REFERENCES

GENERAL DATA
C.R.S
61/M
Married
Mabalacat, Pampanga
Chief complaint: fever

1 month
prior to
consult

5 days
prior to
consult

3 days prior
to consult

Non-productive
cough
Anorexia
Weight loss
Undocumented on
and off fever

Persistense of
cough
Intermittent
fever
Body weakness
anorexia

Consulted to PMD started azithromycin

and co-amoxiclav BID

Few hour prior to consult persistence of

signs and symptoms hence consulted in
our institution

PAST MEDICAL
(-) HPN
(+) DM
(-) ASTHMA
(+) PTB > 20 years ago completed 6 months
treatment
Glipizide 60mg/tab OD
Pioglitazone 45mg/tab OD
Fenofibrate 200mg/cap OD

PERSONAL SOCIAL
(+) smoker 45 packs per year
(+) occasional drinker

FAMILY HISTORY
(-) HPN
(+) DM
(-) Asthma
(-) Cancer

REVIEW OF SYSTEM
General: (+) weakness, (+) fatigue, (+) weight loss,
(-)rashes, (-) itching and dryness of skin
HEENT: (-) headache, (-) dizziness, (-) blurring of
vision, (-) vertigo, (-) tinnitus, (-) nosebleeds, (-)sore
throats, (-) nasal stuffiness, (-) Stiffness in neck.
Respiratory: (+) cough, (+) sputum, (-) hemoptysis,
(-) dyspnea

REVIEW OF SYSTEM
Cardiovascular: (-) chest pain, (-) palpitations, (-)
dyspnea
Gastrointestinal: (-) heartburn, (-) nausea, (-) rectal
bleeding, (-) hemorrhoids
Peripheral Vascular: (-)leg cramps, (-) swelling in calves,
legs or feet
Urinary: (-) polyuria, (-) nocturia, (-) dysuria, (-)
hematuria, (-) flank pain

REVIEW OF SYSTEM
Musculoskeletal: (-) joint pain, (-) stiffness,
(-)limitation of motion
Hematologic: (-) Anemia, (-) easy bruising, (-)
transfusion reaction
Endocrine: (-) heat or cold intolerance, (-) excessive
sweating
Neurological: (-) involuntary moments, (-) seizures, (-)
changes in orientation, memory, insight or judgement
Cranial Nerves Intact

PHYSICAL EXAMINATION
BP: 120/80 HR: 80

RR:24

Temp: 36C

Conscious, coherent, not in cardiorespiratory distress, (-)

conjuctival pallor, Anicteric sclerea, (-) tonsillopharayngeal
congestion, symmetrical chest expansion, (-) retractions, (+)
decrease breath sounds on left lung fields, Adynamic
precordium, regular rate and rhythm, (-) murmur, flabby and
soft abdomen, (-) tender, full and equal peripheral pulses, (-)
edema

COMPLETE BLOOD
COUNT

EXAMINATION

RESULT

REFERENCE RANGE

HEMOGLOBIN

124

140-175 g/L

HEMATOCRIT

0.37

0.41-0.50

RED BLOOD CELL

COUNT

4.85

4.52-5.90 X 10^1/L

WHITE BLOOD CELL

COUNT

10.47

4.50- 11 X 10^9/L

NEUTROPHILS

0.64

0.18-0.70

LYMPHOCYTES

0.26

0.10-0.48

MONOCYTES

0.08

0.00-0.04

EOSINOPHILS

0.02

0.00-0.03

PLATELET COUNT

308

150-400 X 10^9/L

Examinatio
n

CLINICAL CHEMISTRY
Result

Reference
Range

CREATININE

118.37

71-115 umol/L

SODIUM

126.8 (sep 24)

136.2 (sep 28)

135-150 mmol/L

SGPT/ALT

24.38

0.00-45.00 U/L

GLUCOSE (RBS)

10.14

Mmol/L

POTASSIUM

4.18

3.50- 5.50 mmol/L

CHEST XRAY

URINALYSIS ( SEP 25)

Color: light yellow
Appearance: clear
pH: 6.0
Specific gravity: 1.005
Pus cells: 0-2/hpf
Red cells: 0-1/hpf
Bacteria: few
Sugar: negative
Albumin: negative

INITIAL IMPRESSION
t/c pulmonary tuberculosis reactivation
t/c pleural effusion left probably parapneumonic
DM-II - non insulin requiring

OFFICIAL CHEST XRAY

READING
Thick- walled Cavity in left upper lung measuring 5.7 X 3.5 cm
in length and transverse dimensions, respectively. Hazy
opacities in right upper lung, left midlung and left lower lung .
The left lateral costophrenic is blunted.
IMPRESSION:
1) Consider tuberculosis in both upper lungs with
endobronchial spread or pneumonia in left midlung and left
lower lung. Due to configuration of left upper lung cavity,
new growth is not totally ruled out.
2) Minimal pleural effusion or thicknening, left

AFB STAIN (SEP 25)

AFB STAIN: 2+
0 = No acid fast bacilli seen in 300 visual fields
+n = 1-9 acid fast bacilli seen in 150 visual fields
1+ = 10 - 99 acid fast bacilli seen in 300 visual fields
2+ = 1-10 acid fast bacilli in at least 50 visual fields
3+ = More than 10 Acid Fast Bacilli in at least 20 visual
fields

SEP 24, 2016 (HD 0)

SEP 25, 2016 (HD 1)

SEP 26, 2016 (HD 2)

S: (+) cough
(+) fever
(-)DOB

S: (+) Cough
(+) fever
(-) DOB

S: (+) cough
(-) fever
(-)DOB

O: BP: 130/80 HR:

80 RR:24
Temp:
38 C
Decrease breath
sound on left lung
field
IVF: PNSS 1L X
120cc/hr
Diet: diabetic diet
1) Azithromycin 500/tab OD D3
completed
2) Co-amoxiclav 625 mg/cap BID
D5
3) Cefepime 1gm/IV q12 -1st dose

CBC, RBS, creatinine,

Na, K, SGPT
Urinalysis

O: BP: 120/80 HR: 90

RR:22
Temp: 38.2 C
Cefipime 2gms IV q12
Start streptomycin 1gm
IM once a day, Monday
to Friday

O: BP: 120/80 HR:90

RR: 25 Temp: 36 C
Cefipime- D2 +1
Streptomycin D1
Suggested for Gene
expert test at JBL
Repeat CXR

Planned to refer to JBLTB

DOTS OPD basis for
Gene
Continue paracetamol
Glimperide 2mg BID

Sep 27, 2016 (HD

3)

Sep 28, 2016 (HD 4) Sep 29, 2016 (HD 5)

S: (+) occasional
cough
(-) fever
(-)DOB
(+) weakness
(+) poor appetite

S: (+) occasional
cough
(-) fever
(-)DOB
(+) weakness
(+) poor appetite

O: BP: 130/80 HR:

80 RR:24
Temp:
36 C
Decrease breath
sound on left lung
field
Repeat Na+
IVF: PNSS 1L X 40
cc/hr

O: BP: 120/80 HR:

80 RR:22
Temp:
36 C
Plan for discharge
Shift cefipime to
Cefixime 200mg BID
for 5 days

Patient discharged
THM
1)Myrin P forte 3
tablets OD
2) Streptomycin
1gm IM once a day
Monday to Friday
only
3) Cefixime
200mg/tab BID for 5
days
4) Bcomplex 1 tab
OD
Followup gene
expert test on OPD

TUBERCULOSIS
Tuberculosis (TB), which is caused by bacteria of the
Mycobacterium tuberculosis complex, is one of the
oldest diseases known to affect humans and a major
cause of death worldwide.
This disease most often affects the lungs, although
other organs are involved in up to one-third of cases.
If properly treated, TB caused by drug-susceptible
strains is curable in the vast majority of cases. If
untreated, the disease may be fatal within 5 years in
5065% of cases.
Transmission usually takes place through the airborne
spread of droplet nuclei produced by patients with

ETIOLOGIC AGENTS
Mycobacteria belong to the family Mycobacteriaceae
and the order Actinomycetales.
Of the pathogenic species belonging to the M.
tuberculosis complex, which comprises eight distinct
subgroups, the most common and important agent of
human disease is M. tuberculosis.

 M. bovis (the bovine tubercle bacilluscharacteristically resistant

to pyrazinamide, once an important cause of TB transmitted by
unpasteurized milk, and currently the cause of a small percentage
of human cases worldwide),
M. caprae (related to M. bovis),
M. africanum (isolated from cases in West, Central, and East
Africa),
M. microti (the vole bacillus, a less virulent and rarely
encountered organism),
M. pinnipedii (a bacillus infecting seals and sea lions in the
Southern Hemisphere and recently isolated from humans),
M. mungi (isolated from banded mongooses in southern Africa),
M. orygis (described recently in oryxes and other Bovidae in Africa
and Asia and a potential cause of infection in humans), and

 M. tuberculosis is a rod-shaped, non-spore-forming, thin

aerobic bacterium measuring 0.5 m by 3 m.
Neutral on Grams staining. However, once stained, the
bacilli cannot be decolorized by acid alcohol; this
characteristic justifies their classification as acid-fast
bacilli
Acid fastness is due mainly to the organisms high
content of mycolic acids, long-chain cross-linked fatty
acids, and other cell-wall lipids.
In the mycobacterial cell wall, lipids (e.g., mycolic acids)
are linked to underlying arabinogalactan and
peptidoglycan. This structure results in very low
permeability of the cell wall, thus reducing the
effectiveness of most antibiotics.
Another molecule in the mycobacterial cell wall,
lipoarabinomannan, is involved in the pathogenhost

EPIDEMIOLOGY

Estimated tuberculosis (TB) incidence

rates (per 100,000 population) in

EPIDEMIOLOGY

PHILIPPINES

NEPAL

 This guideline provides recommendations on the

clinical and public health management of
tuberculosis in children and adults in settings in
which mycobacterial cultures, molecular and
phenotypic drug susceptibility tests, and
radiographic studies, among other diagnostic
tools, are available on a routine basis.
Nine PICO (population, intervention,
comparators, outcomes) questions and
associated recommendations, developed based
on the evidence that was appraised using GRADE
(Grading of Recommendations Assessment,
Development, and Evaluation) methodology

OBJECTIVES OF
ANTITUBERCULOSIS
THERAPY
The objectives of tuberculosis therapy are
(1) to rapidly reduce the number of actively growing bacilli
in the patient, thereby decreasing severity of the disease,
preventing death and halting transmission of M.
tuberculosis;
(2) to eradicate populations of persisting bacilli in order to
achieve durable cure (prevent relapse) after completion of
therapy; and
(3) to prevent acquisition of drug resistance during therapy.

ORGANIZATION AND
SUPERVISISON OF TREATMENT
QUESTION

RECOMMENDATION

1) Does adding case

management interventions
to curative therapy
improve outcomes
compared to curative
therapy
alone among patients with
tuberculosis?

We suggest using case

management
interventions during treatment
of patients with tuberculosis

2) Does self-administered
therapy (SAT) have similar
outcomes compared to
directly observed therapy
(DOT) in patients with
various forms of
tuberculosis?

We suggest using DOT rather

than SAT for routine treatment of
patients with all forms of
tuberculosis

RECOMMENDED TREATMENT REGIMENS

QUESTION

RECOMMENDATION

3) Does intermittent
dosing in the
intensive phase have
similar outcomes
compared to daily
dosing in the
intensive phase for
treatment of drugsusceptible pulmonary
tuberculosis?

We recommend the use of daily rather than

intermittent dosing in the intensive phase of
therapy for drug susceptible pulmonary
tuberculosis.
Use of thrice-weekly therapy in the intensive
phase (with or without an initial 2 weeks of daily
therapy) may be considered in patients who are
not HIV infected and are also at low risk of
relapse.
In situations where daily or thrice-weekly DOT
therapy is difficult to achieve, use of twice-weekly
therapy after an initial 2 weeks of daily therapy
may be considered for patients who are not HIVinfected and are also at low risk of relapse

RECOMMENDED TREATMENT REGIMENS

QUESTION

RECOMMENDATION

4) Does intermittent
dosing in the
continuation phase
have similar outcomes
compared to daily
dosing in the
continuation
phase in patients with
drug-susceptible
pulmonary tuberculosis
patients?

We recommend the use of daily or thrice

weekly dosing in the continuation phase of
therapy for drug susceptible pulmonary
tuberculosis
If intermittent therapy is to be
administered in the continuation phase,
then we suggest use of thrice-weekly
instead of twice-weekly therapy
We recommend against use of onceweekly therapy with INH 900 mg and
rifapentine 600 mg in the continuation
Phase. In uncommon situations where
more than once-weekly DOT is difficult
to achieve, once-weekly continuation
phase therapy with INH 900 mg plus
rifapentine 600 mg may be considered for
use only in HIVuninfected persons without
cavitation on chest radiography.

TREATMENT IN SPECIAL SITUATIONS

QUESTION

RECOMMENDATION

5) Does extending
treatment beyond 6
months improve
outcomes compared
to the standard 6month treatment
regimen
among pulmonary
tuberculosis patients
coinfected with HIV?

For HIV-infected patients receiving ART, we

suggest using the standard 6-month daily
regimen consisting of an
intensive phase of 2 months of INH, RIF, PZA,
and EMB followed by a
continuation phase of 4 months of INH and
RIF for the treatment of
drug-susceptible pulmonary tuberculosis
In uncommon situations in which HIVinfected patients do NOT receive ART during
tuberculosis treatment, we
suggest extending the continuation phase
with INH and RIF for an
additional 3 months (ie, a continuation phase
of 7 months in duration,
corresponding to a total of 9 months of
therapy) for treatment of drugsusceptible
pulmonary tuberculosis

TREATMENT IN SPECIAL SITUATIONS

QUESTION

RECOMMENDATION

6) Does initiation of ART

during tuberculosis
treatment compared to
at the end of
tuberculosis treatment
improve outcomes
among tuberculosis
patients coinfected with
HIV?

We recommend initiating ART during

tuberculosis treatment. ART should
ideally be initiated within the first 2
weeks of tuberculosis treatment for
patients with CD4 counts <50
cells/L and by 812 weeks of
tuberculosis treatment initiation for
patients with CD4 counts 50 cells/L

7) Does the use of

adjuvant corticosteroids
in
tuberculous pericarditis
provide mortality and
morbidity benefits?

We suggest initial adjunctive

corticosteroid
therapy not be routinely used in patients
with tuberculous pericarditis

TREATMENT IN SPECIAL SITUATIONS

QUESTION

RECOMMENDATION

8) Does the use of

adjuvant corticosteroids
in
tuberculous meningitis
provide mortality and
morbidity benefits?

We recommend initial
adjunctive corticosteroid
therapy with
dexamethasone or
prednisolone tapered
over 68 weeks for
patients with
tuberculous meningitis.

9) Does a shorter duration of

treatment have similar
outcomes compared to the
standard 6-month treatment
duration among HIVuninfected patients with
paucibacillary tuberculosis
(ie, smear negative, culture

We suggest that a 4-month

treatment regimen is
adequate for treatment of
HIV-uninfected adult patients
with AFB smear- and culturenegative pulmonary
tuberculosis.