Unit 7 Treatment of TB:
B Family Case
Botswana National Tuberculosis Programme
Manual Training for Medical Officers
B Family Background
You’ll remember that…
• Mrs. B has HIV and starts on IPT
• Her husband, Mr. B, presents at the clinic with
a cough, and has recently had contact with his
uncle who has TB
• Though his exam is mostly normal, he gives a
spot sputum sample and is told to come back
the next day
Unit 7: Case Study
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B Family Case (1)
• Mr. B weighs 58kg
• After you examine Mr. B and take an initial
spot sputum sample, Mr. B returns the next
day (day 2) with his morning specimen
• You obtain another spot sample and all 3
samples are sent to the lab for acid-fast
staining (direct microscopy)
• You ask Mr. B to return in 3 days
Unit 7: Case Study
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B Family Case (2)
• When he returns (day 5), Mr. B is feeling worse
• He reports loss of appetite and seeing blood in his sputum
• His results are:
• Sputum AFB positive (scanty) x 1
• 2 sputum negative
• HIV positive
• Mr. B is TB positive
• With the new BNTP manual, ONE positive sputum
specimen is adequate for the diagnosis of TB (previously, 2
positives were needed)
Unit 7: Case Study
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B Family Case: Question 1
1. How do you manage Mr. B’s case?
2. Does Mr. B qualify for HIV treatment?
Unit 7: Case Study
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B Family Case: Answer 1 (1)
1. Start Category I treatment
• FDC
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4 tablets (R150/H75/Z400/E275) daily
Make sure all patients are weighed at initiation of
treatment
Single drugs
•
Isoniazid (INH) 300mg daily, Rifampicin (R)
600mg daily, Pyrazinamide (Z) 2000mg daily,
Ethambutol (E) 1200mg daily
Unit 7: Case Study
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B Family Case: Answer 1 (2)
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Educate the patient
Provide counselling
Start cotrimoxazole, 400/80mg, 2 tabs daily
Take blood for CD4
Take baseline bloods: FBC, Chemistry (renal
function, electrolytes, LFT)
• Refer him to the nearest HIV site 35 km away
• Ask him to return for ART assessment and to review
results
Unit 7: Case Study
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B Family Case: Answer 1 (3)
2. All HIV positive TB patients qualify for HIV
treatment
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Treatment start time is variable
Review BNTP manual
Unit 7: Case Study
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B Family Case: Question 2 (1)
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2 weeks later, Mr. B returns to the clinic
Haemoglobin is 8.0
CD4 is 300
You provide him with iron supplements and
continue to monitor him until completion of TB
treatment 6 months later
• At completion of treatment, he is considered
cured
Unit 7: Case Study
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B Family Case: Question 2 (2)
• 5 months after completing TB treatment (month 11),
Mr. B. returns to the clinic complaining of cough,
difficulty swallowing and pain in his feet
• He looks moderately ill
• He says he never followed up with the HIV clinic
because the hospital is too far for him to travel and
he doesn’t have the taxi fare
What should you do now for Mr. B?
Unit 7: Case Study
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B Family Case: Answer 2
• Obtain a sputum specimen on the spot and
send it for microscopy
Unit 7: Case Study
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B Family Case: Question 3
What other tests should the
medical officer order?
Unit 7: Case Study
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B Family Case: Answer 3
• Other tests ordered by the MO
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2 more sputum specimens
Sputum for culture
FBC
Repeat CD4
Chemistry : LFTs, creatinine, BUN, electrolytes
Chest X-ray
• NOTE: ESR is not helpful in diagnosis and is not
recommended
Unit 7: Case Study
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B Family Case: Question 4
• CXR shows reticular nodular pattern
• Examination shows:
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Wt 52kg
T 38.2
RR 26
HR 118
White patches on
soft palate
Unit 7: Case Study
• Cervical
lymphadenopathy
• Course lung sounds
• Enlarged liver
Based on these results,
what should be the next
step of Mr. B’s treatment?
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B Family Case: Answer 4
• Admit Mr. B
• Start him on:
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Crystalline penicillin & cotrimoxazole, 4SS tabs
Fluconazole, 200mg daily x 14
Paracetamol, 500mg TDS-PRN
IV fluids
Unit 7: Case Study
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B Family Case: Question 5
What is Mr. B being presumptively treated for?
Unit 7: Case Study
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B Family Case: Answer 5
• PCN and cotrimoxazole are to treat bacterial
pneumonia and as a prevention for PCP
• Fluconazole, at 200mg daily x 14, is to treat
oesophageal candidiasis
• NOTE: It is not appropriate to use fluconazole for
oral candidiasis
Unit 7: Case Study
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B Family Case: Question 6
Tests show:
• 1 sputum smear
positive
• 2 sputum smear
negative
• CD4 50
• ALT 75
• AST 77
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Alk Phos 150
Total bili – O/S
Hb 7.6
WBC 3.0
Platelets 75
Na 125
How do you manage Mr. B’s case?
Unit 7: Case Study
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B Family Case: Answer 6 (1)
• Continue X-PCN x 10 days
• For bacterial pneumonia coverage
• Change cotrimoxazole dose to 2 tabs daily for
prophylaxis
• CXR was not indicative of PCP, so cotrimoxazole
treatment dosage was stopped
Unit 7: Case Study
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B Family Case: Answer 6 (2)
Send a sputum specimen for culture and drug
susceptibility testing
Start TB treatment immediately
• FDC
• 4 tablets (R150/H75/Z400/E275) daily + Streptomycin, 1g
IM daily
• Single drugs
• Streptomycin, 1g IM daily, Isoniazid, 300mg daily,
Rifampicin, 600mg daily, Pyrazinamide, 2000mg daily,
Ethambutol, 1200mg daily
Unit 7: Case Study
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B Family Case: Question 7 (1)
Botswana National HIV Programme states:
• If CD4 <100, start 1-2 weeks after initiating TB
treatment
• If CD4 100-200, start 2-3 weeks after initiating TB
treatment
• If CD4 >200, start treatment after completion of ATT
• HAART
• AZT/3TC (Combivir) + Efavirenz
Unit 7: Case Study
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B Family Case: Question 7 (2)
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Mr. B is discharged after 5 days and is referred
to IDCC for HIV management and a local clinic
for DOT
Mr. B. presents to the IDCC with laboratory
results from the hospital the following week
He attends a counselling session with DOTS
supporter
He is started on ART
Unit 7: Case Study
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B Family Case: Question 7 (3)
1. What ART regimen is he started on and
when does he begin treatment?
2. What lab test is important in choosing an
ART regimen?
Unit 7: Case Study
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B Family Case: Answer 7
1. Combivir + Efavirenz
•
2 weeks after initiating ATT
2. Haemaglobin
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If Mr. B’s Hb is <7.5, he will be started on d4T
instead of AZT (AZT causes bone marrow
suppression, which leads to anaemia)
Unit 7: Case Study
Slide 24