at least 30 days apart), or
bacteriological reversion (two consecutive positive cultures at 30
day apart) or amplification

Death Death from any cause during XDR-T treatment

 FOLLOW-UP AFTER TREATMENT
Patients Type of Follow-up

Have a satisfactory response to Routine follow-up after treatment is not necessary

6- or 9- month regimen with
both INH and RIF

Have organisms that were fully Patients should promptly report any of the following
susceptible to drugs being used symptoms:
● Prolonged cough
● Fever
● Weight loss

Have organisms resistant to INH Patients should be monitored for 2 years

and RIF posttreatment

Have organisms resistant to INH Follow-up must be individualized

or RIF

REFERENCE: www.cdc.gov
 TREATMENT INTERRUPTION DURING
INITIAL PHASE
If the interruption occurred
during the initial phase, the
following guidelines apply:
● Lapse is ≥14 days – restart
treatment from the beginning
● Lapse is <14 days – continue
treatment to complete planned
total number of doses (as long
as all doses are completed
within 3 months)

REFERENCE: www.cdc.gov
 TREATMENT INTERRUPTION DURING
CONTINUATION PHASE
If the interruption occurred during the continuation
phase, the following guidelines apply. If the patient
received:

● ≥80% of doses, and sputum was acid-fast bacilli

(AFB) smear negative on initial testing–further
therapy may not be necessary;
● ≥80% of doses, and sputum was AFB smear positive
on initial testing– continue therapy;
● <80% of doses, and lapse is less than 3 months in
duration– continue therapy until all doses are
completed (full course); or
● <80% of doses, and lapse is greater than 3 months in
duration– restart therapy from the beginning of initial
phase.

REFERENCE: www.cdc.gov
NON - PHARMACOLOGICAL MANAGEMENT
1. Medical staff must wear high-efficiency disposable masks
2. Isolate patients with possible tuberculosis infection in a private room
3. Encouraged patients to follow good cough hygiene
4. Provide vitamins & minerals supplements when required
5. Integrated nutritional assessment counselling and support for the duration of
the illness.
COMPLICATIONS
● Hemoptysis ● Anorexia
● Impairment of lung functions ● Abdominal pain
● Bronchiectasis ● Night sweats
● Pulmonary aspergillosis ● Fever
● Dyspnea ● Chest pain
● Acute respiratory distress ● Nausea
syndrome ● cough/ sputum
● Headache ● Chills
● Weight loss
PROGNOSIS
● Pulmonary tuberculosis can be treated and is usually curable.
● Patients with tuberculosis who are left untreated may progress as severe and
can be fatal
○ 5 yrs in 50-65% of the case
● Failure of the treatment: (Patient who is previously treated for TB and the
sputum smear or sputum culture is positive at 5 months or later during
treatment)
○ Poor patient adherence to the treatment
○ Drug resistant TB
● For this case patient has good prognosis.
THANK YOU!