Patients with co morbid conditions
After going through this module we will understand
Management of tuberculosis with co morbid conditions
- Breast feeding
- Hepatic diseases
- Renal diseases
- Paradoxical response
- HIV/Aids with TB (Separate guide lines)
- MDR-TB (Separate guide lines)
If tuberculosis is diagnosed in pregnant women or a tuberculous patient gets pregnant ensure that patient and start / continue first line anti TB drugs for tuberculosis in the same way as for other patients. However injection Streptomycin should not be used because of the risk of ototoxicity to the fetus. Give treatment as recommended in NTP guideline. Successful treatment of tuberculosis with recommended standard regimen is important for successful outcome of pregnancy.
2. Breast Feeding
A lactating mother should receive the full course of therapy, as all anti- Tuberculosis drugs are compatible & safe. Ensure the patient and encourage breast-feeding. However if mother is sputum positive at this stage, baby should be given INH prophylaxis as per NTP guidelines.
3. Liver Disorders
- Patients with past history of hepatitis and carrier of hepatitis virus (B&C)
When LFT’sare normal, treatment is same as other TB patients. However, monitorLFTs regularly as hepatotoxic reaction to anti- tuberculosis drugs is more common in these patients. In case of such events follow the guideline for management of drug-induced hepatitis.
- Patients with established Liver Disease:
Pyrazinamide should not be given to these patients. Give alternative regimen. S-Fq-E/Fq-E If patient is very ill then give Streptomycin, Ethambutol with Fluoroquinolones
Defer treatment till acute hepatitis resolves. Patient’s hepatitis completely resolves treat as ‘patients with past history of hepatitis and carrier of hepatitis virus (B&C)’. in patient with incomplete resolution of hepatitis treat as Patients with established Liver Disease
If patient is very ill due to tuberculosis, give alternative regimen avoiding hepatotoxic drugs i.e. S-Fq-E/Fq-E
Treatment of Tuberculosis in diabetic patient is not different. Monitor and control blood sugar levels in these patients .As Rifampicin is enzyme inducer, adjust the dose of oral hypoglycemic agents in the beginning as well as after completing anti-tuberculosis treatment. Add pyridoxine (10 mg/day) with other drugs to avoid peripheral neuropathy (manifest as burning feet) in these patients.
5. Renal Failure
These patients should be managed in tertiary care hospital and should receive alternative regimen. Dose and frequency of drug depends on creatinine clearance and need for dialysis.
6. Paradoxical Response
In the first 3-12 weeks after initiation of anti tuberculosis treatment, old lesions increase in size or new lesions may develop. This may be associated with high grade fever, lymphadenopathy and worsening of radiological shadows. In these cases continue anti tuberculosis treatment. If reaction is severe, short course of oral corticosteroids (prednisolone 1 mg/kg for 02 week) may be given. If the patient does not respond to this treatment he may be referred to tertiary care hospital for further management.
PATIENTS WITH COMPLICATIONS OF TUBERCULOSIS
Complications of tuberculosis may develop during the course of treatment or as sequelae after treatment.
Coughing up of blood can be classified as mild, moderate or massive (expectoration of more than 500ml of blood in 24 hours or 200ml of blood in one hour with hemodynamic instability) . Reassurance of the patient is needed in case of mild bleeding, but massive hemoptysis can be life threatening. In such cases, clear the airways; replace the blood loss by fluid, or blood transfusion if required. Few cases of massive hemoptysis may require surgery and for that purpose should be referred to tertiary care hospital higher level.
It presents with cough and large volume of sputum. Hemoptysis can also occur and may be the only symptom when the lesion is present in the upper lobe. Repeated Pulmonary infections can occur. Daily chest physiotherapy is advised. Give a course of anti-biotic effective against b lactamase producing organisms in case of infection.
This presents as sudden onset/increase in breathlessness. X-ray chest shows hyper-lucent area devoid of lung markings with collapsed lung borders. If Pneumothorax is small, it may resolve spontaneously but regular monitoring of the Patient is needed. In case of large Pneumothorax patient should be referred for intubation and further management to tertiary care hospital.
4. Chronic respiratory failure:
Chronic respiratory failure results in patients with extensive disease that has destroyed large part of the lungs. Clinical presentations of the patient include breathlessness, altered conscious level, increased heart and pulse rate. These patients require monitoring of arterial blood gases and therefore can only be managed in tertiary care hospitals.
It is the formation of a fungal ball in a preexisting cavity. Patient presents with hemoptysis, which may be massive. X-ray chest shows a rounded opacity with hallows of crescent shape hyper lucent area above it, which changes its position when x-ray is taken in decubitus position. If hemoptysis is massive or recurrent, patient should be referred to a thoracic surgeon for management