1

Addis Ababa University School of Pharmacy

Department of Pharmacology and Clinical Pharmacy

Disseminated tuberculosis (lung +pericardium

Arega Gashaw

December 12, 2014

Patient Presentation ▫Card no : 31968▫bed No: 812/3▫Ward : C 8▫Age : 45 years▫Sex: M▫weight: NA

•CC▫Dry Cough for 2 month▫Shortness of breath for 1 week▫Non trauma

HPIdisseminated TB with massive pericardial effusion with cardiac tamponed secondary to DTV

•PMH : pneumonia •Medications prior to admission…. NA•drug allergies ….NKDA• ADR… NA

Physical examination•Vital sign ▫PR= 90▫RR= 27▫BP =90/60 mm Hg▫T 36.5°C▫Sa O2= 91 %

•HEENT: ▫Eye: pink conjunctivitis▫Distended neck vein

•Leg : lymphatic adenopathy•Abdominal – liver: smooth, tender, SD+•MS - grade II pedal edema

•Chest: clear and good air entry over the right side▫ decrease air entry over the left side▫Several pericurdium effusion with tamponda▫Chest tube insitu over the left side for drainage of fluid

•CVS : distant heart sound•Respiratory: dry cough, SOB•CNS: consciouspertinent laboratory findings• CBC▫WBC---- 6.69 × 103/mm3 ▫RBC----- 5.1 × 103/mm3

▫ Platelet--- 2.97 × 103/mm3

▫Hg ---12.7 g/dL (12-18)▫Hct--- 37 % (38-49)

Investigation ……•Coagulation profile

PT 20.1sec ▫INR 1.65 sec▫PTT 31.7 sec

•AFB 3x negative•No gram stain•Pleural fluid analysis ▫Cell count 200 (ref. < 5 cell/ cc)???

N-20% L-80 %

▫Cytology : reactive infusion

Investigation……• Total protein 5.8 g/dL…….. (6.6-8.7)▫Albumin 3.5 g/dL……….. (3.8-4.65)▫Uric acid 9.5 mg/dL…………(3.4-7.1)▫LDH 601U/L …………(230-430)…..5951

Serum electrolyte▫K 3.8 mEq/L▫Na 131 mEq/L▫Ca 4.4 mEq/L

Investigation……•Organ function test▫BUN 39 mg/dL▫Cr 1 mg/dL▫ALT(SGPT) -166 U/L….(<40)▫AST(SGOT)- 287U/L ….(<40) ▫ALP- 240 U/L….(44-147)▫ Bl T- 1.4 mg/dL

▫D -1mg/dL

Other investigation•Echo examination revels that several

pericardium effusion are present

•CT(chest) : metastasis to the lung with moderate bilateral plural effusion and pericardial effusion

•Abd U/S: hepatomegally, ascities, right renal cortical cyst

•Abd CT: requested

Hospital Course •On 10/3/07 He was started anti TB.

RHZE (150+75+ 400+275 mg)4 tab/day

Steroid (prednisolone 60 mg PO/d after cardiologic side was consulted.

•On 12/3/07 •He develop lower limb acute distal DVT(doppler proved) and start anticoagulant ▫Heparin 17,500 U SC Bid and▫Warfarin 5 mg PO/d

On 23/3/07He was preparing for surgery(window opening for Pericardial fluid drainage▫ Warfarin discontinue▫ Heparin continue

On 24/3/07Pericardial fluid drainage was done and sample sent for analysis and cytology. On the same day pericardial window is done by cardio thoracic gird

On 25/3/07Chest tube is inserted for massive left side.Drain about 1 L of fluid up on insertion

Currently ;He is complaining of the surgical site pain

Currently he is on Anti TB-RHZE/150+75+400+275mg 4 tab/dayPrednisolone 60 mg PO/dPyridoxine 50 mg PO /dHeparin 17500 U sc

Planned to resume warfarin after coagulation profile is updated and discontinue heparin.

Analgesics : petidine 25 mg iv tid tramadole ……….

Discussion and critique of current treatment•Use of prednisolone for TB ???•Prolonged anti coagulant bridge therapy?•Dose of warfarin ?•Drug interaction▫Ref Vs warfarin▫Ref Vs predinsolone▫INH Vs warfarinPyridoxine + warfarin ( increase or decrease INR b/c of clotting factor metabolism may alter

desired therapeutic outcome•Achievement of a noninfectious state•Adherence to the treatment regimen•Cure as quickly as possible (generally with at

least 6 months of treatment)•Reduction or elimination of symptoms•Not complicating or aggravating other

existing disease states.•Avoiding or minimizing adverse effects of

treatment.•Providing cost-effective therapy.•Maintaining the patient’s quality of life.

•Therapeutic Alternatives▫LMWH is available for patient with cancer

associated DVT ▫And where warfarin is contraindicated for

long term treatment▫LMWH is either cost saving or cost effective

compare with UFH ▫Restriction of sodium and fluid▫Compression therapy▫anti-embolism stockings▫Regular exercise▫ Elevate limbs while seated

Design of an optimal individualized pharmaco-therapeutic plan

▫Assess and reinforce adherence/concordance with recommended therapy.

▫Continue both the anti TB drug, pyridoxine ▫Suggest discontinuation of prednisolone and

heparin and increasing warfarin to 7.5 mg PO until to the target INR

▫Educate on purpose of each medication

parameters to evaluate the outcome1. Clinical evaluation2. Bacteriological examination3. Chest radiograph

•Clinical Evaluation▫Patients should have clinical evaluations at

least monthly to▫ Assess adherence; and▫Determine treatment efficacy▫Identify possible adverse reactions to

medications

• For any drugs : Allergic reaction ,Skin rash • For EMB ▫Eye damage (Blurred or changed vision

• INH, PZA, RIF: Hepatic toxicity • For INH ▫Nervous system damage

• Dizziness; tingling or numbness, around the mouth▫Peripheral neuropathy • Tingling sensation in hands

and feet • For PZA ▫Stomach upset Serious, gout

•For RIF Bleeding problems discoloration of body fluidsSensitivity to the sun • Frequent sunburn Minor

For warfarin•Red or dark brown urine and stool•Bleeding •Severe headache or stomach pain or upset•Weakness, faintness, or dizziness•Skin rash or irritation•Unusual fever• Joint or back pain•Swelling or pain at an injection site

Steroids • salt and water retention•extracellular fluid volume expansion•Hypertension•potassium depletion, and•  metabolic alkalosis• Immunodeficiency

Bacteriological examination▫Patients whose cultures have not become

negative after 3 months of▫therapy should be reevaluated for potential

drug-resistant disease,▫as well as for potential failure to adhere to

the regimen.▫AFB ??? ▫AFB cultures?

Drug susceptibility studies NEVER ADD 1 DRUG IF SUSPECT RESISTANCE

▫CXR: Baseline, 2-3 months and after completion

General Approach•Clinical Evaluations at 2 (with PZA), 4 and 8

weeks, then monthly:▫PE: Signs/symptoms of hepatitis▫Lab Exam

CBC/platelets Liver function tests (ALT, AST, Bili, ALP) at

baseline and monthly D/C INH if:▫Patient develops symptomatic hepatitis▫LFTs > 5 times normal or > 3-5 times baseline

Renal function tests (Scr, BUN, U/A)▫Review of Medication Profile (drug interactions)

Monitoring Toxicity•Hepatotoxicity Plan•Clinical or Laboratory Evidence▫S/S hepatitis, jaundice▫AST, ALT > 350 or Bili > 3 D/C INH,

Rifampin and Pyrazinamide 3x baseline or 5 x normal

Monitorng parameter for heparin and warfarin PT/INR at the base line, hg, Hct, plt,

Provision of patient education including discharge medication counseling▫Take your drug at the same time at each day▫Your dose may be adjusted several times

based on the lab. Test▫Do not stop taking your medication with our

your doctor approval▫Inform your doctor or the pharmacist for any

unusual bleeding from any site,▫ the symptoms of warfarin toxicity early▫Notify your doctors if develop chills, fever,

skin rash

Other issue …..•When to seek necessary medical attention• Consequences of not taking their medicine

correctly•Name and description of the medication

(which may include the indication).• Dosage, dosage form, route of administration, and duration of therapy.• Action to be taken in the event of missed doses.

05/01/2023 Presentation on internal medicine ward Attachment 27

Thank you All….