TB CASE PRESENTATION - Triage B

[INSERT TITLE HERE]
A Case Report
In partial fulfillment of the requirements for

Family and Community Medicine IV: TB-DOTS Center
Submitted by:
Alvarez, Arianne Claire S.

Arengo, Alyanna Mae C.
Diocampo, Nikki J.
Hadji Salic, Abrar D.
Obsioma, John Michael H.
Okit, Kristine R.
Patriana, Angelie Earle A.
February 28, 2019

TABLE OF CONTENTS
History 1
Physical Exam 6
Primary Impression 8
Salient Features 8
Differential Diagnosis 9
Pertinent Diagnostics 9
Baseline Diagnostics 10
Working Impression 11
Treatment Plan 11
Progress Notes 11
Case Discussion 22
References 36
OBJECTIVES
1. To discuss extrapulmonary tuberculosis specifically lymphadenitis and in the

context of drug resistant tuberculosis
2. To discuss extrapulmonary tuberculosis with HIV co-infection

HISTORY
I. General Data
This is the case of JDT, 27/male, single, Roman Catholic, Filipino, currently residing at
P-2B Tambacan, Iligan City, Lanao del Norte who was referred from NMMC on
February 17, 2019 for continuation of MDR TB treatment. The source of information was
the patient and his mother with combined reliability of 95%..
II. Chief Complaint
Neck Mass
III. History of Present Illness
Two months PTA, patient noted a mass on the lateral aspect of his neck, 2.5 cm x 2 cm
in size, soft to firm, smooth with well-defined border, movable, non-tender associated
with intermittent fever with a highest temperature of 39`C and night sweats. This was
also associated with pallor and dizziness, body malaise and decreased appetite. No
note of cough, back pain, SOB and DOB. Patient took paracetamol 500mg 1 tab TID
which offered temporary relief of fever. Patient tolerated condition. No consult done.
One and a half month PTA, patient noticed that the mass increased in size to
~5cmx3cm still associated with fever, night sweats, pallor, dizziness and further
decrease in appetite. Patient now noticed a weight loss of more than 10%. No
associated hearing difficulties, dysphagia, and odynophagia. Continued self-medicating
with paracetamol. Still no consult done.
One month PTA, symptoms persisted and neck mass further enlarged, now associated
with discomfort in moving head side to side which prompted consult at a local hospital
where work up was done. Ultrasound of the neck mass (Official reading? YES) revealed
multiple nodules and masses in the right lateral neck likely representing cervical
lymphadenopathy with sonographically unremarkable thyroid gland. Chest X-ray
showed bilateral pneumonia. Patient was given Meropenem 1g TID, Azithromycin 500
mg IV OD, Rebamipide 100 mg 1 tab OD, Paracetamol 300 mg IV every 8 hours, anf
fluconazole 100 mg OD. As claimed by the patient, his CBC revealed low hemoglobin,
in which, 1 unit of blood was transfused for correction of anemia. Patient also underwent
aspiration of about 8 ml of yellowish purulent discharge from the mass. During the
course of the hospitalization, there was no note of night sweats, dizziness gradually
resolved, however, still experienced intermittent late afternoon fever, body malaise and
decreased appetite. Patient was discharged improved with a diagnosis of neck abscess,
right secondary to immunocompromised host with the following home medications:
Rebamipide 100 mg 1 tab TID, Levofloxacin 500mg tab OD, Fluconazole 50mg 2 caps
OD, Cefaclor 300 mg 1 tab OD and Appebon 4 scoops TID and was subsequently
referred to NMMC for further evaluation and management.
Nineteen days PTA, patient was admitted at NMMC with an impression of tuberculous
lymphadenitis, post PTB treatment (Oct 2018) and malnutrition. He was started on
Naproxen 250 mg 1 tab BID, PCM 500 mg 1 tab every 4 hours as needed for fever,
clindamycin 300 mg 2 caps QID, Cotrimoxazole 800/160 1 tab OD, azithromycin 500
mg 1 tab once a week. Patient was referred to ENT department and consequently
underwent incision and drainage of ~50 ml of purulent discharge from the neck mass.
He was then referred to TBDC for gene Xpert MTB/Rif assay of the neck abscess which
revealed high detection of MTB with Rifampicin resistance.
Thirteen days PTA, patient was started on DRTB regimen consisting of Pyrazinamide
500 mg 2 tabs OD, Kanamycin 875 mg 3.5 ml IM, levofloxacin 500 mg 2 tabs OD,
prothionamide 250 mg 3 tabs OD, cycloserine 500 mg 2 tabs OD, and with Vit B6 50 mg
2 tabs OD. In the interim, patient’s neck mass gradually decreased in size with notable
decreasing amount of pus drained everyday. However, still associated with occasional
on and off fever, which was relieved by paracetamol, body malaise and decreased
appetite.
Two days PTA, noted onset of non-productive cough and eruption of diffused rashes on
the trunk and extremities, non-pruritic. No associated chest and back pain, shortness of
breath, nor difficulty breathing.
One day PTA, patient was discharged improved with a final diagnosis of tuberculous
lymphadenitis, anemia of chronic disease and oral candidiasis with the following home
medications: fluconazole 200 mg 1 tab OD, cetirizine 10 mg 1 tab OD, Azithromycin 1 g
1 tab once a week, Cotrimoxazole 800mg/160mg 1 tab OD, omeprazole 40 mg 1 cap
OD, and MDR regimen. He was then referred to this institution for continued treatment.
IV. Past Medical History
Patient is non-hypertensive, non-diabetic, non-asthmatic. He was admitted once on

2017 at Mercy Hospital, Iligan due to fever and night sweats with a diagnosis of
Pneumonia and PTB Category I as claimed by the patient. He was subsequently
referred to the local DOTS center for treatment, wherein he had his PTB treatment
started on January 2018; however, patient had an allergic reaction to the quadtab. He
underwent drug challenge and it was found out that he was allergic to Rifampicin. Upon
assessment prior to the resumption of taking the meds, an increased level of creatinine
and SGPT was noted. Patient was then “discouraged” to continue the treatment (any
alternative treatment?) and was subsequently lost to follow up since patient was already
feeling better with intake of herbal and food supplements. Since then, patient noted to
have an allergic reaction to shrimp.
V. Family History
The patient is the youngest among 4 children. Patient has a family history of
hypertension on the both sides. He has a known history of kidney and liver disease on
the paternal side with no other known comorbidities. He as a family history of family
members having pulmonary TB on both sides.
VI. Personal and Social
Patient is single, a college graduate, and previously worked as a staff in a hotel at

Vietnam (What kind of work?) (2017 and 2018). He is a non-smoker, an occasional
alcoholic beverage drinker around once a month consuming 3 bottles of beer per
episode, and denies use of illicit drugs. Patient has been sexually active since the age
of 15 with sexual preference towards males. Since then, patient had 3 male sexual
partners and had his last sexual contact 2 years ago. (top or bottom?... condom use?)
REVIEW OF SYSTEMS
General
(+) weight loss
(+) body malaise
(+) fever
(+) changes in appetite
Skin
(-) sores
(-) pruritus
(+) dryness
(+) rashes
HEENT
(-) headache
(+) dizziness
(-) blurring of vision
(-) double vision
(-) hearing difficulties
(-) tinnitus
(-) fullness in ear
(-) pain in ear
(-) nasal discharges
(-) epistaxis
(-) sore throat
(-) bleeding gums
(+) mouth ulcers
(-) hoarseness of voice
(-) neck pain
(-) stiffness
Respiratory
(+) cough, non-productive
(+) chest pain
(-) difficulty of breathing
(-) shortness of breath
(-) hemoptysis
Cardiovascular
(-) orthopnea
(+) palpitations
(+) chest pain/discomfort
Gastrointestinal
(-) dysphagia
(-) rectal bleeding
(-) belching
(-) flatulence
(-) change in bowel movements
Peripheral Vascular
(-) leg cramps
(-) swelling of extremities
(-) bleeding manifestations
Genitourinary
(-) polyuria
(-) dysuria
(-) hematuria
(-) flank pain
(-) incontinence
Musculoskeletal
(-) muscle or joint pain
(+) back pain
(-) stiffness in joints
(-) low back pain
Psychiatric
(-) nervousness
(-) mood swings
(-) suicide attempt???????
Neurologic
(-) changes in orientation, memory, insight or judgement
(-) tingling sensation
(-) tremors or other involuntary movements
Hematologic
(-) easy bruising or bleeding
(-g
Endocrine
(-) heat or cold intolerance
(+) excessive sweating
(-) excessive thirst
(+) sleeping problems
(-) polyuria
PHYSICAL EXAMINATION
General Survey
The patient was seen awake, coherent, conversant, ambulatory, and not in respiratory
distress.
Vital Signs
Blood pressure: 130/100 mmHg Temperature: 36.8 oC
Heart Rate: 124 bpm Weight: 42 kgs
Respiratory Rate: 20 cpm Height: 167 cm
O2Sat: 99% BMI: 15.06 kg/m2 (Underweight)
SKIN
Patient was pale with note of generalized macular
erythematous lesions on the trunk and extremities, non-pruritic, warm to touch, with
good skin turgor.
HEENT
Eyes: Anicteric sclera, pink palpebral conjunctiva. Pupils were equally brisk and reactive
to light. quiteVisual acuity 20/20 bilaterally.
Ears: Symmetric, no lesions, no exudates, nontender. Weber test: no lateralization;
Rinne’s test: air conduction greater than bone conduction bilaterally.
Nose: Symmetric, septum midline, nasal mucosa pink, with no sinus tenderness.
Throat: Pink dry lips and oral mucosa, (+) oral ulcers on the tip of the tongue and lower
lip ~4mm x 4mm, and serous crusting on the right corner of the lips approx 3x3mm, (+)
whitish lesion on the right lateral border of the tongue, good dentition with braces, with
no tonsillopharyngeal swelling.
Neck: Trachea midline, neck supple, with no thyroid enlargement, a mass noted on the
right lateral aspect of the neck, ~5cm x 10cm, soft to firm, well-defined smooth border,
non-movable, nontender.
Chest and Lungs

Thorax was symmetric with equal chest expansion and equal tactile fremitus. Both lungs
were resonant with clear breath sounds upon auscultation.
Cardiovascular System
Adynamic precordium, PMI at the 5th ICS along the midclavicular line, left. Distinct heart
sounds, tachycardic, regular rhythm, without murmurs.
Abdomen
Abdomen was flat with normoactive bowel sounds, tympanitic, soft, nontender, with no
palpable masses or hepatosplenomegaly.
Genitourinary System
Negative kidney punch sign.
Extremities
Full pulses, CRT < 2 seconds; no bipedal edema.
Musculoskeletal System
Full range of motion in all joints of the upper and lower extremities. No signs of swelling,
deformities, or weakness.
Nervous System
Mental Status: alert, relaxed, and cooperative, oriented to time, place and person.
Cranial Nerves:
CN I - intact olfaction
CN II, III - pupils equally brisk and reactive to light, good accomodation
CN III, IV, VI - full extraocular movements
CN V - able to masticate, intact facial sensory
CN VII - no facial asymmetry
CN VIII - Weber: no lateralization; Rinnes: AC > BC, bilateral
CN IX, X - able to swallow, intact gag reflex
CN XI - able to raise shoulders
CN XII - tongue midline
Cerebellum: Normal gait, negative Rombergs, no pronator drift
Motor: Good muscle tone, strength 5/5 throughout
Sensory: intact
Reflexes: 2+ all over
PRIMARY IMPRESSION
TB Lymphadenitis, Oral Candidiasis?

SALIENT FEATURES
HISTORY PHYSICAL EXAMINATION
● Intermittent Fever ● Generalized macular

● Night Sweats erythematous lesions on the
● Pallor trunk and extremities
● Dizziness ● Oral ulcers on the tongue and
● Body Malaise lips
● Decrease in Appetite ● mass on the right lateral aspect
● Weight Loss of the neck, 5cm x 10cm, soft to
● US of the Neck: multiple firm, well-defined smooth
nodules and masses in the right border, non-movable,
lateral neck nontender
● Previously diagnosed with PTB
Category I, then lost to follow up
DIFFERENTIAL DIAGNOSIS
Disease Points to Consider Points Against
Lymphoma ● Non tender ● Cannot be totally

cervical ruled out
lymphadenopathy ● Needs biopsy
● Weight loss result
● Fatigue
● Intermittent Fever
● Night sweats
Infectious ● Non tender ● (-) Sore Throat
Mononucleosis cervical ● Cannot be totally
lymphadenopathy ruled out
● Weight loss
● Fatigue
Sarcoidosis ● Non tender ● (-) Respiratory

cervical Complaints
lymphadenopathy ● (-) Skin Lesions
● Weight loss ● (-) Ocular
● Fatigue Complaints
PERTINENT DIAGNOSTICS
1. X-RAY Report
Date of procedure: 01/21/2019
There are hazy streak densities in the right lower lobe and left upper lung. The heart is
not enlarged. The hemidiaphragms and costophrenic sinuses are sharp and distinct.
The bony thorax is within normal.
Impression: Pneumonia, bilateral.
Date of procedure: 01/30/2019

Lungs are clear with normal pulmonary vascular pattern.
Heart is normal in size and configuration.
Aorta is unremarkable.
The diaphragm and costophrenic sulci are intact.
The visualized osseous structures are unremarkable.
Impression: Essentially normal chest findings
2. AFB stain report (09/16/2018)

Sputum 1 2
Result Negative
Grade
3. GENE XPERT (02/04/2019)

Test Result: MTB DETECTED HIGH; Rif Resistance DETECTED
4. Line Probe Assay (10/01/18)

- Pending Results after 2 months
5. Drug Susceptibility Testing (10/01/18)

- Pending Results
BASELINE DIAGNOSTICS
1. Blood Electrolytes (02/04/2019)

ELECTROLYTES RESULTS
Potassium 4.46 mmol/L
Magnesium
Total Calcium 5.76 mg/dL
2. Thyroid Panel (02/06/2019)

TEST NAME RESULT
TSH 2.73 uIU/mL
3. Clinical Chemistry (02/04/2019)

RESULTS
FBS
URIC ACID 2.15 mg/dL (L)
BUN
CREATININE 0.60 mg/dL
SGPT 63 U/L (H)
SGOT 60 U/L (H)
4. Hematology (02/03/2019)
RESULTS
Hematocrit 20.80% (L)
Hemoglobin 7.30 g/dL (L)
Red Cell Count 2.89 x 10^6/ul (L)
White Cell Count 7.38 x 10^3/uL
MCV 72 fL (L)
MCH 25.3 pg (L)
MCHC 35.10 g/dL (H)
Segmenters 92.8% (H)
Lymphocytes 2.0%
Monocytes 4.9%
Platelet Count 178 x 10^3/uL
WORKING IMPRESSION
drug resistant extrapulmonary tuberculosis - lymph adenitis, t/c HIV infection (I don’t
think gina butang ang HIV nga diagnosis)
TREATMENT PLAN
Diagnostic:
Obtain baseline diagnostics:
· Serum electrolytes (Mg, K, Ca)
· Thyroid panel (TSH)
· Blood chemistry (FBS, uric acid, BUN, creatinine, SGPT, SGOT)
· CBC
· ECG
Therapeutic:
Start treatment on short DRTB regimen with the following medications:

Group A. Fluoroquinolones
Levofloxacin
Group B. Second line injectable agent
Kanamycin
Group C. other core second line agent
Prothionamide
Group D. Add on 1st line agents
Pyrazinamide
Pyrazinamide 500 mg 2 tabs OD, Kanamycin 875 mg IM, levofloxacin 500 mg 2 tabs
OD, prothionamide 250 mg 3 tabs OD, cycloserine 500 mg 2 tabs OD, and with Vit B6
50 mg 2 tabs OD
PROGRESS NOTES
First Visit (Treatment Day 2): October 2, 2018

S (+) nonproductive cough
(+) dizziness
(-) headache
(-) dyspnea
(+) nausea
(-) chest/back pain
(-) tinnitus
(-) blurring of vision
(+) anorexia
(-) abdominal pain
(-) palpitation
(-) dysuria
O Vital Signs:
BP: 100/70 mmHg; HR: 120 bpm; RR: 28 cpm; O2sat: 95%;
T: 38.5 C
Skin: warm, good turgor
HEENT: Pink palpebral conjunctivae, anicteric sclerae
Ishihara: able to identify numbers, colors, and patterns
Snellen’s: 20/13 bilaterally
C/L: Clear breath sounds, equal chest expansion
Abdomen: flat, normoactive bowel sounds, no tenderness
Neuro: no neuropathy
Serum electrolytes:
K: 3.83 mEq/L (N); Mg: 2.47 mEq/L (Inc); Ca: 8.86 mEq/L (N)
TSH: 1.13 uIU/mL (N)
CBC: increased WBC with neutrophilic predominance
ECG: sinus rhythm with no abnormal morphologies, no QT
prolongation
A Drug-resistant tuberculosis, treatment failure

P Continue anti-TB medications:
Isoniazid 300mg 1 ½ tab po
Pyrazinamide 500mg 3 tab po
Ethambutol 400mg 2 tab po
Kanamycin 630mg IM
Moxifloxacin 400mg 1 ½ tab po
Prothionamide 250mg 2 tab po
Clofazimine 100mg 1 tab po
Vitamin B6 50mg 2 tab po
October 9, 2018
S Diminished hearing acuity
O Weber: L > R
Rinnes: AC > BC bilaterally
A Hearing Loss secondary to possible adverse drug effect
P Continue anti-TB medications

For Audiometry testing
October 15, 2018

S (+) minimal nonproductive cough, dizziness, headache,
nausea, vomiting, tinnitus, occasional knee pain
(-) dyspnea, chest/back pain, blurring of vision
O Vital Signs:
BP: 110/70 mmHg; HR: 101 bpm; RR: 24 cpm; O2sat: 96%;
T: 38.5 C
Skin: warm, good turgor
HEENT: Pink palpebral conjunctivae, anicteric sclerae
Ishihara: able to identify numbers, colors, and patterns
Snellens: 20/13 bilaterally
Weber: AS > AD
Rinnes: AS: Air conduction > bone conduction; AD: air
conduction > bone conduction
C/L: Clear breath sounds, equal chest expansion
Abdomen: flat, normoactive bowel sounds, no tenderness
Neuro: no neuropathy
A Drug-resistant tuberculosis, treatment failure
October 16, 2018

S (+) Productive cough with greenish sputum, Bitemporal
pulsating headache with pain scale of 3/10, Nausea, Vomiting,
Pre-prandial epigastric pain, lasting bitter taste in the mouth,
Chest tightness, Body malaise, Tinnitus
(-) Loss of appetite, abdominal pain, fever, night sweats,
dysuria, stiffening of the extremities, abnormal sensorium
O Patient was examined awake, alert, conscious, coherent,
cooperative, ambulatory, and not in distress
Vital Signs:
BP: 100/60 mmHg
T: 37ᵒC
PR: 117 bpm
RR: 23 cpm
O2 sat: 92%
Anthropometrics:
Ht: 157 cm.
Wt: 41 kg.
BMI: 16.63 (underweight)
Skin: Brown complexion, no jaundice, no cyanosis, no pallor.

Skin was warm to touch with good turgor.
HEENT:
Head: Normocephalic, no deformities and tenderness noted.
Hair was thin and evenly distributed. Face was symmetric.
Eyes: Pink palpebral conjunctivae and anicteric sclerae.
Ishihara Color Test: Able to recognize colors and figures
Snellen’s Test: OD= 20/13 OS= 20/13
Ears: Auricles were symmetric. No deformities and no lesions.
Hearing Test:
WEBER RINNE
TEST TEST
Right Ear Lesser AC>BC
Left Ear Greater AC>BC
Nose: Nasal septum was midline. No discharge nor

tenderness noted.
Mouth and Throat: Lips and oral mucosa were moist and
pinkish. No ulceration in the oral mucosa. Tongue and uvula
were at midline. Tonsils were not inflamed. No gum swelling or
bleeding was noted.
Neck: Trachea is midline. No anterior neck mass palpated. No

lymphadenopathy and no tenderness noted.
Chest and Lungs: Thorax is symmetric. Equal chest expansion

with clear breath sounds.
Cardiovascular: Adynamic precordium, distinct heart sounds

with regular rate and rhythm, and has no murmurs
Gastrointestinal: Abdomen was flat, soft, and nontender with

normoactive bowel sounds.
Genitourinary: Not assessed. Has light yellow urine.
Musculoskeletal: She has good muscle bulk and tone. No

atrophy, joint swelling and spasticity noted. No limitation of
movement.
Extremities: She has full peripheral pulses, and no edema.

A Drug Resistant Tuberculosis – Treatment Failure
Ongoing - Treatment

Kanamycin 630mg IM
October 19, 2018

S (+) occasional productive cough with whitish and greenish
sputum, bitemporal throbbing headache PS 3/10, heartburn or
epigastric pain, loss of appetite, night sweats, decreased
hearing on the left ear
(-) hemoptysis, nausea or vomiting, fever, dyspnea or SOB

Vital Signs:
BP: 110/60 mmHg
T: 36.1ᵒC
HR: 59 bpm
RR: 26 cpm
O2 Sat: 94%
Anthropometrics:
Ht: 157 cm.
Wt: 40.5 kg.
Skin: No jaundice, no cyanosis, no pallor, no rashes noted.

HEENT:
Eyes: Pale palpebral conjunctivae and anicteric sclerae.
Hearing Test:
WEBER RINNE
TEST TEST
Left Ear Greater AC<BC

tenderness noted.
bleeding was noted.




Genitourinary: Not assessed.

movement.
Extremities: She has strong peripheral pulses, and no edema.

CRT < 2 seconds
A Drug Resistant Tuberculosis – Ongoing treatment – Clinically
Improving; Conductive Hearing Loss probably secondary to
adverse drug effect (Kanamycin)
P For Audiometry Testing

Continue anti-TB medications
Kanamycin 630mg IM
Possible shift of injectable drugs from kanamycin to
capreomycin
Advised
October 24, 2018

S (+) Headache after medication, occasional cough – yellowish
sputum, good appetite, decreased hearing on the left,
abdominal pain after medication, able to void, able to pass
stools
(-) Fever, dizziness, nausea, vomiting, chest/back pain,
dyspnea, night sweats
Vital Signs:
BP: 100/70 mmHg
T: 37ᵒC
PR: 90 bpm
RR: 18 cpm
Anthropometrics:
Ht: 157 cm.
Wt: 40.5 kg.
Skin: Brown discoloration, no jaundice, no cyanosis, no pallor.

HEENT:
Hearing Test:
WEBER RINNE
TEST TEST
Left Ear Greater AC<BC

tenderness noted.
bleeding was noted.


with rales on both upper lung fields. Decreased breath sounds
on the right.



movement.
Extremities: She has full peripheral pulses, and no edema.

CRT < 2 seconds
Neuro:
Sensory: (+) Pain sensation.
Audiometry results:
AC Right – 23.33 dB Left – 53.33 dB;
BC Right & Left – 20 dB
Interpretation: Moderate Hearing Loss

A Drug Resistant Tuberculosis – Treatment Failure
Bacteriologically - confirmed

Kanamycin stopped shifted to Capreomycin 630mg IM
October 25, 2018

S 3 days PTA, patient took her regular TB medications during
the day without any complications until 7 pm that night when
she suddenly had an onset of generalized tonic seizure lasting
less than 3 minutes, the patient was weak post-ictally with no
recollection of the seizure occurring. Her significant others then
called the German Doctor nurses and were advised to have the
patient admitted but opted not to do so since the patient was
already feeling better.
2 days PTA, patient opted not to come to the treatment
center since she was having a headache thus was not able to
take her TB medications that day.
1 day PTA, patient came to the treatment center for her
medications where she felt much better until 4 pm when she
had another seizure attack lasting for 5 minutes, generalized
tonic in quality, she was weak post-ictally with no recollection of
the seizure. No medications were taken and no consult was
done.
18 hours PTA, patient came to the treatment center for her
regular medications and left with no complications until 16
hours PTA when the patient and her family were coming home
from a trip when she had another episode of generalized tonic
seizure in their car lasting around 15 minutes. Thus was
concomitantly rushed to NMMC due to the unrelenting seizure.
O Patient was examined unconscious, not responsive and
intubated hooked to mechanical ventilator.
Vital Signs:
BP: mmHg
T: 36.2 ᵒC
PR: 90 bpm
O2 sat: 99%
Skin: Brown complexion, no jaundice, no cyanosis, no pallor.

HEENT:
Head: Normocephalic, no deformities noted. Hair was thin and
evenly distributed. Face was symmetric.
Nose: Nasal septum was midline. No discharge noted.
bleeding was noted.

lymphadenopathy noted.




movement.
Extremities: She has weak peripheral pulses, and no edema.

CRT 2 seconds.
Neuro Exam:
A Hypoxic Ischemic Encephalopathy – Status Epilepticus;
Central Nervous System Infection (T/C Tuberculous
Meningitis);
Drug Resistant Tuberculosis – On Treatment;
S/P Cardiopulmonary Arrest X 1 episode (24 hours)
P Monitor VS qhourly with neuroexam q hourly

Monitor seizure episodes – record timing, duration and
characteristic
Strict I & O monitoring
IVF: PNSS 1L at 30 gtts/min
Medications:
· Continue anti – TB medications
· Phenytoin 400 mg 1 amp TID per NGT
· Diazepam 50 mg IVTT prn
· KCl tab 2 tabs TID
Moderate high back rest
Daily hygiene and care
CASE DISCUSSION
Tuberculosis (TB) caused by Mycobacterium tuberculosis which is one of the top 10

causes of death worldwide1 and considered as a major public health problem in the
Philippines, can be classified based on the anatomical site of the disease. 2 The two
types of clinical manifestation of tuberculosis (TB) are pulmonary TB (PTB) and
extrapulmonary TB (EPTB). As tuberculosis is spread via inhalation of bacilli-containing
droplets, it is expected that the first clinical manifestations secondary to local innate and
acquired immune responses are related to the pulmonary infection. The former which is
more common refers to any bacteriologically confirmed or clinically diagnosed case of
TB involving the lung parenchyma or the tracheobronchial tree. Miliary TB is classified
as PTB because there are lesions in the lungs. A patient with both pulmonary and
extrapulmonary TB should be classified as a case of PTB.3
Extrapulmonary tuberculosis, according to WHO, refers to any bacteriologically

confirmed or clinically diagnosed case of TB which affects tissues and organs outside
the pulmonary parenchyma. This can either affect the pleura, lymph nodes, abdomen,
genitourinary tract, skin, joints and bones, meninges however, all organ systems may
virtually be affected. Tuberculous intra-thoracic lymphadenopathy (mediastinal and/or
hilar) or tuberculous pleural effusion, without radiographic abnormalities in the lungs,
constitutes a case of extrapulmonary TB.3 Extra-pulmonary TB is considered an
atypical presentation of TB, as it is expected that an adequate immune response will
quarantine the infectious agent to the lung.
In EPTB, the most common presentation in both HIV-seronegative and HIV-infected

patients, accounting to 35% of the cases worldwide, are those involving the lymph
nodes or tuberculous lymphadenitis. This presentation is frequently observed in HIV-
infected patients and among children. Once caused mainly by M. bovis, tuberculous
lymphadenitis today is due largely to M. tuberculosis. The most commonly involved
nodes are those in the posterior cervical region and supraclavicular sites (called
scrofula in the historical literature), sometimes in association with axillary, inguinal or
hilar lymphadenopathy. Patients usually present with painless lymphadenopathy along
the upper border of the sternocleidomastoid muscle, systemic symptoms are mostly
mild except in HIV-infected patients. At an earlier stage, lymph nodes may be discrete
but may eventually form into matted nontender mass with caseous discharges. If left
untreated, lymph nodes may liquify, rupture and cause sinus formation. Mediastinal
affectation is usually associated with pulmonary forms of the disease (18-42%). Lymph
node swelling in this location can compress neighbor structures and produce tracheal
bronchial or esophageal obstruction.
EPTB results from the hematogenous and lymphatic spread of M.tuberculosis bacilli. As
a result of that spread and to the development of specific cell-mediated immunity
mechanisms, protective immunity against the bacteria is developed, with the resulting
formation of encapsulated granuloma which contain viable bacilli. Although this can
happen at any point after primary infection, it most commonly occurs years or decades
later, because of the alteration of responsible immune response mechanisms such as
extreme ages (children or elderly), concurrent medical conditions or treatments entailing
an alteration of cell-mediated immunity. The alteration of the immune mechanisms
involved in the formation of granuloma predisposes the reactivation of latent TB and the
development of active TB infection. Diagnosis of lymph node TB is established through
fine-needle aspiration or surgical excision biopsy. Cases of lymph node TB are
bacteriologically confirmed in most cases, granulomatous lesions may present with or
without AFBs, and cultures are positive in 70-80% of cases. Granulomas are less well
organized or maybe entirely absent in HIV-infected patients although heavier bacterial
loads are observed compared to HIV-seronegative when examined through microscopy
and culture.
Risk factors involved in the development of EPTB are mainly age, female gender,
concurrent HIV infection and comorbidities such as chronic renal disease, diabetes
mellitus or immunosuppression. The mean age of EPTB patients is higher than for
pulmonary TB. Among EPTB patients those who develop pleural or meningeal
affectation are generally younger than those who present lymphatic, osteoarticular,
genitourinary and gastrointestinal forms of the disease.
Diagnosis
Diagnosis requires a high index of suspicion. Delayed diagnosis of extrapulmonary
forms is frequent and it entails an increased morbidity and mortality. Symptoms and
signs can be relatively vague and sometimes occur in normal chest x-rays and smear-
negative patients, therefore hampering the consideration of the disease in the initial
approach. According to the Clinical Practice Guidelines for the Diagnosis, Treatment,
Prevention and Control of Tuberculosis in Adult Filipinos: 2016 UPDATE, similar to
PTB, diagnostic bacteriologic confirmation of EPTB includes direct microscopy, TB
culture and Xpert® MTB/Rif. A patient with histological and/or clinical radiologic
evidence consistent with active EPTB without laboratory confirmation by direct
microscopy, culture or Xpert® MTB/Rif, and decided to be treated by a physician with
full course of anti-TB drugs is Clinically Diagnosed EPTB. In as such, culture remains
the gold standard for diagnosis. In selecting the appropriate clinical specimen, tissue
biopsy yields a positive culture result more often than fluid aspirate. Since there are
generally fewer M. tuberculosis organisms in extrapulmonary sites, identification of acid
fast bacilli in specimens from these sites is less frequent & culture is more important.
Due to the low yield of microscopy, histopathologic examination is also an important
diagnostic test. However, even if pathologic examination revealing granulomatous
lesions with Langhans giant cells are more suggestive of TB granulomas, the presence
of acid fast bacilli may represent either typical or atypical mycobacterial infection. The
use of Xpert® MTB/Rif for specimens from selected extrapulmonary sites is now also
recommended in diagnosing EPTB. Specifically, for lymph node TB, one of the most
common extrapulmonary sites, the best diagnostic procedure is excisional biopsy, which
yields the diagnosis in 80% of cases.
Management
All diagnosed TB patients are provided and managed with the appropriate anti-TB
treatment regimen. The effective treatment regimen for majority of new EPTB cases in
sites other than CNS, bones/joints, is Category I (2HRZE/4HR). However, some
persons should be considered high risk in developing DR-TB which include the
following:
1. New Cases – contacts of confirmed DR-TB cases; non-converters of
Category I; persons living with HIV (PLHIV) with signs and symptoms of
TB (Strong recommendation, high quality evidence)
2. All retreatment cases – relapse, treatment failure, lost to follow-up (TALF),
previous treatment outcome unknown (PTOU), others (Strong
recommendation, high quality evidence)
For those confirmed to be DR-TB patients, they are further screened according to a
certain criteria recommended by the WHO, based on which they are given the Standard
Short Treatment Regimen (SSDR), or an individualized regimen. The criteria for
classification for treatment for RR- and MDR-TB patients is shown in figure 1. The
SSDR comprises 4-6 months of kanamycin, moxifloxacin, prothionamide, clofazimine,
pyrazinamide, ethambutol, and high-dose isoniazid, followed by a 5-month continuation
phase of moxifloxacin, clofazimine, pyrazinamide, and ethambutol. The core drugs of
the conventional individualized treatment regimen comprises pyrazinamide, kanamycin,
moxifloxacin, prothionamide, and cycloserine, with further modification upon the return
of DST results.
Figure 1: Algorithm for treatment classification of RR- and MDR-TB patients
For our patient JDT, with his lost to follow up status on his previous TB treatment and
the corresponding result of Xpert® MTB/Rif (from lymph node aspirate) MTB
DETECTED HIGH; Rif Resistance DETECTED, he is now classified as DR-TB. With
that, MDR regimen consisting of Pyrazinamide 500 mg 2 tabs OD, Kanamycin 875 mg
IM, levofloxacin 500 mg 2 tabs OD, prothionamide 250 mg 3 tabs OD, cycloserine 500
mg 2 tabs OD, and with Vit B6 50 mg 2 tabs OD was started.
Furthermore, it is important to note that TB lymphadenitis can increase in size during

treatment and this phenomenon is called paradoxical response to treatment. Treatment
can still be continued under close observation. Aside from medical treatment, surgical
treatment is reserved when lymph nodes are about to spontaneously drain. Surgical
excision of lymph nodes has been recommended for patients experiencing worsening of
symptoms during treatment, or treatment failure caused by drug-resistant organisms
and for patients who have discomfort from tense, fluctuant lymph nodes.
EPTB AND HIV CO-INFECTION.

HIV/AIDS is a known risk factor for the development of pulmonary tuberculosis (PTB).
However, the association is less clear between HIV and extrapulmonary tuberculosis
(EPTB). Before the HIV pandemic, about 15%–20% of TB cases developed EPTB. In
HIV-positive patients, however, EPTB cases increased dramatically to more than 50%
of all cases of TB. In a study, the risk of developing EPTB in HIV positive patients is as
high as 5-fold of that in HIV negative patients, after controlling age, race, and gender.
The most common extrapulmonary site in HIV-positive individuals is the lymph node.
However, other extrapulmonary sites such as neurological, pleural, pericardial,
abdominal involvement have also been described in HIV-positive patients.
The close association between HIV infection and EPTB is very likely due to deficiency
of CD4+ T cells among HIV infected patients. It is well known that HIV targets on CD4+
T cells and causes reduced CD4+ T cells and less cytokine production. CD4+ T-helper
cells are major players for controlling M. tuberculosis infection. Among HIV positive
patients, the risk of EPTB increases as the CD4+ lymphocyte count declines. Thus, the
presentation of TB in patients living with HIV differs according to the degree of
immunosuppression. The typical clinical manifestation of cough, sputum, dyspnea,
fever, and weight loss, with radiographic findings of apical lobe infiltrates or cavitary
lesions are found in patients without significant decreases in CD4+ T-cell counts, whose
immune systems are comparable to HIV-uninfected individuals. However, TB in HIV
patients with CD4+ cell counts less than 300 cells/more often present atypically: chest
radiographic studies may show middle and lower lobe infiltrates, miliary TB, tubercular
pneumonia, and hilar or mediastinal lymphadenopathy. Chest radiographs can also be
normal in immunocompromised patients despite extensive infection, due to there being
insufficient numbers of CD4+ cells to mount an effective immune response.
The clinical presentation of TB also factors into HIV staging. In clinically staging HIV
infection, generalized lymphadenopathy not related to TB infection falls under clinical
stage 1. Pulmonary TB places an HIV-infected individual at stage 3, which roughly
correlates to CD4+ count levels at 200-349 cells/μl. Extrapulmonary tuberculosis places
the patient at clinical stage 4, or a CD4+ cell count at <200 cells/μl.
In other countries, TB prevalence is low enough so that HIV becomes a very significant
risk factor to consider; thus HIV testing in these settings becomes almost imperative.
While HIV testing for all TB patients in the Philippines would be ideal, the sheer volume
of TB patients makes this much more challenging. That being said, TB disease
screening is regularly done for PLHIV. Conversely, HIV testing ideally is offered to all
TB patients, with patients belonging to populations at high risk for HIV infection being
particularly encouraged to have themselves tested. These populations at high risk
include patients with high-risk behavior (illicit injectable drug use, multiple sexual
partners), patients living in HIV Category A and B sites (Cebu & Cagayan de Oro City
falling into said categories respectively), and patients with DR-TB, especially those with
no history of previous TB treatment12. Figure 3 details the HIV diagnostic algorithm for
TB patients deemed necessary to receive Provider-Initiated Counseling and Treatment
for HIV (PICT).
Figure 2. Diagnostic Algorithm for HIV in Patients with TB
Due to high risk of developing TB disease in PLHIV, surveillance for TB is regularly

done; given the serious implications of TB infection developing in a PLHIV, a low
threshold for diagnostic evaluation using Gene Xpert is maintained.
Following the diagnostic algorithms previously discussed, JT upon CXR was found to
have atypical lung involvement—hilar lymphadenopathy. This raised the suspicion of
HIV co-infection. Gene Xpert testing detected a medium rifampicin-resistant MTB load.
MDR Repeated rapid HIV screening test yielded positive results. Confirmatory HIV
testing is pending. Thus JT is diagnosed:Bacteriologically confirmed TB—New with
extrapulmonary involvement (TB lymphadenopathy); MDR-TB; HIV co-infection.
Treatment of drug-resistant TB in persons with HIV infection is the same as for patients
without HIV; however, management of HIV-related TB requires expertise in the
management of both HIV and TB.Anti-retroviral therapy should ideally be initiated within
the first 2 weeks of TB treatment for patients with CD4 cell counts <50/mm3 and by 8-12
weeks of TB treatment initiation for patients with CD4 cell counts ≥50/mm3. An
important exception is HIV-infected patients with TB meningitis, in whom antiretroviral
therapy should not be initiated in the first 8 weeks of anti-tuberculosis therapy.
In a patient with a high risk of death during the period of TB treatment (i.e.,
disseminated TB and/or CD4 count <200/mm3), it may be necessary to start ART
concomitantly with TB treatment.
On the other hand, for a patient with bacteriologically-confirmed PTB as the first
manifestation of HIV infection and who does not appear to be at risk of dying, it may be
safer to defer ART until the initial phase of TB treatment has been completed. This
decreases the risk of immune reconstitution syndrome and avoids the risk of drug
interaction between Rifampicin and a Protease Inhibitor (PI). Possible options include
the following:
a. Defer ART until completion of TB treatment.
b. Defer ART until the completion of the intensive phase of TB treatment and
then use Ethambutol and Isoniazid in the continuation phase.
c. Treat TB with a Rifampicin-containing regimen and use efavirenz + two
Nucleoside Reverse Transcriptase Inhibitors (NRTIs).
Patients with TB/HIV co-infection should also receive Co-Trimoxazole as prophylaxis for
other infections. Persons with HIV infection who, after careful evaluation, do not have
active tuberculosis should be treated for presumed latent tuberculosis infection with
Isoniazid preventive therapy (IPT).
Complications of Treatment
Occurrences of minor and major reaction to drugs are usually during the intensive
phase. Minor adverse drug reactions (ADRs) should be managed appropriately while
the major side effects that necessitate withdrawal of the responsible drug require
selection of equivalent-classification drugs to ensure efficacy of the treatment regimen.
If the offending drug cannot be immediately identified or if the ADR is severe enough,
immediate discontinuation of all anti-TB drugs is warranted. Once the ADR has
resolved, anti-TB drugs are reintroduced, starting with the drug least likely responsible
for the reaction at a small challenge dose and the dose gradually increase over 3 days. 9
Second-line aminoglycoside anti TB drugs (capreomycin, kanamycin, and amikacin) are

renally excreted as unchanged compounds and are unlikely to have metabolic drug
interactions with antiretrovirals. Fluoroquinolones (like ofloxacin, moxifloxacin, or
levofloxacin) are also unlikely to have drug interactions with antiretrovirals. Since
patients with MDR TB do not receive rifampicin, the risk is markedly reduced. However,
overlapping toxicities such as nephrotoxicity, QT prolongation in ECG, psychiatric side
effects, and gastrointestinal intolerance may limit co-treatment of HIV and MDR TB.
The provision of HIV antiretroviral therapy and anti TB drug treatment at the same time
involves a number of potential difficulties including: Cumulative drug toxicities, Drug–
drug interactions, high pill burden, and Immune Reconstitution Inflammatory Syndrome
(IRIS). IRIS is a phenomenon experienced by people with HIV who have recently
started antiretroviral therapy. The partial recovery of the immune system can result in an
exaggerated inflammatory response against any concurrent opportunistic infection. TB
IRIS reported to be the most frequent pathogen associated with IRIS that occurs
especially when a patient has active Mycobacterium tuberculosis infection. It occurs in
11% to 45% of patients co-infected with TB and HIV.
Monitoring
For extrapulmonary TB patient, treatment response is assessed clinically (e.g. weight
gain, resolution of lymphadenopathy). CD4+ cell counts/ Viral Load should also be
monitored. Finally, other HIV clinical stage 4 diseases such as pneumocystis
pneumonia infection and chronic HSV infection should be monitored for. For baseline
laboratories, check for ALT, bilirubin, platelets, creatinine and hepatitis panel for all TB
patients prior to giving of medication. Monthly ALT and Bilirubin check. Patient’s general
well-being is monitored monthly along with progression or resolution of symptoms,
adverse drug reactions, compliance to the treatment and DOTS and other concerns
regarding the treatment. It is also important to weigh the patient monthly and record and
always check scheduled for their shifting treatment and DSSM follow-up.
Prognosis
Patients with MDR-TB have lower cure rates and higher mortality than those with drug-
susceptible TB. Treatment of HIV associated TB with anti-TB drugs and simultaneous
use of ART are associated with reduced mortality risk and AIDS related events. With
34-48% reduction in mortality rates with good results in patient with CD4 count of
<50/ul7. Survival rates were not significantly different in HIV-infected and HIV-uninfected
participants having 86% vs 94%, respectively. A CD4 count ≤100 cells/mm3 was
associated with increased mortality risk.
Given JDT’s motivation for therapy, and given the fostering community provided by the
XU-CHCC along with the ready accessibility of chemotherapeutic agents for both TB
and HIV, JT’s prognosis is favorable compared to the median of TB-HIV patients.
Provided that her TB treatment is optimized, her ART is consistent, and close
monitoring for other life-threatening HIV-associated diseases is conducted, without
knowing the exact probabilities it is likely that JT has a longer, fruitful life ahead of her.
REFERENCES
1. World Health Organization. 2018. Global Tuberculosis Report Executive Summary

2018. Accessed October 23, 2018 from
http://www.who.int/tb/publications/global_report/tb18_ExecSum_web_4Oct18.pdf?ua=1
2. National Tuberculosis Control Program Manual of Procedures 5th edition. Sta Cruz,
Manila. 2014
3. World Health Organization. Definitions and reporting framework for tuberculosis:

2013 revision (updated December 2014) Geneva: World Health Organization; 2013.
World Health Organization. 2018. Global Tuberculosis Report Executive Summary
2018. Accessed February 18, 2018 from
http://www.who.int/tb/publications/global_report/tb18_ExecSum_web_4Oct18.pdf?ua=1
3. World Health Organization. 2017. MultiDrug Resistant TB (MDR TB) 2017 Update.
http://www.who.int/tb/challenges/mdr/MDR-RR_TB_factsheet_2017.pdf?ua=1
4. Makeshkumar V, Madhavan R, Narayanan S. Polymerasa chain reaction targeting

insertion sequence for the diagnosis of extrapulmonary tuberculosis. Indian J Med Res.
2014; 139: 161-6
Mlotshwa, M. et al. 2016. Risk factors for tuberculosis smear nonconversion in Eden
district, Western Cape, South Africa, 2007–2013: a retrospective cohort study. BMC
Infectious Diseases Volume 16 p 365 Accessed October 23, 2018 from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4971671/
5. Bouti, K et al. 2013. Factors Influencing Sputum Conversion among Smear-Positive

Pulmonary Tuberculosis Patients in Morocco. ISRN Pulmonology Volume 2013.
Accessed October 23, 2018 from https://www.hindawi.com/journals/isrn/2013/486507/
6. Geo, FB et al. 2007. Jawetz, Melnick, & Adelberg’s Medical Microbiology 24th
Edition. McGraw-Hill, USA.
7. Kasper, DL et al. 2015. Harrison’s Principles of Internal Medicine 19th edition.

McGraw-Hill, USA.

TB CASE PRESENTATION - Triage B

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

TB CASE PRESENTATION - Triage B

Uploaded by

Copyright:

Available Formats

[INSERT TITLE HERE]

In partial fulfillment of the requirements for

Alvarez, Arianne Claire S.

February 28, 2019

1. To discuss extrapulmonary tuberculosis specifically lymphadenitis and in the

2. To discuss extrapulmonary tuberculosis with HIV co-infection

II. Chief Complaint

III. History of Present Illness

IV. Past Medical History

Patient is non-hypertensive, non-diabetic, non-asthmatic. He was admitted once on

VI. Personal and Social

Patient is single, a college graduate, and previously worked as a staff in a hotel at

Heart Rate: 124 bpm Weight: 42 kgs

Respiratory Rate: 20 cpm Height: 167 cm

O2Sat: 99% BMI: 15.06 kg/m2 (Underweight)

Chest and Lungs

TB Lymphadenitis, Oral Candidiasis?

HISTORY PHYSICAL EXAMINATION

● Intermittent Fever ● Generalized macular

Disease Points to Consider Points Against

Lymphoma ● Non tender ● Cannot be totally

Sarcoidosis ● Non tender ● (-) Respiratory

Impression: Pneumonia, bilateral.

Date of procedure: 01/30/2019

Impression: Essentially normal chest findings

2. AFB stain report (09/16/2018)

3. GENE XPERT (02/04/2019)

4. Line Probe Assay (10/01/18)

5. Drug Susceptibility Testing (10/01/18)

1. Blood Electrolytes (02/04/2019)

Potassium 4.46 mmol/L

Total Calcium 5.76 mg/dL

2. Thyroid Panel (02/06/2019)

TSH 2.73 uIU/mL

3. Clinical Chemistry (02/04/2019)

URIC ACID 2.15 mg/dL (L)

CREATININE 0.60 mg/dL

SGPT 63 U/L (H)

SGOT 60 U/L (H)

Hematocrit 20.80% (L)

Hemoglobin 7.30 g/dL (L)

Red Cell Count 2.89 x 10^6/ul (L)

White Cell Count 7.38 x 10^3/uL

MCH 25.3 pg (L)

MCHC 35.10 g/dL (H)

Segmenters 92.8% (H)

Start treatment on short DRTB regimen with the following medications:

First Visit (Treatment Day 2): October 2, 2018

A Drug-resistant tuberculosis, treatment failure

A Hearing Loss secondary to possible adverse drug effect

P Continue anti-TB medications

October 15, 2018

A Drug-resistant tuberculosis, treatment failure

P Continue anti-TB medications

October 16, 2018

Skin: Brown complexion, no jaundice, no cyanosis, no pallor.

Right Ear Lesser AC>BC

Left Ear Greater AC>BC

Nose: Nasal septum was midline. No discharge nor

Neck: Trachea is midline. No anterior neck mass palpated. No

Chest and Lungs: Thorax is symmetric. Equal chest expansion

Cardiovascular: Adynamic precordium, distinct heart sounds

Gastrointestinal: Abdomen was flat, soft, and nontender with