Tuberculosis

MYCOBACTERIUM DISEASE

Aaron, Anna Mae T.

Dela Cruz, Angel
Del Luna, Heinrich
Gonzales, Cedric
Gorgonio. Franklin Kirby
 Topic Outline
QUESTIONS AND
INTRODUCTION
ANSWERS

CASE PROPER REFERENCES

Introduction
 Tuberculosis
A disease caused by a
specific type of bacteria
that spreads from one
person to another through
the air. Tuberculosis can
affect many parts of the
body, but most often
affects the lungs.
SYMPTOMS:
productive
cough
fever
weight loss
malaise
PHYSIOLOGY
The physiology of TB involves a complex interaction between
the bacterium, the host's immune system, and environmental
factors. M. tuberculosis is an acid-fast bacterium with a unique
cell wall that is rich in mycolic acids, which make the bacterium
resistant to many antibiotics and host immune defenses. The
bacterium is transmitted through the air when an infected
person coughs, sneezes, or speaks, and the droplets containing
the bacterium are inhaled by another person.
Pathophysiology
Etiology
Mycobacterium Poverty, and other
tuberculosis infections like HIV

Persons who have

Taking medication or
immigrated from areas of the
substances that weakens the
world with high rates of TB
immune system
Laboratory
and Diagnostic
Tests
Acid-fast stain and Sputum Test
culture Breath Test
Tuberculin skin test Procedure to remove
(TST) or interferon- sputum from your lungs
gamma release assay with a special tube
(IGRA)
Urine Test
Nucleic Acid
Test of the fluid around
Amplification Test
the spine and brain,
(NAAT)
called cerebrospinal
Blood Test
X-ray fluid
Treatment
algorithm,
treatment plan
Pharmacologic Non-
pharmacologic
The first-line Staying at home
Avoiding visitors (except for
drugs isoniazid
previously exposed family
(INH), rifampin members)
(RIF), Covering coughs with a tissue,
separate things such as plates,
pyrazinamide spoons, and etc from other family
(PZA), and members and usage of surgical
masks to prevent the spread of
ethambutol (EMB) disease and infection.
Surgical
LOBECTOMY
 Case Proper
Patient information/
Demographics
Lab test and diagnostic procedures
Drug profile
ADR and DI
 Patient
Demographics Medical History
Name: JR NONE
Age: 35 Years Old

Citizenship: Hispanic
 Social History
Family History
Moved to the United States
Mother has from Mexico 4 years ago but
has not recently traveled.
DM and HTN. Has 10-pack-year history of
smoking but quit several
• Father died weeks ago when the current
of MI 6 illness started
Drinking alcohol socially on
months ago. weekends
Laborer and is currently The patient does not
working for cash on a new have any medical
home construction project
insurance. He lives with
in close contact with other
several adult friends in
workers.
an apartment.
Several of his coworkers
have recently moved to
the United States from
Mexico and have similar
respiratory symptoms
 Significant Review of Systems

Chief General: Somewhat thin-appearing Hispanic

Complaint man in mild respiratory distress

HEENT: PERRLA, EOMI, no scleral icterus
Neck/Lymph Nodes: Supple
Been
Lungs: Rhonchi and dullness to percussion in
coughing up RUL
Cardiovascular: Slightly tachycardic, no
blood for the
MRG
past 3 days Abdomen: Soft NTND; (+) bowel sounds; no
hepatosplenomegaly
 Significant Review of Systems

Chief Ext.: No CCE, pulses 2+ throughout; full

Complaint ROM
Neuro: A&O × 3; CN II–XII intact; reflexes
Been 2+, sensory and motor levels intact
Vital Signs: BP 131/70, P 100, RR 24, T
coughing up
38.8°C, 93% O2 saturation on room air;
blood for the Wt 65 kg, Ht 5′9′′
past 3 days Skin: No lesions
Physical Examination
BP 131/70
P 100
RR 24
T 38.8°C
93% O2 saturation on room air
Wt 65 kg
Ht 5′9″
Productive cough, which was originally productive of yellow sputum
but is now accompanied by the presence of blood streaks in the
sputum for the past 3 days.
Unintentional 20-lb weight loss
Laboratory Tests and Diagnostic Procedures
Laboratory Tests and Diagnostic Procedures
Drug Profile
i. Drug- drug
OTC Antitussive Drugs
Dextrometorphan (Robitussin Cough, Vicks 44 Cough and Cold,etc.)
The patient do not take other medication aside from OTC Antitussive so
there wont be any drug drug interaction
Drug Profile
ii. Drug- disease
Precipitant: The precipitant is the presence of tuberculosis in the body,
which is a serious infectious disease caused by the bacterium
Mycobacterium tuberculosis.
Object: The object is the use of antitussive medications to relieve coughing
in patients with tuberculosis.
Interaction: Antitussive medications are designed to suppress coughing,
which can be beneficial for patients with conditions such as the common
cold or bronchitis.
Intervention: The intervention, in this case, is to avoid the use of
antitussive medications in patients with tuberculosis unless absolutely
necessary, and to closely monitor the patient's condition if such
medications are used.
 Drug Profile
iii. Drug- Lab test
All of the following tests do not have an interaction with OTC antitussive

Tuberculin skin test (TST)

Interferon-gamma release assay (IGRA)
Sputum AFB smear
XPert® _MTB/RIF real-time PCR
Sputum AFB culture
HIV antibody test
Question and Answers
 What subjective and objective information
indicates the presence of active tuberculosis
in this patient?
OBJECTIVE INFORMATION:
Unintentional 20-lb weight loss over the past several
weeks
Productive cough, which was originally productive of
yellow sputum but is now accompanied by the
presence of blood streaks in the sputum for the past 3
days
 What subjective and objective information
indicates the presence of active tuberculosis
in this patient?
SUBJECTIVE INFORMATION:
Fevers
Chills
Sweats
Dyspnea that worsens on exertion
Fatigue
What are the goals of pharmacotherapy in
this case?
Cure Mr. JR, our patient
Minimize risk and prevent death
Reduce the transmission of the bacteria
Persuade the patient’s colleague to have test as
well for the reason that they’re experiencing same
symptoms as Mr. JR
 Medication therapy.
Antitussives should be discontinued as it does not produce an effect to
manage the symptoms.
Empirical treatment like broad spectrum antibiotics should be
administered to the patient while waiting for the results:
4-drug regimen: isoniazid, rifampin, pyrazinamide, and either
ethambutol or streptomycin. Once the TB isolate is known to be fully
susceptible, ethambutol (or streptomycin, if it is used as a fourth drug)
can be discontinued.
Recommend the patient to apply for DOTS for free therapy, it would be a
great help since he doesn't have insurance.
Monitoring of liver and kidney function must be done
CLINICAL COURSE
What factors place this patient at increased risk
for acquiring TB?
Immunosuppression: The patient's age (65 years) and history of chronic
alcoholism can weaken his immune system, making him more susceptible
to infections such as TB. aside from that, he also has a strong history of
smoking which further adds to the risk of having TB
Close contact with an infectious TB case: The fact that he works
closely with his co workers and the fact that he lives with other people in
an apartment also increases the risk of having TB
Health care workers: The patient's history of working as a health care
worker in the past also places him at an increased risk of acquiring TB, as
health care workers are at higher risk of exposure to infectious diseases.
How should other close contacts of the
patient be evaluated and treated?
Other close contacts of the patient should be
evaluated and screened for TB infection. This may
involve performing a TST or IGRA to detect TB
infection. If the test result is positive, the contact
should undergo further evaluation, such as a chest X-
ray, to determine if they have active TB disease or
latent TB infection.
How should the results of the susceptibility report of
this patient’s M. tuberculosis isolate influence his
drug therapy?
The susceptibility report of this patient's M. tuberculosis isolate showed
susceptibility to isoniazid, rifampin, pyrazinamide, ethambutol, and
streptomycin. This means that the patient's current drug therapy is
appropriate and effective. If the susceptibility report had shown
resistance to any of these drugs, the patient's therapy would need to be
modified accordingly. For example, if the isolate was resistant to rifampin,
an alternative drug would need to be used in its place, such as a
fluoroquinolone or a second-line injectable drug. The susceptibility report
is an important tool in guiding the selection of appropriate drug therapy
for tuberculosis.
How should AST and ALT elevations greater than
five times the upper limit of normal be managed
in a patient on antituberculosis therapy?

The increase in AST and ALT in this patient could indicate liver
toxicity from the anti-tuberculosis drugs. The current regimen of
isoniazid, rifampin, pyrazinamide, and ethambutol should be
reviewed to determine which drug is causing the hepatotoxicity. If
it is determined that one of the drugs is causing liver toxicity, that
drug should be discontinued immediately and the patient should
be monitored closely for any signs of worsening liver function.
If necessary, the dose of the remaining drugs can be adjusted
based on the severity of the patient's liver function tests. The
patient should be advised to avoid alcohol and other
hepatotoxic substances and to promptly report any symptoms
of liver disease, such as nausea, vomiting, abdominal pain,
jaundice, or fatigue. Liver function tests should be monitored
closely and frequently until they return to normal. If the patient's
liver function does not improve after discontinuing the
offending drug, further evaluation may be necessary.
How should AST and ALT elevations greater
than five times the upper limit of normal be
managed in a patient on antituberculosis
therapy?
AST and ALT elevations greater than five times the upper limit
of normal in a patient on antituberculosis therapy are
considered severe hepatotoxicity and require immediate
action. The antituberculosis regimen should be discontinued,
and the patient should be evaluated by a specialist in liver
disease.
Treatment options for severe hepatotoxicity may include
corticosteroids and other medications to support liver
function. Once liver function has improved and the patient's
symptoms have resolved, antituberculosis therapy can be
restarted with a modified regimen that excludes the
hepatotoxic drugs. The patient should continue to be closely
monitored for liver function throughout the course of
treatment.
What would be the adjustments for the drug therapy
of the patient? What must be continued,
discontinued and added? Rationalize
The recommended approach in this case would be to discontinue
pyrazinamide, as it is known to be hepatotoxic and is associated
with an increased risk of liver injury in patients with underlying liver
disease. Isoniazid and rifampin should be continued, as these are
the core drugs in the treatment of tuberculosis and have been
shown to be effective in treating the patient's strain of M.
tuberculosis. Ethambutol can also be continued as it is generally
considered to be safe in patients with liver dysfunction.
If necessary, the use of other
hepatoprotective agents such as
ursodeoxycholic acid and N-acetylcysteine
can be considered to minimize further liver
injury
 References:
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 Proof of
Discussion: