1. Case Discussion 1 - TREATMENT OF TB IN ADULTS by Dr. Razul Md Nazri Md Kassim 1

2. History 30 year-old Malay gentleman, smoker Active IVDU - last injection was a week prior to admission 1 week history of fever, chills & rigors, associated with productive cough, LOA & LOW 2

3. History (cont.) 2 days before admission, patient had headache & his family members noticed that his speech was incoherent & he was talking irrelevantly He denied h/o contact with TB patients, no palpitations, no shortness of breath 3

4. History (cont.) Clinically, patient was conscious & alert. However, he took time answering questions. Mild pallor, no lymphadenopathy Weight: 45 kg, height: 165 cm BP: 110/70 mm Hg, PR: 90/min, T: 37.6C, RR: 20 Lungs: Clear CVS: S1 S2, no murmurs Neurology: Cranial nerves grossly intact, Power of left side 3/5, right side 4/5 4

5. Q1 List the differential diagnoses. What are the investigations would you like to order? 5

6. 6 List the differential diagnoses. What are the investigations would you like to perform? 1.Infective endocarditis 2.Brain abscess & meningitis 3.Opportunistic infections 1.CXR 2.Blood culture & sensitivity 3.Echocardiography 4.CT Brain A1

7. Q2 Interpret the chest radiograph. 7

8. 8 Interpret the chest radiograph. – Right upper zone opacities with air bronchogram Reduced lung volume A2

9. Management of Tuberculosis (3 rd Edition) 9

10. Q3 Interpret the CT brain findings. 10

11. 11 Interpret the CT brain findings. 1.Subdural effusion 2.Brain edema 3.Tuberculoma 4.Midline shift 5.Infarct Space occupying lesion A3

12. Initial Investigations 12 Other IxFBCLFT TWBC5.14 x 10 3 T. Protein60 g/L Hb10.2 g/dL Albumin34g/L Platelet43 x 10 3 Bilirubin35 IU/L ALT158 U/L ALP655 U/L Sputum AFB -ve BUSENaKClUreaCreat 140 mmol/L 3.5 mmol/L 102 mmol/L 8 mmol/L 80 mmol/L

13. Management of Tuberculosis (3 rd Edition) 13

14. Investigations 14 InvestigationResults HIVNon-reactive Hepatitis CReactive Random Blood Glucose4.5 mmol/l

15. Management of Tuberculosis (3 rd Edition) 15

16. Investigations (cont.) 16 Echocardiography: Normal, no vegetation Blood C&S: NO GROWTH Q4. What is your diagnosis?

17. A4 17 Smear negative PTB with tuberculous meningitis (Stage II)

18. Q5 18 How to treat this patient?

19. A5 19 AIM 1.Cure 2.Reduce transmission Post-exposure history Site of infection Heath education to the patient & family members/carers DOT/S PTB Meningitis No

20. Management of Tuberculosis (3 rd Edition) 20

21. Dosages of First-line AntiTB Drugs 21

22. EPTB 22 Duration of treatment Steroids

23. Patient Had Been Started With: 23 Isoniazid: 300 mg OD Rifampicin: 450 mg OD Ethambutol: 1000 mg OD Pyrazinamide: 1250 mg OD Dexamethasone 12 mg OD +

24. Q6 24 What forms need to be filled-up?

25. A6 25 TBIS format ActivityAccessoryRegistrationReport PATIENT MANAGEMENT AND CONTACT TBIS 10A-1, 10A-2, 10B,10C,….. TBIS 101A, TBIS 101B TBIS 201A, 201B,….. LABORATORYTBIS 20A, 20B,,,,,, TBIS 102A, 102B TBIS 202A,….. BCGTBIS 30A, 30BTBIS 103ATBIS 203A,…..

26. TBIS FORM 26 TB Registry Notification TB TBIS 10B-2 TBIS 10B-1 TBIS 10A-1 TBIS 10E TBIS 10 I

27. 10A-1 / 10B-1 27

28. 10B-2 / 10C-1 28

29. 10G-2 / 10E 29

30. 10F / 10G 30

31. 10J / Notification 31

32. 32

33. 33

34. Investigations (cont.) 34 FBC22/1/1326/1/1328/1/1330/1/131/2/135/2/13 TWBC5.145.073.502.622.52 Hb10.210.68.87.66.8 Platelet433714 4791

35. Investigations (cont.) 35 LFT22/1/1326/1/1328/1/1330/1/131/2/133/2/13 T.protein605250434446 Albumin342018171920 Bilirubin351699161 ALT158130120804038 ALP655661614427278283

36. Take Home Messages 1.High clinical suspicion & prompt diagnosis are very important in managing PTB & EPTB. 2.Dosage & duration of treatment are important in TB management. 3.Rifampicin-based regimen is preferred in all types of TB infection. 4.Ensure all TBIS forms are filled-up. 36

37. THANK YOU  drrazulmn@moh.kdh.gov.my