disseminated TB

case presentation on disseminated TB

1. 1 Addis Ababa University School of Pharmacy Department of Pharmacology and Clinical Pharmacy Disseminated tuberculosis (lung +pericardium Arega Gashaw December 12 , 2014

2. Patient Presentation Card no : 31968 bed No: 812/3 Ward : C 8 Age : 45 years Sex: M weight: NA CC Dry Cough for 2 month Shortness of breath for 1 week Non trauma HPI disseminated TB with massive pericardial effusion with cardiac tamponed secondary to DTV

3. PMH : pneumonia Medications prior to admission…. NA drug allergies ….NKDA ADR… NA

4. Physical examination Vital sign PR= 90 RR= 27 BP = 90/60 mm Hg T 36.5°C Sa O2= 91 % HEENT: Eye: pink conjunctivitis Distended neck vein Leg : lymphatic adenopathy Abdominal – liver: smooth, tender, SD+ MS - grade II pedal edema

5. Chest: clear and good air entry over the right side decrease air entry over the left side Several pericurdium effusion with tamponda Chest tube insitu over the left side for drainage of fluid CVS : distant heart sound Respiratory: dry cough, SOB CNS: conscious pertinent laboratory findings CBC WBC---- 6.69 × 10 3 /mm 3 RBC- ---- 5.1 × 10 3 /mm 3 Platelet--- 2.97 × 10 3 /mm 3 Hg ---12.7 g/ dL (12-18) Hct --- 37 % ( 38-49)

6. Investigation …… Coagulation profile PT 20.1sec INR 1.65 sec PTT 31.7 sec AFB 3x negative No gram stain Pleural fluid analysis Cell count 200 (ref. < 5 cell/ cc)??? N-20% L-80 % Cytology : reactive infusion

7. Investigation…… Total protein 5.8 g/ dL …….. (6.6-8.7) Albumin 3.5 g/ dL ……….. (3.8-4.65 ) Uric acid 9.5 m g/ dL ………… (3.4-7.1 ) LDH 601U/L …………(230-430 )…..5951 Serum electrolyte K 3.8 mEq /L Na 131 mEq /L Ca 4.4 mEq /L

8. Investigation…… Organ function test BUN 39 mg/ dL Cr 1 mg/ dL ALT(SGPT) - 166 U/L….(< 40) AST(SGOT)- 287U/L ….(<40) ALP- 240 U/L….( 44-147) Bl T- 1.4 mg/ dL D - 1 mg/ dL

9. Other investigation Echo examination revels that several pericardium effusion are present CT(chest) : metastasis to the lung with moderate bilateral plural effusion and pericardial effusion Abd U/S: hepatomegally , ascities , right renal cortical cyst Abd CT: requested

10. Hospital Course On 10/3/07 He was started anti TB. RHZE (150+75+ 400+275 mg)4 tab/day Steroid (prednisolone 60 mg PO/d after cardiologic side was consulted. On 12/3/07 He develop lower limb acute distal DVT( doppler proved) and start anticoagulant Heparin 17,500 U SC B id and Warfarin 5 mg PO/d

11. On 23/3/07 He was preparing for surgery(window opening for Pericardial fluid drainage Warfarin discontinue Heparin continue On 24/3/07 Pericardial fluid drainage was done and sample sent for analysis and cytology. On the same day pericardial window is done by cardio thoracic gird

12. On 25/3/07 Chest tube is inserted for massive left side. Drain about 1 L of fluid up on insertion Currently ;He is complaining of the surgical site pain

13. Currently he is on Anti TB-RHZE/150+75+400+275mg 4 tab/day Prednisolone 60 mg PO/d Pyridoxine 50 mg PO /d Heparin 17500 U sc Planned to resume warfarin after coagulation profile is updated and discontinue heparin. Analgesics : petidine 25 mg iv tid tramadole ……….

14. Discussion and critique of current treatment Use of prednisolone for TB ??? Prolonged anti coagulant bridge therapy? Dose of warfarin ? Drug interaction Ref Vs warfarin Ref Vs predinsolone INH Vs warfarin Pyridoxine + warfarin ( increase or decrease INR b/c of clotting factor metabolism may alter

15. desired therapeutic outcome Achievement of a noninfectious state Adherence to the treatment regimen Cure as quickly as possible (generally with at least 6 months of treatment) Reduction or elimination of symptoms Not complicating or aggravating other existing disease states. Avoiding or minimizing adverse effects of treatment. Providing cost-effective therapy. Maintaining the patient’s quality of life.

16. Therapeutic Alternatives LMWH is available for patient with cancer associated DVT And where warfarin is contraindicated for long term treatment LMWH is either cost saving or cost effective compare with UFH Restriction of sodium and fluid Compression therapy anti-embolism stockings Regular exercise Elevate limbs while seated

17. Design of an optimal individualized pharmaco -therapeutic plan Assess and reinforce adherence/concordance with recommended therapy. Continue both the anti TB drug, pyridoxine Suggest discontinuation of prednisolone and heparin and increasing warfarin to 7.5 mg PO until to the target INR Educate on purpose of each medication

18. parameters to evaluate the outcome 1. Clinical evaluation 2. Bacteriological examination 3. Chest radiograph Clinical Evaluation Patients should have clinical evaluations at least monthly to Assess adherence; and Determine treatment efficacy Identify possible adverse reactions to medications

19. For any drugs : Allergic reaction ,Skin rash For EMB Eye damage (Blurred or changed vision INH, PZA, RIF: Hepatic toxicity For INH Nervous system damage • Dizziness; tingling or numbness, around the mouth Peripheral neuropathy • Tingling sensation in hands and feet For PZA Stomach upset Serious, gout For RIF Bleeding problems discoloration of body fluids Sensitivity to the sun • Frequent sunburn Minor

20. For warfarin Red or dark brown urine and stool Bleeding Severe headache or stomach pain or upset Weakness, faintness, or dizziness Skin rash or irritation Unusual fever Joint or back pain Swelling or pain at an injection site

21. Steroids salt and water retention extracellular fluid   volume expansion H ypertension potassium  depletion, and   metabolic alkalosis Immunodeficiency

22. Bacteriological examination Patients whose cultures have not become negative after 3 months of therapy should be reevaluated for potential drug-resistant disease, as well as for potential failure to adhere to the regimen. AFB ??? AFB cultures? Drug susceptibility studies NEVER ADD 1 DRUG IF SUSPECT RESISTANCE CXR: Baseline, 2-3 months and after completion

23. General Approach Clinical Evaluations at 2 (with PZA), 4 and 8 weeks, then monthly: PE: Signs/symptoms of hepatitis Lab Exam CBC/platelets Liver function tests (ALT, AST, Bili , ALP) at baseline and monthly D/C INH if: Patient develops symptomatic hepatitis LFTs > 5 times normal or > 3-5 times baseline Renal function tests ( Scr , BUN, U/A ) Review of Medication Profile (drug interactions)

24. Monitoring Toxicity Hepatotoxicity Plan Clinical or Laboratory Evidence S/S hepatitis, jaundice AST, ALT > 350 or Bili > 3 D/C INH, Rifampin and Pyrazinamide 3x baseline or 5 x normal Monitorng parameter for heparin and warfarin PT/INR at the base line, hg , Hct , plt ,

25. Provision of patient education including discharge medication counseling Take your drug at the same time at each day Your dose may be adjusted several times based on the lab. Test Do not stop taking your medication with our your doctor approval Inform your doctor or the pharmacist for any unusual bleeding from any site, the symptoms of warfarin toxicity early Notify your doctors if develop chills, fever, skin rash

26. Other issue ….. When to seek necessary medical attention Consequences of not taking their medicine correctly Name and description of the medication (which may include the indication). • Dosage, dosage form, route of administration, and duration of therapy. • Action to be taken in the event of missed doses.

27. 12/11/2014 Presentation on internal medicine ward Attachment 27 Thank you All….