Case Report

38 yo male with Drug Resistance Pulmonary TB,

Pyopneumothorax, and 20 days hospitalization

Irma Fitriani
Pulmonology and Respiratory Medicine Department
Medical Faculty of Hasanuddin University
(July, 20th 2022)
 CASE REPORT

Identity :
Name : Mr. A
Age : 38 yo
Admission : July, 1st 2022
Room : Second floor of Infection Centre
Pulmonologist : Dr. dr. Nur Ahmad Tabri Sp. PD, K-P, Sp. P (K)

Admission Diagnosis:
1. Left Hydropneumothorax
2. Presumptive New Case of Pulmonary Tuberculosis
 History Taking

Chief complain : Shortness of breath

Auto-anamnesis:
Patient come with shortness of breath since last 3 weeks and getting worse if
the patient lying down at right side. Patient also has occasional cough with white
phlegm since 2 month ago. No coughing up blood or history of coughing up
blood. No fever, no history of history. No chest pain or history of chest pain. No
heartburn, no nausea or vomiting. No sweating at night without activity. Patient
has a good appetite and no weight lose. Urination or defecation in normal limit.
 History Taking

₋ History of taking intensive phase of ATT for 2 days. Patient receive the medication from another Pulmonologist due
to positive result of sputum AFB a month before at Balai Paru Hospital.
₋ No history of close contact with Pulmonary Tuberculosis patient.
₋ History of Diabetes Mellitus since 2 years ago, taking glimepiride and metformin regularly.
₋ History of dyslipidemia and hypertension since a day before admitting ER and medicated with Candesartan 16mg
and atorvastatin 20mg.
₋ No history of covid 19 vaccination. No history of being confirmed with covid 19.
₋ History of smoking for 10 years about 8 sticks/day, stop smoking 4 years ago (IB 80, mild smoker)
₋ Work as a civil servant
 History of Illness
July 18th 2022
Patient still has empyema. We still evaluate pleural
fluid, side effect of LTR, and clinical condition of the
patient
July 14th 2022
Start LTR. Pleural fluid production became empyema

July 8th 2022

Increase of IOP, 5 days observation with timolol from
ophthalmologist before start Long Term Regiment

July 5th 2022

GenXpert Mtb detected, Rifampicin resistant

July 1st 2022

Chest tube insertion due to hydropneumothorax of left
hemithorax

Early May
Positive sputum AFB, start ATT at June 28 th 2022
 Physical Examination
General Condition : Moderate Illness/Normoweight
(Wight: 68, Height: 172, BMI: 20.96)/E4V5M6 • Thorax (position) :
SpO2 97% room air • Inspection: symmetric on both hemithorax,
Chest tube insertion at ICS IV anterior axilla left
BP : 130/70 mmHg hemithorax
HR : 82 times/minute • Palpation: tactile fremitus are same on both
hemithorax
RR : 20 times/minute
• Percussion: hyperonor at left hemithorax
BT : 36.8oC • Auscultation: decrease breath sound at ICS IV-
basal hemithorax
• Abdomen: soepel, no tenderness, hepar and lien
Head and eye : Normocephal, no pale conjunctiva,
are not palpable
no yellowish sclera
• Extremity: no pretibial oedem, warm acral
Neck : midline trachea, no enlargement of
lymphnode
 Laboratory Finding
LAB 1-7-2022 5-7-2022 Normal Range

WBC 8.4 8.1 4.0-10.0

HB 12.8 14.9 12-16

PLT 96 244 150-400

Neut 68.5 60.4 52-75

Lymph 17.9 23.1 20-40

135-145/3.5-
Na/K/Cl 140/3.6/105 140/4.0/104
5.1/97-111

PT/INR/APTT - 9.3/0.89/22.6 -

RBG/Hba1c 130 281/ 11.0 140/<6.5

Ur/Cr 13/0.70 19/0.52 10-50/<1.1

SGOT/PT 16/12 26/14 <38/<41 Other Date

laboratory Result
Albumin 3.6 4.2 3.5-5.0 finding
HbsAg/Anti Sarcov-2 PCR 1-7-2022
nonreactive - Nonreactive negative
HCV

Procalcitonin 0.23 - <0.05

 Laboratory Finding

Other Date
laboratory Result
finding

Sarcov-2 PCR 1-7-2022

negative

Sputum Gram 4-7-2022 Gram positive,

gram negative
Gram sputum 4-7-2022 Positive 4+ and
Quantity Positive 2+

BTA 4-7-2022
Positive

TCM 5-7-2022 Mtb found,

resistant
Rifampicin
Pleural Fluid Analysis (July 1st 2022)
Item May, 5th 2022

Color Clear yellow

pH 7.5

Light Criteria
Clotting Not found
July, 19th 2022
Rivalta test Positive PF protein/serum protein 2000/5.9 >0.5
PF LDH/serum LDH 2000/4.26 >0.6
Leukocyte MN 17%, PMN 83% PF LDH > 2/3 upper limit Serum LDH

exudate
LDH 5034

Glucose 6

Total protein 5500

Radiology Finding (Chest Xray)
Radiology Finding
Radiology Finding
Radiology Finding
 Diagnosis and Treatment
Assessment : Therapy:
1. Left Pyopneumithorax on Chest tube d-20 1. Clindamycin 300 mg/12 hour/oral
2. Drug Resistant Pulmonary Tuberculosis 2. Bedaquiline 400 mg/24 hour/oral
3. Type 2 Diabetes Mellitus 3. Moxifloxacin 800 mg/24 hours/oral
4. Grade I Hypertension 4. Linezolid 600 mg/24 hours/oral
5. Clofazimine 100 mg/24 hours/oral
Problems : 6. Sikloserin 750 mg/ 24 jam/oral
1. Seroxhantochrome pleural fluid drainage become 7. Amlodipine 10 mg/24 hours/oral
empyema 8. Acetaminophen 500mg/8 hours/oral
2. Left lung have not expanded 9. B6 vitamin 100 mg/24 hours/oral
3. Uncontrolled blood glucose

Planning :
1. Clinically evaluation
2. Chest physiotherapy
 Treatment from Other Divisions

EMD
• Levemir 0-0-10
• Novorapid 4-4-4

Ophtalmologist
• Timol 0.5% 1 gtt/24hours/OD
 Follow Up Daily List
11-7-2022 14-7-2022 15-7-2022 19-7-2022
S: S: S: S:
Occasional cough. No shortness of breath Occasional cough. No shortness of breath Occasional cough. No vomiting or nausea, no Occasional cough. No vomiting or nausea, no
O: O: heartburn heartburn
Moderate illness/composmentis Moderate illness/composmentis O: O:
BP: 110/80 mmhg HR: 86 times/minute BP: 120/80 mmhg HR: 78 times/minute Moderate illness/composmentis Moderate illness/composmentis
RR: 20 times/minute BT: 36.4oC RR: 18 times/minute BT: 36.2oC BP: 120/80 mmhg HR: 90 times/minute BP: 110/70 mmhg HR: 84 times/minute
SpO2: 97% room air SpO2: 97% room air RR: 20 times/minute BT: 36.9oC RR: 18 times/minute BT: 36.5oC
Thorax: Thorax: SpO2: 97% room air SpO2: 98% room air
I: Asymetric, left hemithorax is lagging on statis I: Symetric, left hemithorax is lagging on statis or Thorax: Thorax:
or dynamic dynamic I: Symetric, left hemithorax is lagging on statis I: Symetric, left hemithorax is lagging on statis or
P: decrease fremitus tactile on left hemithorax P: Tactile fremitus are same on both hemithorax or dynamic dynamic
P: Hipersonor on Apex-ICS V left hemithorax P: Dullness at basal left hemithorax P: Tactile fremitus are same on both P: Tactile fremitus are same on both hemithorax
A: Bronchovesicular, no ronchi or wheezing A: Bronchovesicular, no ronchi or wheezing hemithorax P: Dullness at basal left hemithorax
A: A: P: Dullness at basal left hemithorax A: Bronchovesicular, no ronchi or wheezing
1. Left Hydropneumothorax on Chest tube d-11 1. Left Hydropneumothorax on Chest tube d-14 A: Bronchovesicular, no ronchi or wheezing A:
2. Drug Resistant Pulmonary Tuberculosis 2. Drug Resistant Pulmonary Tuberculosis A: 1. Left Hydropneumothorax on Chest tube d-19
3. Type 2 Diabetes Mellitus 3. Type 2 Diabetes Mellitus 1. Left Hydropneumothorax on Chest tube d-15 2. Drug Resistant Pulmonary Tuberculosis
4. Decrease of IOP OD 4. Grade I Hypertension 2. Drug Resistant Pulmonary Tuberculosis 3. Type 2 Diabetes Mellitus
4. Grade I Hypertension R/ 3. Type 2 Diabetes Mellitus 4. Grade I Hypertension
R/ Codein 10 mg/8hour/oral 4. Grade I Hypertension R/
IVFD 0.9% sodium clorida 20 dpm Paracetamol 500 mg/8 hour/oral R/ Clindamycin 300 mg/12 hour/oral
Metamizole 1 gram/12 hour/IV Amlodipin 10 mg/24 hour Clindamycin 300 mg/12 hour/oral Bedaquiline 400 mg/24 hour/oral
Codein 10 mg/8hour/oral P: Bedaquiline 400 mg/24 hour/oral Moxifloxacine 800 mg/24 hours/oral
Paracetamol 500 mg/8 hour/oral Start ATT Long therapy regiment Moxifloxacine 800 mg/24 hours/oral Linezolide 600 mg/24 hours/oral
Amlodipin 10 mg/24 hour Chest tube evaluation Linezolide 600 mg/24 hours/oral Clofazimine 100 mg/24 hours/oral
P: Clofazimine 100 mg/24 hours/oral Sikloserin 750 mg/ 24 jam/oral
Consult to ophthalmologist at July 13th 2022 Sikloserin 750 mg/ 24 jam/oral Amlodipine 10 mg/24 hours/oral
Blow balloons Amlodipine 10 mg/24 hours/oral Acetamonophen 500mg/8 hours/oral
Aff chest tube Acetamonophen 500mg/8 hours/oral B6 vitamin 100 mg/24 hours/oral
B6 vitamin 100 mg/24 hours/oral P:
P: Chest tube evaluation
Chest tube evaluation Monitoring ATT side effect
Monitoring ATT side effect
 Monitoring Chart
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RBG PF Undulation
THANK YOU