CASE STUDY TB

JS, a 46 year old male patient, returned from India with cough, malaise,weight loss and
night sweats. Sputum culture showed acid fast bacilli and 3 days later Mycobacterium
tuberculosis was isolated.

Questions

1. What is TB causes it and what is the most common source of infection?

2. What drug could be used to treat it, what makes resistance likely?

This patient was commenced on triple therapy with rifampicin 600 mg daily, isoniazid 300
mg daily and streptomycin 750 mg daily. All three agents are bactericidal against fast
growing extracellular bacilli so they produce rapid sterilisation of sputum to decrease
spread. Rifampicin is also active against dormant intracellular organisms that undergo
phases of rapid growth. The patient was already taking carmazepine 200 mg b.d
throughout for epilepsy.

3. Are there any problems with this. And how might they be managed?

4. JS received only 750 mg daily streptomycin, why was this reduced and how should it
be monitored?

Three weeks later he was admitted to hospital complaining of increasing malaise, muscular
aches, nausea, decreased apptite, shortness of breath, cough and fever. He was jaundiced
with hepatomegaly, blood pressure 120/70 mmHg, pulse 76 beats perminute, regular.
Chest X-ray showed a right plural effusion and biochemistry showed increased bilirubin,
ALP, ALT and AST, albumin was low.

5. What is likely to be causing these sign and symptoms?

JS was diagnosed as having drug-induced hepatitis and all anti-TB medication was stopped.

6. What can be done to reduce drug-related toxicity?

7. With reference to the biochemistry result

a. What is the significance of the raised INR on day 19 admission?

b. What is the significance of the raised ESR on day 23?
c. Why is the white count stable at 4.7-7.3?
d. Compare the profile of bilirubin,CGT,ALT dan ALP?

A week after stopping the anti-TB drugs his liver function test had settled and isoniazid
was re-introdused at 150 mg dose, after 3 days increased to 300 mg daily. Rifampisin was
then started initially at 300 mg then increased to 600 mg daily. Three weeks into the
admission streptomycin was recommended and 4 days after commencing streptomycin
level were checked and found to be trough; ˂1mg/L, peak; 23mg/L (target peak;˂ 40mg/L,
trough; ˂mg/L). Note rifampicin can increase risk of streptomycin-induced renal
dysfunction.
A week later he went home on full anti-tuberculosis drugs with stable liver function
test and carbamazepine and the addition of pyridoxine. The white count does not suggest
resistance has emerged during this treatment gap but should be monitored over the full
treatment course. Any acute liver insult on top of this treatment would be very difficult to
resolve. Compliance with the pyridoxine is very important to prevent any toxicity.
 KASUS TBC

 IDENTITAS PASIEN
Nama : An. M A
Umur : 29 bulan
Jenis kelamin : Laki-laki
Tanggal MRS : 15 Agustus 2020
Tanggal Pemeriksaan : 18 Agustus 2020

1. Keluhan Utama
Batuk lama.

2. Riwayat Penyakit Sekarang

Pasien dikeluhkan batuk grok-grok disertai dahak berwarna putih sejak 1,5 bulan
yang lalu dan tidak kunjung sembuh. Batuk dialami setiap hari dan semakin lama
semakin memberat. Batuk lebih parah saat malam hari hingga pasien kesulitan
tidur. Batuk tidak disertai darah. Ketika pasien batuk kadang disertai muntah. Batuk
tidak disertai pilek dan tidak juga disertai sesak. Pasien dikeluhkan mengi ketika
tidur. Pasien sudah diberi obat batuk oleh ibunya namun batuk tidak berkurang.
Pasien dikeluhkan sering berkeringat di malam hari. Pasien juga dikeluhkan demam
sumer-sumer sepanjang hari tak kunjung sembuh sejak 3 minggu yang lalu
walaupun sudah dikompres oleh ibunya. Nafsu makan pasien menurun. Aktivitas
pasien menurun dan tidak seaktif sebelumnya. Berat badan pasien juga mulai
menurun dibandingkan bulan-bulan sebelumnya. Berat badan bulan lalu 9,5kg dan
bulan ini menjadi 8,5kg. BAK+ Normal, BAB + normal. Pasien juga dikeluhkan
tampak pucat sejak dua hari yang lalu (14 Agustus 2020). Akhirnya ibu membawa
pasien ke RSD dr.S
3. Riwayat Pemberian Obat
 Obat batuk dan penurun panas dari PKM.
 Ampisilin sulbactam dan paracetamol di IGD RSUD dr. S
4. Riwayat Penyakit Dahulu
Pasien dikeluhkan batuk selama 2 bulan saat pasien usia 1 bulan. Saat itu pasien
sudah diperiksakan ke PKM namun tidak membaik. Keluarga tidak memeriksakan
pasien ke fasilitas kesehatan rujukan.
Riwayat asma dan alergi disangkal.

5. Riwayat Penyakit Keluarga

Paman pasien menderita batuk lama namun tidak dalam pengobatan TB.
 PEMERIKSAAN FISIK (H1 MRS)
Keadaan umum
 Keadaan umum : Lemah
 Kesadaran : Kompos Mentis
 Frekuensi Nadi : 128 x/menit, reguler, kuat angkat
 Frekuensi Pernapasan : 52 x/menit, reguler
 Suhu : 37,5 0C suhu aksila
 Waktu pengisian kapiler : < 2 detik
Status gizi
 Umur : 29 bulan
 BB Sekarang : 8,5 kg
 PB : 78,5 cm
 Status gizi : -2<Z<-3 (Gizi kurang)

 PEMERIKSAAN PENUNJANG

 Pemeriksaan Laboratorium
Jenis Nilai Hasil Nilai Normal Satuan
Pemeriksaan Pemeriksaan
Hematologi Lengkap
Hemoglobin 7,8 11,5-15,5 gr/dl gr/dL
Leukosit 22 9 109/L
4,5 - 13 x 10 /L
Hematokrit 25,3 35-45 % %
Trombosit 987 9 109/L
150-450 x 10 /L
GDA 100 <200 mg/dL
Kesan :

 Anemia, leukositosis, penurunan Hematokrit

o Thorax Foto
Kesan : KP (koch pulmonum)
Tes MANTOUX : indurasi 11mm
 DIAGNOSIS KERJA
TB Milier dan anemia
 DIAGNOSIS BANDING
 TB paru
 ISPA
 Bronkitis

 terapi:

- Inf. D5 1/4 NS 500cc/24 jam

- Inj. Amphi Sulbaktam 3x300 mg

- Inj Paracetamol 100 mg (bila panas)

- Mulai terapi TB Milier

o OAT
INH 1X85mg
Rifampisin 1x120mg
Pirazinamid 1x250
Ethambutol 1x170mg

 Fase intensif : 16 Agustus – 15 Oktober 2020

 Fase lanjutan : 16 Oktober 2020 – 16 Agustus 2021

o Kortikosteroid 3x5mg
Mulai tanggal 16 Agustus 2020 – 30 Agustus 2020
Tappering off mulai tanggal 31 Agustus 2020 – 13 September 2020