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Unit 10 Treating the Dually Infected
Patient: B Family Case
Botswana National Tuberculosis Programme
Manual Training for Medical Officers
B Family Case: Question 1
• Mr. B is on TB retreatment and ART
• Mr. B returns with nausea, vomiting, and
jaundice
What do you do for Mr. B?
Unit 10: Case Studies
Slide 2
B Family Case: Answer 1
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Take a detailed history
Do a physical examination
Make sure to assess Mr. B’s liver
Take blood for liver function, electrolytes, full blood
count
• Bilirubin (100), AST (400 range), ALT (500 range)
• Admit Mr. B to the hospital for observation
• Stop all TB and HIV medications, but maintain
cotrimoxazole
Unit 10: Case Studies
Slide 3
B Family Case: Question 2
1 week later, Mr. B’s LFTs have
decreased to less than 2 x ULN
What do you do for Mr. B now?
Unit 10: Case Studies
Slide 4
B Family Case: Answer 2
• Reintroduce TB drugs
• Monitor liver function tests
Unit 10: Case Studies
Slide 5
B Family Case: Question 3
After a 16 day re-introduction, the patient’s
LFTs remain < 2x ULN and Mr. B is without
jaundice
1. When do you consider starting ART
again?
2. Which drugs should Mr. B take?
Unit 10: Case Studies
Slide 6
B Family Case: Answer 3
1. 2-4 weeks after re-starting full doses of antituberculosis drugs
2. Medications
• Alluvia, 2 tabs BD
• Ritonavir, 3 capsules BD
• Combivir, 1 tab BD
*Alluvia is now available in Botswana – it is a tablet form of
Kaletra and does not need to be refrigerated
Unit 10: Case Studies
Slide 7
B Family Case: Question 5
Why should Mr. B take Alluvia + Ritonvir
instead of restarting EFV?
Unit 10: Case Studies
Slide 8
B Family Case: Answer 5
• EFV can cause heptatotoxicity
• Since Mr. B is tolerating the ATT, you assume
it was the efavirenz that caused the deviation
in liver function and jaundice
Unit 10: Case Studies
Slide 9
Unit 10 Treating the Dually Infected
Patient: Case
Botswana National Tuberculosis Programme
Manual Training for Medical Officers
Additional Case
• A 45 year old female
named TT with fever for
4 weeks, cough with
bloody sputum, sweats
and weight loss of 7 kg
• Sputum is AFB+
• Her HIV test is positive
and CD4 is 20 cell/cu
mm
Unit 10: Case Studies
Chest X-ray shows right
paratracheal adenopathy
Slide 11
Additional Case: Question 1
1. What questions do you ask her?
2. What medications do you start her on?
Unit 10: Case Studies
Slide 12
Additional Case: Answer 1
1. Ask her if she is still menstruating
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TT reports that her menses stopped at 43 years
of age
2. Start patient on rifampicin, isoniazid,
pyrazinamide and ethambutol plus
cotrimoxazole
Unit 10: Case Studies
Slide 13
Additional Case: Question 2
• TT is started on a four drug TB
therapy and is discharged
• She returns after 1 month
• Her fevers, night sweats and
cough have stopped and she
has gained 5kg
• She is tolerating the TB drugs
• TB therapy is continued
• She is started on ARVs
including zidovudine, lamivudine
and efavirenz
Unit 10: Case Studies
X-ray shows improvement
Why is she taking
efavirenz instead of
nevirapine?
Slide 14
Additional Case: Answer 2
TT is taking efavirenz instead of nevirapine
because she is beyond child bearing age and
because efavirenz is the preferred NNRTI for
use in patients taking rifampin
Unit 10: Case Studies
Slide 15
Additional Case: Question 3
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She comes back to your facility 2 weeks after
starting ARVs
• She says that her fever, cough and night sweats
have come back
• She has taken her ARTs as prescribed, but thinks
they are making her more sick and she would like
to stop them
1. What other information do you want from her
history?
2. How would you assess her?
Unit 10: Case Studies
Slide 16
Additional Case: Answer 3
1.
You want to know whether or not she was adherent to all
her medications
2. Assessing TT
• Check for other signs/symptoms: nausea, vomiting and
diarrhoea, which may indicate other infections or
malabsorption
• Check blood pressure, heart rate, temperature,
respiratory rate and oxygen saturation
• Perform labs: sputum smear for AFB, sputum culture,
FBC, liver tests, CD4 count, viral load
• Perform a chest x-ray
Unit 10: Case Studies
Slide 17
Additional Case: Question 4
1. What is your differential diagnosis?
2. What do you look for on physical exam?
Unit 10: Case Studies
Slide 18
Additional Case: Answer 4 (1)
1. Differential diagnosis
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TB IRIS
Drug-resistant TB
Failure of TB therapy due to poor adherence or
malabsorption of medications
Bacterial pneumonia
PCP
Drug toxicity
Unit 10: Case Studies
Slide 19
Additional Case: Answer 4 (2)
2. Physical examination
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Close evaluation of the chest
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Listen for adventitious sounds, symmetrical excursion
Check for enlarged lymph nodes
Assess for body swelling (oedema)
Assess for abdominal distention
Asses for jaundice
Complete neurologic exam
Unit 10: Case Studies
Slide 20
Additional Case: Question 5 (1)
• TT reports excellent
adherence and denies
nausea, vomiting or
diarrhoea
• Oxygen saturation is 96%
on room air
• Heart rate, respiratory rate
and other vital signs are
normal
• Remainder of physical exam
is normal
• Sputum smear negative
Unit 10: Case Studies
Diffuse bilateral infiltrates
Slide 21
Additional Case: Question 5 (2)
1. What condition(s) do you suspect now?
2. What is your management plan now?
Unit 10: Case Studies
Slide 22
Additional Case: Answer 5
1. Narrowed differential diagnosis
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TB IRIS
PCP
Bacterial pneumonia
2. Management
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Advise her to continue ART and the TB continuation regimen
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Educate her, using a caring, respectful attitude
• Ask questions and listen
• Ensure she understands the benefit of remaining on both
treatments
• Encouragement
Schedule her to come back in 1-2 weeks, or sooner if she gets worse
•
Unit 10: Case Studies
Slide 23
Additional Case: Question 6
• 2 weeks later her symptoms
are worse
• Sputum culture from last
visit shows no growth to
date
• Sputum smear is AFB
negative
• Respiratory rate is 28
• Oxygen saturation is 90%
on room air
• Crackles heard bilaterally
Unit 10: Case Studies
X-ray shows no improvement
What is your diagnosis?
Slide 24
Additional Case: Answer 6
• TB IRIS: Occurs in 10-40% of patients
• The immune system is likely reacting to dead mycobacteria
in the system
• The inflammation is worsening as her immune system
reconstitutes itself on ART
• Risk factors
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Starting ARVs within 6 weeks of TB treatment
Disseminated, extra-pulmonary disease
Low baseline CD4 count
Rise in CD4 %
Fall in viral load
Source: www.who.int/entity/tb/events/tbiris.ppt
High bacillary burden
Unit 10: Case Studies
Slide 25
Additional Case: Question 7
How do you manage TT now?
Unit 10: Case Studies
Slide 26
Additional Case: Answer 7
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Admit her to hospital
Give oxygen
FBC, chemistry panel
Administer corticosteroids to reduce inflammation
• If she continues to worsen despite steroid treatment:
• Stop ART until she has clinically improved (resolution of chest xray, respiratory distress)
• Restart ART once clinically stable
• Continue TB treatment regimen throughout
• If a culture turns positive:
• Suspect drug resistance
• Do sensitivity testing
Unit 10: Case Studies
Slide 27
Additional Case: Question 8
• 1 week later, TT
remains on ART and TB
treatment + steroids
• T.T. reports feeling
much better
• Lungs sound normal
• Sputum culture is still
negative
Chest x-ray shows improvement
How long should steroids be continued?
Unit 10: Case Studies
Slide 28
Additional Case: Answer 8
• Consider a 4 week taper
• May need to restart if IRIS recurs
Unit 10: Case Studies
Slide 29