Treatment of Tuberculosis:New Case

Case Studies

Module 7A2 – March 2010

Project Partners

Funded by the Health Resources and Services Administration (HRSA)

Learning Objective

This session is intended to give participants an opportunity to apply their knowledge related to the treatment and management of the new TB patient using two case scenarios

Case Study 1

Case 1

29-year-old man Presents with 2-3 years of cough, 2-3

months of night sweats, and 15 lb weight loss

HIV negative Past Medical History:• Mantoux TST + in 1991

Question: What would you do now?

All Pulmonary TB Suspects

Sputum AFB Microscopy; Assess for HIV

TB Diagnostic Algorithm:HIV Negative or Low Prevalence Area

Case 1 (2)

Two spontaneous sputum specimens were smear negative for AFB

Question: How would you manage this patient?

All Pulmonary TB Suspects

TB Diagnostic Algorithm:HIV-Negative or Low Prevalence Area

Sputum AFB MicroscopyAssess for HIV

Yes TB*

Any smear +

Repeat AFB smearOrder TB culture

> 1 smear +or TB culture +

All smears -

CXR & medical officer’sjudgmentYes TB*

No

Rx: Non-anti TB antibioticsImprovement?

No TB

> 2 smears -

Yes

The patient was given a course of antibiotics but there is no improvement after 1 week

Question: What would you do now?

Case 1 (3)

A repeat sputum specimen was sent using sputum induction

Chest X-ray was also obtained

The sputum specimen was smear-positive

Question: What now?

Case 1 (4)

The patient is started on INH, rifampicin, ethambutol, and pyrazinamide

The sputum culture result returns positive for M. tuberculosis complex

A sputum specimen is obtained after 2 months of treatment and is smear-positive

Question: What do we do now?

Case 1 (5)

Collect sputum for smear, culture and drug susceptibility testing (DST)

Proceed to continuation phase regardless of smear result• Alter treatment, if appropriate, based on DST

Case Study 2

Case 2, Part 1

A 32-year-old man diagnosed with sputum smear-positive PTB is ready to begin TB treatment under your care. He has never been diagnosed or treated for TB before

He reports 4 weeks of a productive cough with fever, sweats and weight loss. He currently weighs 53 kg

Two sputum smears are positive on direct microscopy

Q1: How do you classify this patient?

Case 2, Part 1 (2)

Q2: What medications do you start with for the initial phase?

Q3: How many pills per day does he take with FDCs according to his weight?

Q4: Approximately how many pills per day does he take with traditional individual tablets?

Case 2, Answer Q2

What medications do you start for the initial phase? • Isoniazid (INH, H)

• Rifampicin (RIF, R)

• Pyrazinamide (PZA, Z)

• Ethambutol (EMB, E)

Body Weight KG

Initial Phase[RHZE]

Continuation Phase [RH]

30-37 2 2

38-54 3 3

55-74 4 4

≥75 5 5

Case 2, Answer Q3

Case 2, Answer Q4

Daily Tablets by Weight ≥ 50 kg < 50 kg

RIF 150 mg

RIF 450 mg

RIF 300 mg

4

1+ 1 150 mg

2

3

1

1+ 1 150 mg

INH 300 mg 1 1

PZA 500 mg 3 2

EMB 400 mg 3 2

Traditional = 9 or more pills daily (+ pyridoxine)

Case 2, Part 2

The patient has successfully completed the initial 2 months of treatment and had 2 negative sputum smears at week 8

He now weighs 55 kg

Case 2, Part 2 (2)

Q5: What medications and dosages does the patient take in the continuation phase? How many pills per day does he take

with FDCs (Fixed Dose Combination pills)?

How many pills per day does he take with traditional individual tablets?

Case 2, Answer Q6

Isoniazid, rifampicin and pyridoxine (B6) FDCs = 4 pills daily (plus pyridoxine)• He gained weight and now has an increased

dose

Case 2, Answer Q6 (2)

Daily Tablets by Weight ≥ 50 kg

RIF 300 mg 2

INH 300 mg 1

PZA 500 mg –

EMB 400 mg –

Traditional = 3 pills daily (+ pyridoxine)