CASE I

COMMUNICABLE DISEASE

PULMONARY TUBERCULOSIS
Introduction

Tuberculosis (TB) is globally emerging problem due to its correlation with HIV-AIDS.
Tuberculosis is often caused by Mycobacterium tuberculosis. It commonly affects the lungs and
causes pulmonary tuberculosis. It can also affects the meninges, intestine, lymph-node and other
various tissues of the body. Tuberculosis occurs disproportionately among disadvantaged
population such as those living in overcrowded and substandard housing. There is an increased
occurrence of tuberculosis among HIV-positive individuals.

Clinical Manifestations of Tuberculosis include :

- Chronic cough

- Night sweating

- Weight loss

- Chest pain

- Fatigue

- Loss of appetite - Hemoptysis

- Low grade fever

PROBLEM STATEMENT

A. Nepal
 Tuberculosis (TB) is still a major public health problem in Nepal. Directly Observed
Treatment Short-course (DOTS) have successfully been implemented throughout the
country since April 2001 and a total of 4382 DOTS treatment centers are providing
TB treatment service throughout the country among which 4204 are government
health institutions.
  In Fiscal Year 2075/76, total of 32,043 cases of TB were registered. Among them,
82% were pulmonary bacteriologically confirmed (PBC).
 Most cases were reported among the middle-aged group with the highest among 15-
24 year of age (63%). The childhood TB (new and relapse) was 5.5%.
 Male TB cases were reported nearly 1.73 times more than female.
 The Case Notification Rate (CNR) all forms was 112 per 100,000 population.
 The overall treatment Success rates for new and relapse cases is 91%.
 Treatment failure rate was 1% across all the provinces of Nepal.

Epidemiological Determinants

A. Agent Factors
a) Agent: -
Mycobacterium species specially Mycobacterium tuberculosis, also M. avium, M. bovis,
M. microti and M. africanum. - Slow growing aerobes, non-motile, non-spore forming
and noncapsulated acid fast bacilli, arranged singly or in groups.
b) Source of infection
There are two source of infection-
a) Human source: Sputum positive and cases who haven’t received treatment or not fully
treated.
b) Bovine source: Infection usually from infected milk.

c). Communicability: -

Untreated patient is infective as long as it is. Effective antimicrobial treatment reduces

infectivity by 90% within 48 hours.

c) Mode of Transmission: Droplet infection and droplet nuclei

d) Incubation Period: may be weeks, months or years. It takes 3-6 weeks for the
development of +ve tuberculin test after infection.
B. Host Factors
 a. Age: Affects all ages, developing countries show a sharp rise in infection rates from
infancy to adolescence.

b. Sex: More common in males than in females

c. Nutrition: Malnutrition one of the major cause

d. Immunity: No inherited immunity against Tuberculosis infection. Acquired immunity

develops from natural infection or BCG vaccination.

C. Environmental Factors

a. Poor quality of life, low socio economic status, poor housing, over crowding

b. Under nutrition

c. Lack of education

d. Lack of awareness of causes of illness

e. Tuberculosis thrives in condition of poverty and can worsen poverty.

 Case Study

We first met our patient through the DOTS clinic of Manipal College Of Medical Sciences And
Teaching Hospital. We were searching through the files for selecting a case, when we came
across this particular case that could fit into the category of 'infectious disease'. Then we
gathered necessary information from duty staff there, contacted her personally and explained
about our family health program and requested to meet her along with her family and she agreed
to help us.

 Rationale Tuberculosis is often regarded as barometer of social welfare and remains one of
major public health problem in Nepal. It is a chronic disease and requires active and conscious
participation of the patient and family. It reflects the multiple dimensions of disease, assesses
impact on the family and also fulfills of objectives of the FHE. Treatment aspects including
compliance and risk of developing MDR tuberculosis are the important factors to be identified.

Case History

Patient’s Profile

Name: Ganga Devi Acharya

Age: 69 years

Sex: Female

Marital Status: Married

Religion: Hindu

Occupation: Housewife

Address: Kaudada, Pokhara

Education: Illiterate

Chief complaint :
 Cough for 2 weeks

History of present illness:

The patient was asymptomatic 2 weeks prior , then she complained of cough which was acute in
onset ,continuous and persistant. It was associated with production of yellow colored sputum
which was sometimes stained with blood streaks. Cough was also associated with fatigue, night
sweats, evening raise of temperature and significant loss of weight.

No history of nausea , vomiting , diarrhea , constipation or abdominal pain.

No history of chest pain , breathlessness or palpitation.

No history of syncope , seizure , dizziness.

No history of burning micturition or increase in the urgency or frequency of micturition.

 Past history:

She had been diagnosed with Hypertension 19 years back and is on oral medication

She had also been diagnosed with Type II Diabetes Mellitus 4 years back and is on oral

Medication

No significant past history of seizure attacks or congenital diseases.

 Personal history

She consumes mixed diet (Non Vegeterian)

 She has been smoking 5 cigarettes per day for past 20 years.

Pack Year = ( 5 * 20) / 20

= 5 pack year

She does not consume alcohol or any other tobacco products.

Menstrual history

Menarche : 16 years

Menopause : 40 years

 Drug history

No documented history of allergy to any food or drug.

Family history

There is no significant history of Tuberculosis, Diabetes, Hypertension and Epilepsy in the

family.

Socio-economic history

She belongs to lower class family.

Treatment history

No significant history of past surgeries or hospital admission.

Dietary History

Meal Time

Breakfast(Tea /bread/Biscuit /) 7:00 AM

Lunch (rice/dal/tarkari ) 11:00 PM

Nasta (Noodles/bread) 4:30 pm

Dinner (Roti+Dal+Tarkari) 8:00 PM

Physical examination

The patient was comfortable.

General condition: fair

Weight: 54 kg

Height: 5’2”

Vitals: B.P.: 150/80mmHg

Pulse: 78beats/min

Temperature: 98.2 degree F

Respiratory rate: 18 breaths/min

Cardinal signs:

Icterus – absent.

Pallor – absent.

Clubbing – absent.

Cyanosis – absent.

Lymphadenopathy – absent.

And well hydrated

 Systemic Examination

Respiratory System–

Inspection

a) chest is bilaterally symmetrical

b) no bulging, scar marks

c) chest expansion equal on both side

d) intercostal space normal

Palpation:
a) inspection finding are confirmed

b) trachea not shifted

c) increased vocal fremitus

d) no tendeness in the chest region

Percussion:

a) resonate on both side

b) normal liver dullness from 5th intercostals space to lower costal margin

Auscultation:

a) normal vesicular breath sound

b) voice resonance normal

c) crepitation are heard in end inspiratory phase in left infra scapular

Alimentary system:

a) abdomen is soft, non-tender

b) spleen and liver are not palpable

c) normal bowel sound heard

Cardiovascular system:

a) on palpation, apex beat at 5th intercostals space

b) no thrills and additional sound heard

c) on auscultation, normal s1 and s2 heard with no abnormal hear sound

Central nervous system:

a) cranial nerves function intact

b) sensory, motor and autonomic functions normal

c) superficial and deep reflex intact

d) no headache, ocular pain or seizures.

 INVESTIGATIONS

1) Complete blood count.

Hb: 11gm%

WBC: 11,600/mm3 Neutrophils: 56% Lymphocytes: 41% Monocytes: 2% Eosinophils: 1%

ESR: 94mm in 1st hour Platelets: 320,000/ mm3

2) Sugar:
Fasting blood glucose =91mg/dl
Post prandial blood glucose =125 mg/dl

3) sputum for AFB: negative

 Diagnosis: pulmonary tuberculosis

Treatment:

He is being treated according to DOTS category-I regimen as given by the government. Intensive
phase:2(HRZE) + and continuation phase:4(HR)

 Intensive phase: From 2077/07/23 to 2077/09/23 (2 months) –

- Tab Rifampicin 600 mg.

- Tab Isoniazide 300 mg.

- Tab Pyrazinamide 1500 mg.

- Tab Ethambutol 1000mg.

 Continuation phase: From 2077/09/23 Onwards.

Following drugs were given orally daily for 4 months: -

- Tab. Isoniazide 300 mg.

- Tab. Rifampicin 600 mg.

- Tab. Ethambutol 100mg.

 Family Visit
First visit (2077/11/10)

Objectives:

a) To locate the house of the patient

b) Introduction and rapport building with the family members, key informant interview and
interview with the head of the house

c) To observe the physical facilities and evaluate socio-economic ststus

d) To know in the detail awerness of disease in the patient and family

Activities

We had found the patient’s number and address through DOTS file . So, it was not so difficult
to locate it. We asked the neighbor as she asked us to locate the house. We observed its built and
its surrounding environment. The objective of rapport building was achieved. After conversation
with her and the family members we left reminding them that we shall meet again next week.

Outcomes:

Housing and environment: The house was " kachha-pakka" . The rooms were not well ventilated
with and not enough adequate light entering rooms. There were two rooms with a separate
kitchen. They used LP-Gas for cooking. The surrounding was clean and they didn’t have lots of
open space .They had piped water supply. The toilet is properly maintained. Disposable waste
was disposed in a pits and non-disposable waste are taken by sub-metropolitan truck.

Family profile with education, occupation and income

There are 4 members in the family.

Family type: Nucler

Household Head : Ganga Devi Acharya ( self)

Family composition and structure:

S.N. Name Age Pt’s relation Education Occupation

1. Ganga Devi 69 Self illiterate housewife

Acharya
2. Bikash 45 Son 12 passed Foreign
Acharya employment
3. Aarati Acharya 40 Daughter-in-law 10 passed Foreign
employment
4. Kriti Acharya 18 Grand daughter 11 class Student

FAMILY GENOGRAM:

69

45 40 42

18

INDEX

Male-

Female-

Patient-

Dead-
Socioeconomic history
According to Kuppuswamy's Socio Economic Scale, estimated score is 20 (education-3,
occupation-5, family income – 12), so this family belongs to upper middle class.
Observational finding:
1. Housing
 Type of house – Semi-pakka
 Status of house - Own house
 No. of rooms: 2
 No. of windows per room: 2
 Lighting – not adequate
 Cross Ventilation – no
 No. of people living in a same room: 1

2. Sanitation
 Kitchen – Separate
 Toilet – Water seal
 Distance to toilet:
 Dust on smooth surfaces – no
 Odor – unremarkable
 Flies – no
 Garbage/Waste Disposal site – collected by Municipality
 Source of water – tap
 If tap- everyday
 Sufficiency of water - sufficient
 Access/ Time taken to obtain water: none
 Use of water purification techniques – boiling and filter
 Source of fuel – LPG / electricity
 Pets - none

3. Environment
 Nearby forests/Trees/Greenery? - yes
 Nearby factories – no
 Noise – none
 Nearby open spaces – yes
 Nearby open sewage/polluted rivers – no
 Road access –Smaller
 Nearest hospital - 30 min–1hour
4. Assets
 Information system
• Television
 Furniture – well-furnished
 Kitchen appliances
• Cooking appliances
 Vehicle
• No
 Health related instruments
• None