Republic of the Philippines Department of Education REGION II – CAGAYAN VALLEY SCHOOLS DIVISION OF CAUAYAN CITY CAUAYAN CITY STAND-ALONE SENIOR HIGH SCHOOL CLINICAL PRESENTATION AND DIAGNOSIS OF PULMONARY TUBERCULOSIS REINFECTION: A CASE STUDY ABSTRACT This manuscript presents the clinical scenario of a case involving the reinfection of tuberculosis (TB) in a 55-year-old male patient who also has Type II Diabetes Mellitus (DM). The coexistence of these two conditions poses significant challenges in terms of management and treatment outcomes. This case report aims to highlight the complexities associated with TB reinfection in patients with Type II DM, emphasizing the need for comprehensive care and effective strategies for diagnosis, treatment, and prevention. INTRODUCTION Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis. It primarily affects the lungs but can also affect other parts of the body, such as the kidneys, spine, and brain. It is one of the major health concerns worldwide, which contributes to global morbidity and mortality. According to World Health Organization, a total of 1.6 million people died from TB in 2021 (including 187 000 people with HIV), and an estimated 10.6 million people fell ill with tuberculosis worldwide. TB is intricately linked to poverty, as socioeconomic factors play a pivotal role in its transmission and persistence. Countries with lower income levels often experience higher TB incidence rates due to several contributing factors. Limited access to quality healthcare, overcrowded living conditions, malnutrition, and co-existing diseases like HIV/AIDS further exacerbate the burden of TB. In 2020, the WHO estimated that around 95% of TB deaths occurred in low-income to middle-income countries, indicating the disproportionate burden on resource-limited settings. Some of which are in the regions of sub-Saharan Africa, Southeast Asia, and parts of the Western Pacific. According to a study by Pirina et al. (2014), clinical features associated with tuberculosis (TB) include cough, fatigue, fever, night sweats, chest pain, difficulty breathing (dyspnea), and coughing up blood (hemoptysis) in cases where the lungs are affected. Incidentally, many asymptomatic cases of tuberculosis (TB) are identified through chest radiography, despite these patients often showing negative results for acid-fast bacilli staining and culture, even though they have active TB. Address: P. Albano St., Barangay Turayong, Cauayan City, Isabela 3305 Contact No.: 0995-988-2914 Email Address: ccsashs01@gmail.com Facebook Page: Cauayan City Stand Alone - Senior High School Republic of the Philippines Department of Education REGION II – CAGAYAN VALLEY SCHOOLS DIVISION OF CAUAYAN CITY CAUAYAN CITY STAND-ALONE SENIOR HIGH SCHOOL The following case report presents a clinical scenario involving the reinfection of tuberculosis (TB) in a 55-year-old male patient with a documented history of Type II Diabetes Mellitus (DM). CASE REPORT A 55-year-old male patient presented to the outpatient department of a general hospital with a constellation of symptoms, including chronic cough, intermittent fever, night sweats, and unintentional weight loss of 10 pounds over the past three months. The patient had a confirmed diagnosis of Type II DM and was under treatment with oral hypoglycemic agents. He reported adherence to his diabetic medications and denied any recent changes in treatment or lifestyle. The patient had previously completed a six-month course of first-line antituberculosis therapy (ATT) approximately five years ago for a pulmonary TB infection. At that time, he responded well to treatment and remained asymptomatic. CAUSATIVE AGENT Pulmonary tuberculosis (TB) is caused by the bacterium Mycobacterium tuberculosis. This acid-fast, rod-shaped organism is primarily transmitted through inhalation of respiratory droplets containing the bacteria. Transmission of pulmonary tuberculosis occurs when individuals inhale droplet nuclei containing Mycobacterium tuberculosis. These droplet nuclei are generated when a person with active TB disease coughs, sneezes, speaks, or sings. The bacteria can remain suspended in the air and can infect susceptible individuals who inhale them. While not everyone who inhales the bacteria develops active tuberculosis, those with weakened immune systems, such as individuals with HIV/AIDS or comorbidities like diabetes, are at higher risk of progressing from latent infection to active disease. Moreover, the incubation period for pulmonary tuberculosis varies from a few weeks to several months or even years. On average, it lasts around 2 to 12 weeks. During this period, Mycobacterium tuberculosis multiplies and establishes infection in the lungs. Infected individuals may remain asymptomatic during this time, with the infection staying latent. However, if the immune system weakens, latent infection can reactivate, leading to active tuberculosis and the onset of clinical symptoms. Address: P. Albano St., Barangay Turayong, Cauayan City, Isabela 3305 Contact No.: 0995-988-2914 Email Address: ccsashs01@gmail.com Facebook Page: Cauayan City Stand Alone - Senior High School Republic of the Philippines Department of Education REGION II – CAGAYAN VALLEY SCHOOLS DIVISION OF CAUAYAN CITY CAUAYAN CITY STAND-ALONE SENIOR HIGH SCHOOL In the presented case, the patient had a history of completing a six-month course of antituberculosis therapy five years ago. Despite this, he developed symptoms indicating reinfection and a new episode of active tuberculosis. The presence of Type II Diabetes Mellitus may have increased his susceptibility to reinfection and reactivation of latent tuberculosis infection. SIGNS AND SYMPTOMS Pulmonary tuberculosis (TB) is characterized by a range of signs and symptoms. These include a persistent cough lasting for more than two weeks, fatigue, low-grade or intermittent fever, night sweats, unintentional weight loss, chest pain, difficulty breathing, and coughing up blood. These manifestations can vary in severity and may be influenced by the extent of the disease. In the case of reinfection, as observed in a 55-year-old male patient with a history of Type II Diabetes Mellitus, the presence of these symptoms raised concerns about the reactivation of tuberculosis. Individuals with comorbidities like diabetes mellitus may exhibit atypical or more severe symptoms. EXAMINATION FINDINGS The patient underwent a comprehensive set of diagnostic evaluations to confirm the reinfection of pulmonary tuberculosis (TB) and assess the extent of the disease. During the clinical examination, abnormal breath sounds, including crackles and decreased breath sounds, were detected through lung auscultation, indicating pulmonary involvement. A chest X-ray revealed infiltrates and cavities, consistent with active TB infection. Initial sputum smear microscopy yielded negative results, possibly due to a low bacterial load or inadequate sample collection. However, subsequent sputum culture confirmed the presence of Mycobacterium tuberculosis, confirming active TB. To guide treatment decisions, the GeneXpert MTB/RIF assay was performed on the sputum samples. This molecular diagnostic test confirmed the presence of Mycobacterium tuberculosis and provided valuable information on drug susceptibility, aiding in the selection of appropriate anti-TB medications. Additionally, an Interferon-gamma release assay (IGRA) has been considered to assess the patient's immune response and differentiate between latent TB infection and active disease. Address: P. Albano St., Barangay Turayong, Cauayan City, Isabela 3305 Contact No.: 0995-988-2914 Email Address: ccsashs01@gmail.com Facebook Page: Cauayan City Stand Alone - Senior High School Republic of the Philippines Department of Education REGION II – CAGAYAN VALLEY SCHOOLS DIVISION OF CAUAYAN CITY CAUAYAN CITY STAND-ALONE SENIOR HIGH SCHOOL In other laboratory investigations, the complete blood count revealed a mild leukocytosis with a slightly elevated erythrocyte sedimentation rate (ESR), indicating an inflammatory response. Liver function tests showed mildly elevated liver enzymes, suggesting potential liver involvement or medication side effects. Renal function tests were within normal limits, indicating no significant impairment in kidney function. HIV testing was negative, ruling out HIV infection as a comorbidity. Collectively, the diagnostic findings confirmed the reinfection of pulmonary TB in the patient with Type II Diabetes Mellitus, highlighting the need for appropriate treatment and comprehensive management strategies. CLINICAL HYPOTHESIS INTERVENTION In this case, the management approach involved a comprehensive intervention to achieve treatment goals. The patient was initiated on anti-tuberculosis therapy (ATT), which consisted of a multidrug regimen. During the intensive phase, the patient received a daily combination of isoniazid, rifampicin, pyrazinamide, and ethambutol for two months. This was followed by a continuation phase, during which the patient continued taking isoniazid and rifampicin for an additional four months to ensure complete eradication of the bacteria and prevent disease relapse. To ensure optimal medication adherence, the patient was placed under directly observed therapy (DOT). Healthcare providers or trained observers directly supervised the patient's medication administration, either through regular visits to the healthcare facility or home visits. This approach was particularly important considering the patient's history of tuberculosis treatment and the presence of Type II Diabetes Mellitus, which increased the risk of non-adherence and treatment failure. Throughout the treatment period, the patient's health was closely monitored for adverse effects. Regular assessments, including liver function tests, renal function tests, and other relevant laboratory parameters, were performed to detect and manage any adverse effects promptly. This proactive monitoring approach aimed to minimize the risk of medicationrelated complications and ensure the patient's well-being during treatment. Address: P. Albano St., Barangay Turayong, Cauayan City, Isabela 3305 Contact No.: 0995-988-2914 Email Address: ccsashs01@gmail.com Facebook Page: Cauayan City Stand Alone - Senior High School Republic of the Philippines Department of Education REGION II – CAGAYAN VALLEY SCHOOLS DIVISION OF CAUAYAN CITY CAUAYAN CITY STAND-ALONE SENIOR HIGH SCHOOL OUTCOME Clinical symptomatology, including chronic cough, intermittent fever, and unintentional weight loss, was monitored throughout the treatment period. The resolution or improvement of these symptoms indicated a favorable treatment response and contributed to the eradication of Mycobacterium tuberculosis infection. Adherence to directly observed therapy (DOT) was rigorously monitored to ensure consistent intake of anti-tuberculosis medications. This approach significantly reduced the risk of nonadherence and treatment failure, enhancing the effectiveness of the intervention. Laboratory investigations, particularly liver function tests, showed the normalization or improvement of liver enzyme levels which demonstrated a positive treatment response without significant hepatotoxicity. And, radiographic imaging, such as chest X-rays or computed tomography (CT) scans, provided objective evidence of treatment efficacy. The resolution of pulmonary infiltrates and cavities indicated improved lung function and successful eradication of the infection. Address: P. Albano St., Barangay Turayong, Cauayan City, Isabela 3305 Contact No.: 0995-988-2914 Email Address: ccsashs01@gmail.com Facebook Page: Cauayan City Stand Alone - Senior High School
