Pulmonary Tuberculosis management.

Abstract
This case reports the treatment of an immunocompromised woman after
chemotherapy who is suffering from pulmonary tuberculosis. Treatment of antituberculosis: isoniazid, pyrazinamide, ethambutol and rifampicin were started on
this patient and the patient should continue this regime for at least 2 months.
Pulmonary tuberculosis is one of chronic infection that is occurring in Malaysia.
Tuberculosis is spread through air-borne, thus its aim of management is to
eradicate the infection as well as reducing its transmission to others. Its full
course of treatment could take at least 6 months and compliance is often a
problem. Patients education on the importance of finishing the 6 months
treatment should clearly mentioned in order to reduce its complication incidence.
Keywords: pulmonary tuberculosis, Mycobacterium tuberculosis.
Introduction
A Malay woman was presented to the emergency department with persistent
cough, shortness of breath and chest pain. She had been coughing for about 3
months, and it was accompanied with yellowish sputum. She complained of
having shortness of breath for the past 2 days and chest pain for 1 day. The pain
was on her left side; however it was not radiated to other side. She also stated
that she had lost 3kg since the fasting month in August. She had history of
breast carcinoma and had completed her chemotherapy and radiotherapy in
2012. She is a teacher and married and granted with 4 children. She had strong
family history of cancer. The patient was not a smoker and never consumes
alcohol. She also at time of admission was not pregnant.

Initial Examination and Investigation

The patient was thin (40kg), alert, able to speak in full sentence and afebrile. Her
blood pressure was noted at 101/72 mmHg and pulse rate of 90 beats per
minute. Her lungs sound had creptations over the right lower zone with no
rhonchi. Her sputum was sampled and sent for culture and sensitivity test. Blood
and urine sample was taken for renal function test and full blood count.

Impression and initial management

The initial impression was to cover for pneumonia and to rule pulmonary
tuberculosis out. The patient was placed on bed rest, on put on nasal prong for
oxygen supply and to be checked for chest x-ray, mantoux test, c-reactive
protein and erythrocyte sediment rate. The patient was started IV amoxicillin and

clavulanic acid (Augmentin) 1.2g 3 times daily. The patient was also started on
erythromycin ethylsuccinate tablet 800mg BD for pneumonia empirical
treatment and tablet bromhexine 8mg three times daily was given for her cough.
Progress
On the second day, patient was comfortable under nasal prong. She felt better
with less cough and sputum and her chest pain also had lessen. On third day,
she was put on chest tube insertion due to chest x-ray finding of pneumothorax.
On the fourth day, the patient claimed that she had done mantoux test and
sputum acid fast bacilli test and all of them turned out negative. However, she
complaint about her sputum became productive and in greenish or yellowish
colour. On the fifth day, patient remembered her contact with a student having
bone tuberculosis. Her erythrocyte sediment rate was increased at 96mm/hr. The
patient was then advised to wear face mask anti-tuberculosis medication was
planned to be started. Mantoux test and sputum acid fast bacilli test was redone.
Her culture result was still pending and the patient was started on antituberculosis regime (EHRZ). With the patients weight of 40kg, the patient was
started on Isoniazid 200mg OD, Rifampicin 450mg OD, Pyrazinamide 1000mg
OD, Ethambutol 600mg OD and Pyridoxin 20mg OD. She was stopped from
taking Augmentin and planned to be sent to isolation ward.

Discussion
Tuberculosis is a type of infection caused by Mycobacterium tuberculosis and
usually affecting the human lungs. In Malaysia alone, the number of tuberculosis
cases has increased from 15,000 in 2005 to 19,251 in 2011. 1 Pulmonary
tuberculosis is a chronic infection that can caused severe complications like
haemoptysis, pneumothorax, bronchiectasis and pulmonary aspergillosis if not
treated well. 2 The aim of treatment for pulmonary tuberculosis is to cure the
tuberculosis infection, decrease the transmission of tuberculosis to other people,
preventing the development of acquired drug resistance , prevent relapse and
also complications.3
In order to eradicate tuberculosis infection, a combination of antimicrobials is
used together. The common regime used as anti-tuberculosis is called 2 EHRZ/ 4
HR regime. This regime is consisting of Ethambutol (E), Isoniazid (H), Rifampicin
(R) and Pyrazinamide (Z). Ethambutol, Isoniazid, Rifampicin and Pyrazinamide
should be taken daily for 2 months and then continues with 4 months of Isoniazid
and Rifampicin daily. 1
Ethambutol is a bacteriostatic antimicrobial and has a low potency towards
tuberculosis. However, its addition to the regime can minimize the emergence of
drug resistance tuberculosis. Isoniazid has the bactericidal effect after 24 hours.
It can kill more than 90% of bacilli in first few days of treatment. Rifampicin is
also a bactericidal antimicrobial with effective time within 1 hour. It is also has
high potency against tuberculosis bacilli. Pyrazinamide on the other hand is

showing bactericidal properties with low potency against bacilli. It will achieve its
sterilizing action within 2-3 months of consumption. 3
Like every other treatment, anti-tuberculosis therapy is not void of side effects.
Its side effects can be categorized into minor and major side effects. Minor side
effects includes abdominal pains and orange or red coloured body fluid caused
caused by Rifampicin. However, its major side effects that require medical
attention are liver impairment caused by Isoniazide, Rifampicin and
Pyrazinamide. Purpura also can occur caused by Rifampicin. Isoniazid may cause
peripheral neuropathy, thus pyridoxine is usually give together with antituberculosis regime to reduce this incidence of side effects. 3
Its common for patients to developed liver impairment during the first two
months of anti-tuberculosis. When patient is presented with liver impairment, all
4 anti-tuberculosis drugs should be stopped and be introduced again one by one,
to figure out the causative agent for liver impairment. Since patient would stop
the regime during this trial, it is important to take note the number of days
patients have been taking full regime. Patient should be taking EHRZ regime for
60 days and HR regime for 120 days. 3

Conclusion
Tuberculosis is a chronic infection that most commonly affecting the lungs and it
could cause severe complications if not treated well. The treatment for
pulmonary tuberculosis takes as long as 6 months for full eradication and
compliance is often a problem. Non-compliance could lead to patients
experiencing the complications such as bronchiectasis and aspergillosis. Thus,
patients education on anti-tuberculosis treatment should be focused on.

References:
1. Ministry of Health. CPG-Management of Tuberculosis 2012:
[Internet]November 2012
2. Pozniak A Clinical manifestations and evaluation of pulmonary
tuberculosis. [Internet] UpToDate; 2015 [cited on 27 th February 2015]
3. Department: Health Republic of South Africa. National Tuberculosis
Managemnt Guidelines 2014. [Internet] 2014.