TB case 1

Assessment :
35 2

5-6 kg

2
CXR patchy infiltrates in both
lungs with cavitation on left pleural effusion
Sputum smear AFB positive
tuberculosis Mycobacterium tuberculosis
Anit-HIV (+) CD4 count 68 cells/mm3
HIV
pulmonary tuberculosis with HIV infection

TB 2HRZE/4HR
45 .

Isoniazid(H) 5 MKD = 225 mg/day ( 100 mg)
Rifampicin (R) 10 MKD = 450 mg/day ( 450 mg)
Pyrazinamide(Z) 25 MKD = 800 mg/day ( 300 mg)
Ethambutol(E) 15 MKD = 675 mg/day ( 400 mg)
2 Antiretroviral
IRIS (Immune reconstitution inflammatory syndrome)
CD4
cotrimoxazole Pneumocystic jiroveci pneumonia
toxoplasmosis Fluconazole
Cryptococcosis
Plan
Goal :

-
-
-
ARVs

- CD4 count 3

ARVs

- viral load
50 copies/ml 12
-

Therapeutic Plan
Isoniazid(H) 100 mg

2 tab

Rifampicin (R) 450 mg

#32

cap #14

Pyrazinamide(Z) 300 mg 2 tab

#28

Ethambutol(E) 400 mg

#28

2 tab

Cotrimoxazole (80/420) 2 tab OD

Fluconazole (200) 2 cap
weekly
Future Plan
ARV TB 2-8
Tenofovir 300 mg OD
Lapivudine
300 mg OD
Efavirenz 600 mg OD hs
Therapeutic monitoring : -

- Sputum smear for AFB negative
- CD4 Goal >100-150 cells/mm3/year
- Undetectable VL
Safety monitoring :
Isoniazid(H)
: N/V,cutaneous reaction,hepatitis,peripheral
neuropathy
Rifampicin (R) : N/V, cutaneous reaction,hepatitis,orange/Red urine
Pyrazinamide(Z)
: N/V, cutaneous reaction,hepatitis.Arthralgia
Ethambutol(E) : cutaneous reaction, Arthralgia,optic neuritis
Patient education
-

-
-
-

Case 2
Assessment

icteric sclera Jaundice LFT
(AST 215 U/L,ALT 198 U/L,ALP 170,T.bilirubin 5.1 mg/dL)
Isoniazid,Pyrazinamide Rifampicin
EOS
(Ethambutol,Ofloxacin,Streptomycin) AST ALT
2X TB <1.5 mg/dL rechallenge Isoniazid
Rifampicin Pyrazinamide
1 AST ALT
TB 1

rechallenge AST ALT TB
Plan
Goal :

- enzyme (<25 U/L)

-
Therapeutic plan
- Ethambutol
- Ofloxacin
- Streptomycin
Future plan

 rechallenge hepatitis

1. 2
2HRES/7HR
9HRE
2. 1
2SHE/16HE
18-24 HEO
3.
18-24 EOS
Efficacy monitoring : -

- enzyme total bilirubin (AST<35

U/L,ALT<35 U/L,ALP<120)
Safety monitoring :
- Ethambutol : optic neuritis
- Ofloxacin : N/V,Diarrhea
- Streptomycin : Vestibular and auditory nerve
damage,renal damage

HIV case 1
1.
GPO-VirS30
..2553

..2553 GPO-VirS30
(d4T+3TC+NVP)

lipoatrophy/ lipodystrophy, peripheral
neuropathy, hyperlipidemia
(CrCl 37.8 ml/min)

2. TDF + 3TC + EFV 2556

chronic HBV infection

ARVs
2 NRTI backbone

3. genotypic drug resistance testing 2557

genotypic drug resistance testing
viral load > 400 copies/mL
6 viral load > 50 copies/mL
12
viral load 27,000
copies/mL . 57 12 (.56)
4. K65R, V179D, M184V
TDF + AZT + 3TC + LPV/rtv NNRTIs LPV/rtv

 K65R M184V NRTIs

Hypersusceptibility AZT TDF+3TC
NNRTIs LPV/rtv
NNRTIs
mutation (low
genetic barrier)

5. () TDF-induced renal
dysfunction, AZT-induced macrocytic anemia LPV/rtv-induced
dyslipidemia and hyperglycemia
TDF-induced renal dysfunction
Urianalysis urine Scr CrCl
Tenofovir function 6
renal impairment
AZT-induced macrocyticanemia
CBC Zidovudine 2-3 3
3-6
NRTIS Folic acid
LPV/rtv-induced dyslipidemia and hyperglycemia
Lipid profile 3-6
1
,
lipid glucose
dyslipidemia and hyperglycemia metformin,Sulfonylurea,Glitazone
insulin
6. CrCl
CrCl 37.8 mL/min

- 3TC 150 mg mg OD
- AZT
- TDF 300 mg q48 hr
- LPV/rtv

7.
CD4 = 210 cells/mm3

8.


-

-
-

HIV case 2
1. /
Opprtunistic infection
#Pneumocystic jiroveci pneumonia
DOC
(Cotrimoxazole 400/80) 15-20 MKD TMP 68 hr 1280 mg (18 MKD) 21 ;
DRPs MP rash cotrimoxazole
ADR

Secondary prophylaxis PCP 21

Dapsone 100 mg OD Alternative choice
Sulfa CD4>200
cell/mm3 3
#Cerebral toxoplasmosis
toxoplasmosis

alternative choice sulfa
Clindamycin 600 mg TID + Pyrimethamine 200 mg stat
50 mg OD Clindamycin 600 mg
6 hr (QID) Pyrimethamine stat 50-70 mg
71 kg (>60 kg) 75 mg Pyrimethamine 75 mg
(3 tab OD)
Folic acid 5 mg OD

10-25 mg OD
10 mg (2 tab) OD
6 TID secondary
prophylaxis CD4 > 100
cells/mm3 6 CD4 200
cell/mm3
#Cryptococcosis
CD4 < 100 cells/mm3 (60 cell/mm3)

Primary prophylaxis Cryptococcosis Fluconazole 400 cell/mm3

CD4 > 100
cells/mm3 3 12/8/57 (CD4 168 cells/mm3)
3 CD4 > 100 cells/mm3
2. Folic acid Pyrimethamine
Pyrimethamine S/E myelosuppression

3. 2/5/57 10/3/57

 OIs(PCP) 2-4
IRIS d4T+3TC+EFV
S/E TDF+3TC+EFV
19/8/57
4. HIV

- CD4 count : 3 ARVs > 100-150
cells/mm3/year
- Viral load : <50 copies/ml (Undetectable VL) 4-6
o ARVs 2/3/57 CD4
60 cells/mm3 (22/11/56) CD4 12/8/57
166 cells/mm3 >100cells/mm3 1

o VL 40 copies/mL (<50) 12/8/57 ( 6
)
5.
(//
)
1) Serum creatinine
Scr Cotrimoxazole
TDF ( 6 )

2) Hemoglobin,hematocrit,MCV
CBC Cotrimoxazole,dapsone,
Pyrimethamine
3) Serum transaminase
LFTs Cotrimoxazole,dapsone,fluconazole
NVP NVP AST ALT 2,4 1
3 3-6
4) Serum amylase

 d4T amylase
2 2557
amylase pancreatitis
5) Lipid profile
EPV,NVP,TNF 3-6
Lipid profile
3