case mdr tb journal nejm

8/18/2019 Case Mdr Tb Journal Nejm

1/13

Case 18-2009: A 24-Year-Old Woman

with AIDS and T!er"losis with

#ro$ressi%e Co$h& D's(nea& andWastin$

Oleh:

)I*A +A)DI,I

0010101000.

#em!im!in$:

dr. T . Zulfikar, Sp.P


2/13

#resentation o/ Case


3/13

Dr. Anne Griffin edi"ine and #ediatri"s: A 24-'ear-old woman with the a"3ired

immnode/i"ien"'

s'ndrome AIDS and (lmonar' t!er"losis was admitted to ahos(ital in Soth A/ri"a that is a//iliated with this hos(ital& !e"ase o/ (ro$ressi%e

"o$h& d's(nea& and wastin$

A dia$nosis o/ (lmonar' t!er"losis was made months earlier& when she

(resented at another /a"ilit' with a (rod"ti%e "o$h& and a s(tm s(e"imen was

(ositi%e /or a"id-/ast !a"illi on s(tm-smear mi"ros"o(' ,o "hest radio$ra(h was

o!tained She had no 5nown histor' o/ a"ti%e t!er"losis The (atient was enrolled

in a lo"al Dire"tl' O!ser%ed Treatment DOTS (ro$ram& and antim'"o!a"terialthera(' isonia6id& ri/am(in& etham!tol& and ('ra6inamide /or 2 months& /ollowed

!' isonia6id and ri/am(in /or 4 months was administered a""ordin$ to the Soth

A/ri"an ,ational T!er"losis Control #ro$ramme $idelines The ne7t month&

a test /or hman immnode/i"ien"' %irs I in/e"tion was (ositi%e the CD4;

T-l'm(ho"'te "ont was 102 "ells (er "!i" millimeter


4/13

A/ter < months o/ thera('& the (rod"ti%e "o$h (ersisted and

stained s(e"imens o/ s(tm remained (ositi%e /or a"id-/ast

!a"illi Isonia6id and ri/am(in were "ontined A((ro7imatel' <

wee5s !e/ore admission& the (atient=s "o$h worsened andd's(nea de%elo(ed and worsened& with /e%ers& ni$ht sweats&

and wei$ht loss She !e"ame (ro$ressi%el' de!ilitated and was

admitted to the hos(ital


5/13

2 Di//erentialDia$nosis


6/13

Dr. Subba Digumarthy: There are mlti(le "a%ities and air-s(a"e

o(a"ities in the le/t ln$ in%ol%in$ the ((er lo!e >i$ 1& the lin$la& and

the lower lo!e There is loss o/ %olme in the le/t ln$& with a sli$ht shi/t o/the mediastinm to the le/t The le/t heart !order and the mediastinm

are (artiall' o!s"red !' the o(a"ities in the le/t ln$ There is also /o"al

"onsolidation in the ri$ht ((er lo!e ad?a"ent to the minor /issre There

is (leral thi"5enin$ or a small (leral e//sion on the le/t side

lti/o"al as'mmetri" in%ol%ement o/ the ln$s

This (atient& who was in/e"ted with !oth I and t!er"losis&

was re/erred to or hos(ital !e"ase o/ e%iden"e o/

(ro$ressi%e t!er"losis& des(ite a((ro(riate treatment


7/13

Kategori Sistolik

(mmHg)

Diastolik

(mmHg)Normal < 120 < 80

Pre Hipertensi 120 – 139 80 – 89

Hipertensi

Derajat I140 – 159 90 – 99

Hipertensi

Derajat II≥ 160 ≥ 100

FIGURE transFigure

1. Radiograph of the Chest.There are mlti(le "a%ities and air-s(a"e o(a"ities in the le/t ln$in%ol%in$ the ((er lo!e& the lin$la&and the lower lo!e There is loss o/%olme in the le/t ln$& with a sli$ht

shi/t o/ the mediastinm to the le/tThe le/t heart !order and themediastinm are (artiall' o!s"red!' o(a"ities in the le/t ln$ There is(leralthi"5enin$ or a small (lerale//sion on the le/t side There is /o"al

"onsolidation in the ri$ht ((er lo!ead?a"ent to the minor /issre


8/13

Kategori Sistolik

(mmHg)

Diastolik

(mmHg)Normal < 120 < 80

Pre Hipertensi 120 – 139 80 – 89

Hipertensi

Derajat I140 – 159 90 – 99

Hipertensi

Derajat II≥ 160 ≥ 100

Dr. Wilson: I am aware o/ the dia$nosis in this

"ase& whi"h illstrates man' o/ the dia$nosti" and

thera(eti" "hallen$es en"ontered in resor"elimitedsettin$s in sothern A/ri"a This 'on$

woman with I in/e"tion was in a DOTS (ro$ram

that shold ha%e ensred adheren"e to /irstline

thera(' /or t!er"losis& !t she had s(tm

smears that were (ersistentl' (ositi%e /or a"id-/ast!a"illi there is a (a"it' o/ other la!orator' in/ormation&

s"h as "ltre reslts and dr$-sensiti%it'

testin$ Common "ases o/ s(tm smears that

are (ersistentl' (ositi%e /or a"id-/ast !a"illi in Iin/e"ted

adlts are shown in Ta!le 2& and "aseso/ nonres(onse to antit!er"losis thera(' are

shown in Ta!le .


9/13

A re%iew o/ this (atient=s !lood-test reslts shows

se%eral a!normalities er normo"'ti" anemia is

most li5el' anemia o/ "hroni" disease& de to !oth

ntreated I in/e"tion and t!er"losis& and

wold !e e7(e"ted to im(ro%e with e//e"ti%e treatment

o/ the nderl'in$ "ase )otine iron s((lementation

/or anemi" (atients with t!er"losis

is not re"ommended1 ild-to-moderate

throm!o"'to(enia is /re3entl' o!ser%ed in (atients

with ad%an"ed I in/e"tion it is sall'

attri!ted to marrow s((ression !' I !t ma'!e de to atoimmne throm!o"'to(enia sall'

seen earl' in the "orse o/ the disease or to

(latelet "onsm(tion in a (atient with "oa$lo(ath'

Throm!o"'to(enia "an also !e "ased !'

ri/am(in

A!or"al laorator#$test results


10/13

Su""ar#

In this (atient with e7tensi%e ln$ disease& (ositi%e

s(tm smears& and "lini"al deterioration&

(ro$ressi%e t!er"losis was the most li5el' dia$nosiser la"5 o/ a res(onse to /irst-line antit!er"losis

thera(' "old ha%e !een de to an'

o/ se%eral /a"tors Ta!le .& !t the (redominant

"on"ern shold !e a!ot either mltidr$-resistant

or e7tensi%el' dr$-resistant t!er"losis '"o!a"terial

"ltre and testin$ /or dr$ sensiti%it'with the se o/ "on%entional methods "an ta5e

months )es(ondin$ to the (ossi!ilit' o/ mltidr$-

resistant t!er"losis in this seriosl' ill (atient

is di//i"lt and "ontro%ersial


11/13

Clini"al Dia$nosis

#lmonar' in/e"tion with dr$-resistant M. tuberculosis&

either mltidr$ resistant or e7tensi%el' dr$

resistant& in a (atient with I in/e"tion


12/13

#atholo$i"al Dis"ssion

Dr. Wilson: Three months a/ter the (atient=s death&

a s(tm "ltre that had !een o!tained drin$

her hos(itali6ation was re(orted to show M. tuberculosis

that was resistant to isonia6id& ri/am(in&

etham!tol& stre(tom'"in& 5anam'"in& and "i(ro/lo7a"in


13/13

T%A&'S

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