HIV, DM , CKD, HT with

tuberculosis1 pericarditis
42

32 kg 140 cm
BMI

16.327 kg/m2

15/06/54

 CC: 2/6
HPI:
2

d. PTAr ARV
. HIV, Dyslipidemia with URI
()
14 d. PTAr (19/5) .
consult Med :notify TB .med
lab: CBC,RPR,LFT,Lipid profile ;
Advice. topicort
28 d. PTAr (3/5) Dx HIV DM HT
CRF: Advice CD4 , FBS,BUN,Cr,CBC,
electrolyte
15/06/54

HPI:
3

mo 16 d PTA: DTX 40 mg% admit (1626/4/54) Dx HIV with DM with HT with CRF with
AGE , (. . R/O Cardeomegaly,Heart
failure) TB .
off : OI
prophylaxis
1 mo 25 d PTA 6
Imp. Acute Diarrhea admit 5 (7-12/4/54)
DTX 62
mg% TB .
(TB HT DM)
15/06/54

HPI:
4

2 mo 12 d. PTA

R/O Fever with

Dyspneoa , AGE : BP 149/102 pulse 104 R
32 onO2 mask with bag [admit 8 (2129/3/54)] . (22/3/54) Dx
Tuberculosis Pericarditis TB

15/06/54

PMH:
5

1.
2.

3.
4.

5.

6.

Dx DM > 4 (51)
Dx HIV 4 (.51) OI Herpes
Zoster(51) ( 52)
Dx HT 1
Dx CKD 1
Dx Tuberculosis Pericarditis 2 9
(22/3/54)
Dx senile cataract( 8/2/54),
Strabismus() LE 4

15/06/54

MH:

5/10/53-3/11/53
glipizide 5 mg 1 x2 ac
4/11/53-26/1/54
glipizide 5 mg
1 x1 ac
6
27/1/54-31/3/54
glipizide 5 mg x1 ac
1/4/54-15/4/54
glipizide 5 mg 1 x1 ac
5/10/53-16/4/54
Amlodipine 5 mg 1x1 pc
Admitted 21-29/3/54 Dx pericarditis tuberculosis
Admitted 7-12/4/54 Dx Acute diarrhea
rifafour (R150H75Z400E275) 2xhs
22/3/54
23/3/54-16/4/54(25d)
Isoniazid 100 mg 3xhs
15
Rifampicin 300 mg 1x1 ac
16
Pyrazinamide 500 mg 2x1 , ,
admit
Ethambutol 400 mg 1.5xhs , ,
Admitted 16-26/4/54 Dx. Dx HIV with DM with HT with CRF with AGE
DTX 40 mg%[.r/o heart failure] OI prophylaxis
25/4/54-
Co-trimoxazole (400/80) 2x1 pc
Fluconazole 200 mg 1x,

15/06/54

3/5/54 F/U OPD

MED:

19/5/54 OPD Consult Med notify txt TB

Co-trimoxazole
7 (400/80) 2x1 pc
Fluconazole 200 mg 1x,
19/5/54

31/5/54

Topicort cream Lab

GPOvirS(30) 1 tab OD

Simvastatin(20) 1xhs

3TC (150) 1x1 hs

Roxithromycin (150) 1x2 ac

D4T(30) 1x1 hs
Co-trimox(400/80) 2x1 pc

Loratadine (10) 1x1 pc

Dextromethorphan (15) 1x3 pc
Tussis mixture 1 x4 pc

Fluconazole 200 mg 1x, Vitamin B complex 1x2 pc

Special mouth wash 4

15/06/54

FH: 3

SH:
ALL:
*5 2553 ARV
15/06/54

Lab: vital sign

9

5/10/53

4/11/53

2/12/53 27/1/54

BW

31

32

32

BP

160/90 150/90 119/71 122/82 150/102 149/91 130/90 130/98 120/90

32

7/4/54

16/4/54

19/5/54

31/5/54

2/6/54

32

32

32

15/06/54


RBC

5/10/53
4-6
3.848
x106/mcL

4/11/53 2/12/53 27/1/54 7/4/54

mild
10
anemia
macrocytic

16/4/54 19/5/54

3.75

31/5/54
4.11

11.3

12.2

37.5
99.9
30
30

40.6
98.8
29.8
30.2
6.86
18.5
84.5

12-16.5
g/dL
37-52 %

10.84

MCHC

35.21
83-97 fl
91.5
27-33 pg 28.17
31-35 g/dL 30.79

MPV

6.5-11 fl

RDW

10-16 %

Platelet

140-440x103 /mcL

7.789
14.66
133.7

7.03
19
106

Plt smear

Normal

Decreased

Decresed Decresed

Hgb
Hct
MCV

MCH

Normochromi c normocytic

Normal

Normal
15/06/54


WBC

5/10/53
4-11x10 /mcL
7.468

4/11/53 2/12/53 27/1/54 7/4/54 16/4/54

11

19/5/54 31/5/54
4.33
7.04

Neutrophil

37-70 % 47.641

41.2

63

Lymphocyte

10-50 % 40.03

33.6

24

Atypical
Lymphocyte

2%

Monocyte

0-12 %

7.816

Eosinophil

0-7 %

3.82

Basophil

0-2.5 %

0.693

Anisocytosis

normal

Topicort
cream

10.1

13.8 3
1.41
Few
15/06/54

5/10/53

4/11/53

2/12/53 27/1/54 7/4/54

16/4/54

19/5/54

68

86

40
admit

131

39

Blood sugar

70-110 mg/dl

BUN

7-18 mg/dl

43

Creatinine

0.6-1.3 mg/dl

Clcr ()

>90
ml/min
2.6-7.2
mg/dl

2.2
2.4
18.15 19.8

Uric acid
CO2

21-32
mEq/l

288

1269

62+

admit

31/5/54

59
2.2
19.8

2.4
18.15
10.2
Bicarb

12.8

15/06/54

Liver function 2/9/53

7/4/54

16/4/54

19/4/54 31/5/54

0.23

0.16

0.43

Total bilirubin

0-1 mg/dl

Direct bilirubin

0-0.3 mg/dl

0.18

0.13

0.28

Total protein

6.4-8.2 g/dl

7.5

6.4

6.3

Albumin(serum)

3.4-5 g/dl

2.6

2.2

2.3

Globulin

2.5-3.5

Alkaline
phosphatase

50-136 U/L

286

4.9
235

4.2
142

4
98

SGPT/ALT

30-65 U/L 11

182

188

121

10

SGOT/AST

15-37 U/L

864

87

95

22

13

15/06/54


Cholesterol

5/10/53 4/11/53

2/12/53 27/1/54 7/4/54

16/4/54

19/5/54

0-200 mg/dl

31/5/54
262

14

triglyceride

30-150 mg/dl

183

LDL-C ()

0-130 mg/dl

200.4

HDL-C

40-60 mg/dl

25

Sodium

136-145
mEq/l

135

Potassium

3.5-5.1 mEq/l

Chloride

98-107 mEq/l

114

RPR

Non
reactive

Non
reactive
15/06/54

2/9/53

CD4 cell/mm3(%) 256(7%)

15

22/3/54

19/5/54

54(2%)

15(1%)

22/3/54 Echocardiogram :Myocardial disease, severely

impaired LV systolic function with moderate pericardial

effusion, EF 21%
19/4/54

Anti-HBc: Negative
Anti-HBs: Negative
Anti-HCV: Negative
RPR: Negative
Urine analysis: protein(albumin): 2+
2/6/54 Sputum Smear: Negative

2/6/54 CXR = Cardiomegaly , no pulmonary infiltration

15/06/54

Medical Problems
16

1.

Pericarditis tuberculosis

2.
3.

HIV infection

4.

Type 2 diabetes mellitus

5.

Chronic kidney disease

6.

Dyslipidemia

URI

Hypertension

15/06/54

Pericarditis tuberculosis in HIV

DM HTN and CKD patient
S:

17

(2/6)

O: 2/6/54 Sputum: Negative

CXR = Cardiomegaly,no Pulmonary infiltration

19/5/54 U/A =protein 2+

Scr 2.4 mg/dl, Clcr 18.15 ml/min

7-19/4/54 Liver transminase elevation
22/3/54 Eco-cardiogram : abnormally
15/06/54

A: Etiology
42

18

32
CKD (Clcr 18.15 ml/min, stage 4)
HIV infection tuberculosis pericarditis
1-8%
HIV
CD4 500 cells/mm3 100
cells/mm3 CD4 15 cells/mm3

chronic kidney disease

31 ARV (
5 2553) 2 d.PTAr
. HIV Dyslipidemia with URI
15/06/54


19

31/5/54

GPOvirS(30) 1 tab OD

Simvastatin(20) 1xhs

3TC (150) 1x1 hs

Roxithromycin (150) 1x2 ac

D4T(30) 1x1 hs

Co-trimox(400/80) 2x1 pc

Loratadine (10) 1x1 pc

Dextromethorphan (15) 1x3 pc

Tussis mixture 1 x4 pc

Fluconazole 200 mg 1x, Vitamin B complex 1x2 pc

Special mouth wash 4

15/06/54

?
20

A.
B. TB
C. ARV

D. BC

15/06/54


21

31/5/54

GPOvirS(30) 1 tab OD

Simvastatin(20) 1xhs

3TC (150) 1x1 hs

Roxithromycin (150) 1x2 ac

D4T(30) 1x1 hs
Co-trimox(400/80) 2x1 pc

Loratadine (10) 1x1 pc

Dextromethorphan (15) 1x3 pc
Tussis mixture 1 x4 pc

Fluconazole 200 mg 1x, Vitamin B complex 1x2 pc

Special mouth wash 4

Pericarditis
treatment ?
Tuberculosis
?
15/06/54


Pericarditis Tuberculosis

22
A. 2HRZE/4HR
B. 2HRZE/7HR
C. 2HRZE/10HR

15/06/54

Start Anti-TB drug 22/3/54

23

15/06/54
American thoracic society 2003

Extrapulmonary Tuberculosis
24

One in five registered TB patients has extra-

pulmonary TB
Only half of these diagnosed before death.
Lymph nodes, pleural, disseminated most common
and meningeal,pericardial also common
The high mortality rate associated with untreated
tuberculosis pericarditis 2 ( culture
)
1.Getahun H, et al. The Lancet.2007; 369:2042 2049
2.Mayosi BM.et al. Circulation.2005;112 :3608-3616
15/06/54

Case definition
Extra-pulmonary

Tuberculosis
One specimen from an extra-pulmonary site
culture-positive
OR
Histological or strong clinical evidence
consistent with active extra-pulmonary
tuberculosis and decision by clinician to treat
with full course for TB

4 DM ,HIV
1 HTN,CKD
22/3/54 Dx Tuberculosis Pericarditis
1mo.25 d :AGE,
BS 62 (7-12/4)

glipizide(5)

1x1

1x2

1x1

amlodipine(5)

1/2x1

off

1/2x1

15-..

1-..

31-..

27-..

23-..

22-..

27-..

26-..

4-..

2554
3-..

5-..

4-..

27-..

2553

26-..

(21-29/3)

1mo.16 : AGE,
BS40(16-26/4)
24-..

2 mo12d :AGE

1x1

1x1

Co-trimoxazole(400/80)
Fluconazole(200)

2x1
1 cap

rifafour (R150H75Z400E275)

2xhs

H300,R300

OD

Z1000,E600

OD
<------------25 --------------->
26

15/06/54

(5)
27

Z E

concentration-dependent

dosing interval
H R

15/06/54

28

15/06/54

Pyrazinamide
29

70%(4)
metabolism
metabolite (pyrazinoic acid and 5-hydroxy-pyrazinoic acid)
1%14%
25-35 mg/kg/dose 3 (5,Ellard,1993) 800-1120 mg
3

pyrazinamide 1000 mg

3
15/06/54

Ethambutol
30

50%-90%
Clcr <30 ml/min 15-25 mg/kg 3
(5,8) 480-800 mg 3

ethambutol 600 mg 3

15/06/54

3/5/54 F/U OPD

19/5/54 OPD Consult Med notify txt TB
Co-trimoxazole
31 (400/80) 2x1 pc
Fluconazole 200 mg 1x,
19/5/54

31/5/54

Topicort cream Lab

GPOvirS(30) 1 tab OD

Simvastatin(20) 1xhs

3TC (150) 1x1 hs

Roxithromycin (150) 1x2 ac

D4T(30) 1x1 hs
Co-trimox(400/80) 2x1 pc

Loratadine (10) 1x1 pc

Dextromethorphan (15) 1x3 pc
Tussis mixture 1 x4 pc

Fluconazole (200) 1 cap , Vitamin B complex 1x2 pc

TB 46

Special mouth wash 4

15/06/54

Medicine
32

HIV infection
d4T(15) 1 cap OD
3TC(150) 1 tab OD
EFV(200) 2 cap OD

Pericarditis Tuberculosis

A.
B.
C.
D.

Sputum smear
CAT1
CAT1
CAT1

15/06/54

33

15/06/54

Anti-Tuberculosis regimen ?
34

15/06/54

2 mo.12d :AGE(21-29/3)

O:
35

1000
800
600
400
200
0

AST
ALT

1mo.25 d:AGE,BS62(7-12/4)

16

AST,ALT
864

182
11

87

188
121
95

22
10

15/06/54

O: ) off
1mo.15: AGE BS40(16-26/4
36

15/06/54

 TB 15/4
37

Liver
function

2/9/53 7/4/54

16/4/54

19/4/54

31/5/54

Total bilirubin

0-1 mg/dl

0.23

0.16

0.43

Direct bilirubin

0-0.3 mg/dl

0.18

0.13

0.28

Total protein

6.4-8.2 g/dl

7.5

6.4

6.3

Albumin(serum)

3.4-5 g/dl

2.6

2.2

2.3

Globulin

2.5-3.5

4.9

4.2

Alkaline
phosphatase
SGPT/ALT

50-136 U/L

286

235

142

98

182

188

121

10

SGOT/AST

15-37 U/L

864

87

95

22

30-65 U/L

11

15/06/54


38

A.
B.

15/06/54


39

A. Isoniazid
B. Rifampicin
C. Ethambutol
D. Pyrazinamide
E. Glipizide
F. Amlodipine
15/06/54

Etiology(15)
40

Isoniazid

Hepatocellular steatosis and necrosis

Hydrazine [Toxic metabolite]
onset 8-12

Rifampicin

Cholestatsis
onset 2

Pyrazinamide

Hepatocellular hepatitis
onset 1

2 wk.+

15/06/54

41

Rifampicin-induced hepatotoxic

42

Pyrazinamide-induced hepatotoxic
most severe case 1
dose-dependent
1% standard dose 10-20% 40-50
mg/kg/dose
~20%
~ 10%
liver injury hepatocellular hepatitis

43

 hepatic injury ?
44

Benichou c. J hepatol 1990;11:272

ALT

188

ULNALT

65

ALP

235

ULNALP

136

ALT/ULNALT

2.9

ALP/ULNALP

1.7

R-ratio

1.67

Anicteric Cholestasis
Rifampicin onset 2 >>>pt 16

15/06/54

No jaundice
Liver
function

45

2/9/53 7/4/54

16/4/54

19/4/54

31/5/54

Total bilirubin

0-1 mg/dl

0.23

0.16

0.43

Direct bilirubin

0-0.3 mg/dl

0.18

0.13

0.28

Total protein

6.4-8.2 g/dl

7.5

6.4

6.3

Albumin(serum)

3.4-5 g/dl

2.6

2.2

2.3

Globulin

2.5-3.5

4.9

4.2

Alkaline
phosphatase
SGPT/ALT

50-136 U/L

286

235

142

98

182

188

121

10

SGOT/AST

15-37 U/L

864

87

95

22

30-65 U/L

11

AP 1. partial biliary
obstruction primary billiary cirrhosis 2. hepatic infiltration
mycobacterial infection GGT , 5 NT

15/06/54

large pericardial effusions can cause problems

by impairing heart function, liver congestion
46

The sensitivity of AST was highest at 24 h period and

was of 82%. 48 h after onset ofAMI, sensitivity starts

declining. Thus AST is not a useful marker for the
early detection of AMI as well as also not that much
specific, because of its positive results in many other
conditions like liver disease, bone diseases, etc.
AST 10 acute liver injury
100 (20)

http://www.faqs.org/periodicals/201012/2262626431.
html#ixzz1RWnbgE6T
15/06/54


47

A. 2 wk. rechallenge
B. streptomycin

ethambutol Ofloxacin
C. streptomycin
ethambutol 2 wk
Isoniazid
15/06/54

48

American thoracic society 2003,p 610

15/06/54

49

WHO,2003
15/06/54


50

18SEO (5)
SE 2 wk try H 1 wk 2SHE/10HE (19)
SE 2 wk try H 1 wk try R 1 wk

2HRE/7HR
SHE 1 wk HRE OK?
Rifampicin : 2SHE/10HE
isoniazid rifampicin

9 2HRE/7HR (5)
( AST<2 ULN
total billirubin H R rechallenge ) (7)
15/06/54

51

3-7

American thoracic society 2003,p 637

15/06/54

 (Clcr < 30 ml/min dialysis)

American thoracic society 2003

Clcr < 30 ml/min

dialysis

Ethambutol

1525 mg/kg per dose three times

(not daily) 600 mg three times per week

per

week

Ofloxacin

Clcr 20-50 mL/minute: 24

Clcr <20 mL/minute: 24
400 mg OD

Streptomycin

1215 mg/kg per dose two or three times per week (not
daily) 400 mg three times per week

53

()
isoniazid 300 mg 1
isoniazid
(7)

vitamin B6

Rifampicin 300 mg 1
(4)

15/06/54

Therapeutic plan
54
1.
2.
3.
4.
5.
6.
7.

Streptomycin 400 mg three times per week

Isoniazid(100) 3 tab OD
Ethmbutol (400) 1.5 tab three times per week
D4t (15) 1 cap OD
3TC(150) 1 tab OD
EFV(400)1 tab OD
Vitamin B 1-6-12 2x3 pc

1 wk
then change

SR

15/06/54

Goal:
55

Normal liver function test

Heart function Improvement : no cardiomegaly,
no pericardial Effusion , pericardial fluid culture negative

All drugs are Tolerated, no ADRs

Therapeutic monitoring :

,adherence
Vital sign, BW.
Electrocardiogram
Culture : pericardial fluid

15/06/54

Toxicity monitoring: (4,7)

56
rechallege AST, ALT 1
4-6

BUN , SCr, CBC

Streptomycin

Isoniazid:
peripheral neuropathy, hepatotoxicity
Ethambutol:
optic neuritis() , ,
hyperuricemia, Thrombocytopenia, Peripheral neuropathy
Ofloxacin
( ) (
)( )
Rifampicin:
hepatotoxicity
15/06/54

Patient education:
57

1.

2.

3.

( )

4.

(
)

5.

15/06/54

Future plan: (7)

58

HSE
Streptomycin Rifampicin
AST ALT 5
total bilirubin 2

2HRE/7HR

( 1) 2SHE/10HE, 2)18SEO)
15/06/54

Future plan:(cont.)
59

ethambutol

uric acid 13 mg/dl

allopurinol 100 mg OD

vitamin

20 )

B6 100 mg (VitaminB1,6,12
15/06/54


60
1.
2.

3.
4.

5.
6.

7.
8.

National Guidelines on HIV/AIDS Diagnosis and Treatment: Thailand 2010. Sep 2010
Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, et al. Pharmacotherapy: A
Pathophysiologic Approach, 7th ed. New York: McGraw-Hill;2008
TB. 2551
Thomson D, Glocer HT, FitzGerald N, Beattie WG, Banga MS, Cirillo M, et al.
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from: URL: http://www.thomsonhc.com/hcs/librarian
American Thoracic Society, CDC, and Infectious Disease Society of America. Treatment of
Tuberculosis. American Journal of Respiratory and Critical Care Medicine 2003;167: 603-62.
Heather JM. How should we treat tuberculosis in adult patients with chronic kidney
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, , .

Charleys FL, Armstrong LL, Goldman MP, Lance LL.phenobarbital. Drug information
handbook. 2010 Lexi-comp

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9.

10.
11.

12.

13.

14.
15.
16.
17.

18.

19.
20.

, , , .

, 2. : .
2550
Salim S. AK, Kogieleum N, Anneke G, et al. Timing of Initiation of Antiretroviral Drugs during
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Tuberculosis Therapy. N Engl J Med 2010;362:697-706.
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agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. January
10, 2011; 1166.
Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and
Adolescents Recommendations from CDC, the National Institutes of Health, and the HIV Medicine
Association of the Infectious Diseases Society of America, MMWR April 10, 2009 / Vol. 58 / No. RR-4
Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension
2003;42(6):120652.
American diabetes association. Standards of medical care in diabetes-2011. Diabetes Care Jan
2011;34(S1):S11-61.
KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic
Kidney Disease. 2007
Alma T, Martin JB, Rob EA, Wiel CML, Andre JAM, Richard D.Antituberculosis drug-induced
hepatotoxicity: Concise up=to=date review. Journal of Gastroenterology and hepatology 2008,192-202
Treatment of tuberculosis: guidelines 4th ed.WHO/HTM/TB/2009.420
Getahun H, Harrington M, O'Brien R, Nunn P. Diagnosis of smear-negative pulmonary tuberculosis in people
with HIV infection or AIDS in resource-constrained settings: informing urgent policy changes. The Lancet 2007;
369:2042 2049
World Health Organization .Treatment of Tuberculosis guidelines for national programmes. 3rd edition,2003
, .Interpretation and approach to abnormal LFT. . [cited 2011 july 8 ]; available
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62

15/06/54