Welcome guest, please Login or Register

Case Conferences

   

May 28, 2014

Rank

Total Posts: 5

Joined 2014-05-06

PM

Case Description: No PMHx, presents with L draining ear x two wks, not improving with Amoxicillin, 3 days increasing SOB. Hear the discussion and more!

Speaker: Dr. Caitlin Reed

     
Rank

Total Posts: 24

Joined 2014-05-05

PM

Whether QFT was repeated as its indeterminate ?

     
Rank

Total Posts: 8

Joined 2014-05-05

PM

Case 1:
A rare complication of Mycobacterium tuberculosis infection, severe tuberculosis sepsis, is associated with septic shock with multi-organ dysfunction. It has been reported almost exclusively among immunocompromised hosts, But this case is in an immunocompetent host, review the literature, and highlight the practical difficulties of treating tuberculosis in an intensive care unit (ICU) patient.
Rifampin and streptomycin can contribute to renal failure. Rifampin can also cause shock and thrombocytopenic purpura, potentially complicating the ICU patient’s course. In renal failure and AIN, standard doses of rifampin, isoniazid, and pyrazinoic acid can be given. However, there is some concern about accumulation of pyrazinoic acid metabolites (pyrazinoic acid and 5-hydroxy-pyrazinamide) in dialysis(Launay-Vacher et al).
Traditional teaching suggests that corticosteroids impair the ability of the body to fight infection and that this may prove catastrophic if an appropriate antibiotic or drug is not chosen. In recent years, however, the early use of steroid therapy has become progressively established in a wide range of infective conditions including septic shock, its most severe systemic manifestation in TB patients.
First, mycobacterial antigen can induce release of pyrogens from monocytes, lymphokines from specifically sensitized lymphocytes and cytokines, such as tumour necrosis factor, from macrophages and peripheral blood mononuclear cells, which may be responsible for constitutional symptoms and tissue damage. Corticosteroids can inhibit the release and activities of lymphokines and cytokines. Secondly, the granulomatous host response to TB may paradoxically protect sequestered M. tuberculosis from anti-TB therapy. The adjuvant corticosteroids may be beneficial in permitting anti-TB drugs to penetrate into granulomas, by disrupting granuloma formation. [Murray, J.F. HIV-associated tuberculosis (watch for it in your ICU) . Intensive Care Med.]
Administration of corticosteroids as part of the treatment for TB requiring ICU admission has been suggested if the patient is severely hypoxic or has involvement of their central nervous system, peritoneum, or pericardium. Again, drug interactions can be a problem. Isoniazid can increase the level of prednisone, whereas rifampin can decrease it.

Dr Sangita Shelke

     
Rank

Total Posts: 8

Joined 2014-05-05

PM

case 2:

Despite existing MDR-TB treatment guidelines crucial gaps in knowledge persist with regard to the treatment of certain groups at high risk of infection, including pregnant women. Women who are being treated for drug-resistant TB should receive counseling concerning the risk to the fetus because of the known and unknown risks of second-line antituberculosis drugs.
                                                                                                                   
WHO guidelines: “Management of MDR-TB: A field guide-2009 “states Pregnancy is not a contraindication to the treatment of MDR-TB. One should discuss the risks and benefits with the mother. Start treatment of drug resistance in the second trimester, or sooner if the condition of the patient is severe. Since the majority of teratogenic effects occur in the first trimester, therapy may be delayed until the second trimester. Avoid injectable agents. For the most part, aminoglycosides should not be used in the regimens of pregnant patients and can be particularly toxic to the developing foetal ear. Capreomycin may carry the same risk of ototoxicity, avoid ethionamide. Ethionamide can increase the risk of nausea and vomiting associated with pregnancy, and teratogenic effects have been observed in animal studies.

EdaPalacios etal:Drug-Resistant TB and Pregnancy - CID 2009:48 (15 May) 1413 states that rates of success in treating MDR-TB in their cohort of pregnant ladies were comparable to those of other MDR-TB treatment programs in Peru. The birth outcomes of their cohort were similar to those among the general Peru population. Therefore, they advocate that a woman should be given the option to continue treatment of MDR-TB rather than terminating pregnancy or discontinuing MDR-TB treatment.

Dr Sangita Shelke

     
Rank

Total Posts: 21

Joined 2014-05-04

PM

Both cases are interesting.
Case 1 : Csom in high tb burden setting - tb is included in dd. was a csf done in this patient or directly mri brain which showed multiple tuberculomas. TB mastoiditis is not commented upon.
Was aki related to drugs or was it apart of disseminated tb itself.
Use of steroids is indicated in such cases with septic shock and need to be continued. Was it continued in this case and for how long.
Case 2 : mdr tb in pregnancy - why wait for testing results. Why not start therapy and modify when results are available. What about prophylaxis for the baby and regarding breast feeding advice in this case. No mention of these two important aspects in patient care.
What if the lady prefers the option of Mtp for her own health.
What about prophylaxis to her husband.