1. Unit 7 Treatment of TB: B Family Case Botswana National Tuberculosis Programme Manual Training for Medical Officers

2. Slide 2 Unit 7: Case Study You’ll remember that… Mrs. B has HIV and starts on IPT Her husband, Mr. B, presents at the clinic with a cough, and has recently had contact with his uncle who has TB Though his exam is mostly normal, he gives a spot sputum sample and is told to come back the next day B Family Background

3. Slide 3 Unit 7: Case Study B Family Case (1) B Family Case (1) Mr. B weighs 58kg After you examine Mr. B and take an initial spot sputum sample, Mr. B returns the next day (day 2) with his morning specimen You obtain another spot sample and all 3 samples are sent to the lab for acid-fast staining (direct microscopy) You ask Mr. B to return in 3 days

4. Slide 4 Unit 7: Case Study B Family Case (2) When he returns (day 5), Mr. B is feeling worse He reports loss of appetite and seeing blood in his sputum His results are: Sputum AFB positive (scanty) x 1 2 sputum negative HIV positive Mr. B is TB positive With the new BNTP manual, ONE positive sputum specimen is adequate for the diagnosis of TB (previously, 2 positives were needed)

5. Slide 5 Unit 7: Case Study B Family Case: Question 1 1.How do you manage Mr. B’s case? 2.Does Mr. B qualify for HIV treatment?

6. Slide 6 Unit 7: Case Study B Family Case: Answer 1 (1) 1.Start Category I treatment FDC 4 tablets (R150/H75/Z400/E275) daily Make sure all patients are weighed at initiation of treatment Single drugs Isoniazid (INH) 300mg daily, Rifampicin (R) 600mg daily, Pyrazinamide (Z) 2000mg daily, Ethambutol (E) 1200mg daily

7. Slide 7 Unit 7: Case Study B Family Case: Answer 1 (2) Educate the patient Provide counselling Start cotrimoxazole, 400/80mg, 2 tabs daily Take blood for CD4 Take baseline bloods: FBC, Chemistry (renal function, electrolytes, LFT) Refer him to the nearest HIV site 35 km away Ask him to return for ART assessment and to review results

8. Slide 8 Unit 7: Case Study B Family Case: Answer 1 (3) 2.All HIV positive TB patients qualify for HIV treatment Treatment start time is variable Review BNTP manual

9. Slide 9 Unit 7: Case Study B Family Case: Question 2 (1) 2 weeks later, Mr. B returns to the clinic Haemoglobin is 8.0 CD4 is 300 You provide him with iron supplements and continue to monitor him until completion of TB treatment 6 months later At completion of treatment, he is considered cured

10. Slide 10 Unit 7: Case Study B Family Case: Question 2 (2) 5 months after completing TB treatment (month 11), Mr. B. returns to the clinic complaining of cough, difficulty swallowing and pain in his feet He looks moderately ill He says he never followed up with the HIV clinic because the hospital is too far for him to travel and he doesn’t have the taxi fare What should you do now for Mr. B?

11. Slide 11 Unit 7: Case Study B Family Case: Answer 2 Obtain a sputum specimen on the spot and send it for microscopy

12. Slide 12 Unit 7: Case Study B Family Case: Question 3 What other tests should the medical officer order?

13. Slide 13 Unit 7: Case Study B Family Case: Answer 3 Other tests ordered by the MO 2 more sputum specimens Sputum for culture FBC Repeat CD4 Chemistry : LFTs, creatinine, BUN, electrolytes Chest X-ray NOTE: ESR is not helpful in diagnosis and is not recommended

14. Slide 14 Unit 7: Case Study B Family Case: Question 4 Wt 52kg T 38.2 RR 26 HR 118 White patches on soft palate Cervical lymphadenopathy Course lung sounds Enlarged liver CXR shows reticular nodular pattern Examination shows: Based on these results, what should be the next step of Mr. B’s treatment?

15. Slide 15 Unit 7: Case Study B Family Case: Answer 4 Admit Mr. B Start him on: Crystalline penicillin & cotrimoxazole, 4SS tabs Fluconazole, 200mg daily x 14 Paracetamol, 500mg TDS-PRN IV fluids

16. Slide 16 Unit 7: Case Study B Family Case: Question 5 What is Mr. B being presumptively treated for?

17. Slide 17 Unit 7: Case Study B Family Case: Answer 5 PCN and cotrimoxazole are to treat bacterial pneumonia and as a prevention for PCP Fluconazole, at 200mg daily x 14, is to treat oesophageal candidiasis NOTE: It is not appropriate to use fluconazole for oral candidiasis

18. Slide 18 Unit 7: Case Study B Family Case: Question 6 Tests show: 1 sputum smear positive 2 sputum smear negative CD4 50 ALT 75 AST 77 Alk Phos 150 Total bili – O/S Hb 7.6 WBC 3.0 Platelets 75 Na 125 How do you manage Mr. B’s case?

19. Slide 19 Unit 7: Case Study B Family Case: Answer 6 (1) Continue X-PCN x 10 days For bacterial pneumonia coverage Change cotrimoxazole dose to 2 tabs daily for prophylaxis CXR was not indicative of PCP, so cotrimoxazole treatment dosage was stopped

20. Slide 20 Unit 7: Case Study B Family Case: Answer 6 (2) Send a sputum specimen for culture and drug susceptibility testing Start TB treatment immediately FDC 4 tablets (R150/H75/Z400/E275) daily + Streptomycin, 1g IM daily Single drugs Streptomycin, 1g IM daily, Isoniazid, 300mg daily, Rifampicin, 600mg daily, Pyrazinamide, 2000mg daily, Ethambutol, 1200mg daily

21. Slide 21 Unit 7: Case Study B Family Case: Question 7 (1) Botswana National HIV Programme states: If CD4 <100, start 1-2 weeks after initiating TB treatment If CD4 100-200, start 2-3 weeks after initiating TB treatment If CD4 >200, start treatment after completion of ATT HAART AZT/3TC (Combivir) + Efavirenz

22. Slide 22 Unit 7: Case Study B Family Case: Question 7 (2) Mr. B is discharged after 5 days and is referred to IDCC for HIV management and a local clinic for DOT Mr. B. presents to the IDCC with laboratory results from the hospital the following week He attends a counselling session with DOTS supporter He is started on ART

23. Slide 23 Unit 7: Case Study B Family Case: Question 7 (3) 1.What ART regimen is he started on and when does he begin treatment? 2.What lab test is important in choosing an ART regimen?

24. Slide 24 Unit 7: Case Study B Family Case: Answer 7 1.Combivir + Efavirenz 2 weeks after initiating ATT 2.Haemaglobin If Mr. B’s Hb is <7.5, he will be started on d4T instead of AZT (AZT causes bone marrow suppression, which leads to anaemia)