CASE REPORT

Medical Record Number Admission Date Admission Time Name $ender A%e (ccu)ation Address

: 34.99.43 : 20 January 2014 : 19.00 : Mrs # : oman !"

: &' years old : *ouse+i,e : -eta)an%

Anamnesis ./ie, .om)laint 0econdary .om)laint

(Date: 24 January 2014, 06.00 W !" : s/ortness o, breat/e : c/est )ain1 cou%/1 eyes turn yello+1 loss o, a))etite +/ic/ cause si%ni,icant +ei%/t lost

#ist$ry $% Present &&ness T/e )atient came to t/e /os)ital +it/ s/ortness o, breat/e1 s/e already ,elt ,or about 2 +ee2s be,ore admission. T/e s/ortness is ,elt all day lon%1 ,eels li2e s3uee4ed and not in,luenced by acti5ity. 0/e also ,elt e6cessi5e s+eatin%1 es)ecially at ni%/t and c/est )ain1 t/e )ain is not radiatin% to t/e s/oulder1 arm1

nor t/e nec2. T/e )ain increasin%ly become /ea5y +/en s/e in/ale lasts all day lon% and ,eels li2e )ric2led. 0/e also /ad )roducti5e cou%/ ,or t/e last 4 mont/s. .ou%/ more o,ten at ni%/t. it/in 2 days t/e s)utum c/an%es color ,rom %reen to

bro+n. 0ince 2 days a%o /er ,amily noticed t/at /er eyes turn yello+. 7yes turn yello+ +it/out ,e5er. 0/e also loss o, a))etite +/ic/ cause si%ni,icant +ei%/t lost. "e,ore came to R08AM1 )atient /a5e been treated at /ealt/ center1 in t/ere t/e )atient /as c/ec2 s)utum and stated /a5e to under%o treatment ,or 9 mont/s. 0/e /as been ta2in% it ,or 1 +ee2.

#ist$ry $% Past &&ness 0/e /a5e Diabetes mellitus. 0/e ne5er /ad ast/ma or se5ere breat/lessness be,ore.

#ist$ry $% 'ami&y &&ness T/ere +as no ,amily member +/o dia%nosed as tuberculosis1 /a5in% +et cou%/ more t/an 2 +ee2s1 nor )resent any sym)toms li2e t/e )atients.

P(ysi)a& E*aminati$n $eneral a))earance .onsciousness *ei%/t ei%/t : :oo2s ill : .om)os mentis1 74;&M9 : 1&< cm : 42 2%

"lood #ressure #ulse Tem)erature Res)iration Rate *ead

: 90=90 mm*% : '2 b)m 1 re%ular : 39.< .

0

: 2<6=minute : Normoce)/ali1 atraumatic1 normal /air distribution1 /air not easily re5o2ed

7ye

: isoc/or )u)ils1 anemic con>ucti5a ?=?1 icteric sclera @=@ 5isual ,ield intact.

Nose

: 0ymmetrical1 se)tum de5iation A?B1 disc/ar%e A?B1 conc/a oedem A?B

Mout/ T/roat Nec2

: sianosis A?B1 caries 1 stomatitis A?B : tonsil T1?T1 calm1 /y)eremis )/arin% A?B : t/yroid %land normal si4e1 lym)/ nodes not )al)able1 de5iation o, trac/ea A?B

T/ora6 :un%

!ns)ection

: symmetrical s/a)e1 symetrical c/est mo5ement1 accessory muscle use A?B1

#al)ation #ercussion Auscultation Abdomen !ns)ection #al)ation

: ,remitus tactil and ,remitus 5ocal @1 no tenderness. : 0onor : ;esicular A@=@B /ee4in% A?=?B1 .rac2les A@=?B

: abdomen ,lat1 no tension1 no dilated 5eins : )ress )ain at ri%/t /y)oc/ondriac1e)i%astric1le,t /y)oc/ondriac1 le,t lumbar and umbilical1 no de,ense muscular1 no enlar%ed li5er and s)leen

#ercussion Auscultation 76tremity

: tim)anic1 )ercussion )ain A?B1 s/i,tin% dullness A?B : bo+el mo5ement A@B1 normal : +arm 1 oedem A?B1 cyanosis A?B

+a,$rat$ry 'in-in.s

*ematolo%y A20 January 2014B

*emo%lobin

: <13 %r C

". counts

: 29.900 = Dl

Di,,?count

: 0 = 2 = 0 = 90 = 3 = &

0$(T

: &9 8=:

0$#T

: 14 8=:

8reum

: 141 m%=dl

.reatinin

: 410 m%=dl

Natrium

: 12& mmo=:

-alium

: 219 mmo=:

.alcium

: <13 m%=dl

.lorida

: 99 mmo=:

*ematolo%y A23 January 2014B

Total bilirubin

: 91< m%=dl

Direct bilirubin

: 91& m%=dl

!ndirect bilirubin

: 013 m%=dl

&

0$(T

: 49 8=:

0$#T

: 1& 8=:

8rine Test A20 January 2014B

.olor

: yello+

.larity

: clear

Density

: 11010

#/

:'

:eu2osit=lesis : 2&=ul

Nitrit

: ? Ane%ati5eB

#rotein

: ? Ane%ati5eB

$lucose

: ? Ane%ati5eB

-eton

: ? Ane%ati5eB

8robilino%en : ? Ane%ati5eB

"illirubin

: ? Ane%ati5eB

(ccult blood : 1&0=ul

0ediment

o :eu2osit : 3?&=:#" o 7rytrosit : <?1&=:#" o 7)it/el : @ A)ositi5eB o "acteria : ? Ane%ati5eB o .rystal : ? Ane%ati5eB o .ylinder : ? Ane%ati5eB o (t/er : ? Ane%ati5eB

./est E?Ray

'

D A/0OS S #ulmonary Tuberculosis +it/ Dru% !nduced *e)atitis and anemia e.c c/ronic disease and .RF D ''ERE0T A+ D A/0OS S #ulmonary Tuberculosis +it/ Acute 5iral /e)atitis

#ulmonary Tuberculosis +it/ ./olecystitis

<

1ana.ement

Monitorin% sym)toms o, D!*

#/armacolo%ical !nter5ention :

!;FD R: 66 %tt=minute

Anti tuberculosis treatment

7tambutol 1000 m%

Antibiotic : .i)ro,lo6acin 200 m% !;

Mucolytic : Ambro6ol 0yru) 361 .

*e)ato)rotector : .urcuma 361 tab

Non #/armacolo%ical !nter5ention

- "edrest

- (6y%en 2:=minute

- Trans,usion #R. until *b G 10 %r=dl

An$t(er W$r234 (Re)$mmen-e-"

Abdominal ultrasound
9

 Re)eat measurements o, 0$(T and bilirubin

*"sA%

Anti *.;

Anti *A; !% M

PRO/0OS S

Huo ad 5itam

: dubia ad malam

Huo ad ,unctionam

: dubia ad malam

Huo ad sanationam

: dubia ad malam

10

P3+1O0AR5 T3!ERC3+OS S

DE' 0 T O0 #ulmonary tuberculosis AT"B is a /i%/ly conta%ious disease caused by a bacteria 2no+n as Mycobacterium tuberculosis. T" %enerally a,,ects t/e lun%s1 but it also can in5ade ot/er or%ans o, t/e body1 li2e t/e brain1 2idneys and lym)/atic system. T" is s)read by airborne contamination1 meanin% t/e in,ected dro)lets are carried t/rou%/ t/e air and t/en in/aled by ot/er )eo)le. Not e5eryone +/o is e6)osed to T" %ets an acti5e in,ection. (nly t/ose +/o /a5e t/e actual bacteria in t/eir lun%s %et sic2 and are considered in,ectious.

0C DE0C5 T/e orld *ealt/ (r%ani4ation A *(B /as desi%nated !ndonesia a I/i%/

burden countryI ,or tuberculosis. T/ere are 22 /i%/ burden countries +orld+ide1 and to%et/er t/ey account ,or about <0 )ercent o, t/e +orldJs tuberculosis in,ections. 76)atriates or ,re3uent tra5elers +/o s)end si%ni,icant amount o, time

11

in a /i%/?burden country may bene,it ,rom T" screenin%. 0ome countries may recommend t/at in,ants and c/ildren /a5e a ".$ 5accination. T/e annual ris2 o, T" in,ection in 0out/east Asia is 1?2.&C1 re)resentin% an u)+ard trend ,or t/e re%ion. !n !ndonesia1 t/ere are rou%/ly &001000 ne+ cases o, T" annually and 1'&1000 attributable deat/s. Tuberculosis is t/e second ma>or 2iller o, adults a,ter cardio5ascular disease and t/e deadliest )at/o%en out o, all communicable diseases. !n %lobal terms1 t/ere are one billion )eo)le in,ected +it/ tuberculosis at any one time. 7i%/t million ne+ cases are re)orted annually +it/ t/ree million attributable deat/s. *o+e5er1 des)ite t/ese %rim ,i%ures and +it/out t/e in,luence o, consistent treatment and immunisation1 its incidence is not as /i%/ as it +as in t/e 20t/ century. T/e )roblem no+ is t/at +it/ inade3uate and inconsistent treatment re%imes1 a )ool o, )ersistent s)utum )ositi5e cases is bein% created.

PAT#OP#5S O+O/5 !n/alation o, Mycobacterium tuberculosis leads to one o, ,our )ossible outcomes:

!mmediate clearance o, t/e or%anism

12

:atent in,ection T/e onset o, acti5e disease A)rimary diseaseB Acti5e disease many years later Areacti5ation diseaseB.

Amon% indi5iduals +it/ latent in,ection1 and no underlyin% medical )roblems1 reacti5ation disease occurs in & to 10 )ercent o, cases. T/e ris2 o, reacti5ation is mar2edly increased in )atients +it/ *!;. T/ese outcomes are determined by t/e inter)lay o, ,actors attributable to bot/ t/e or%anism and t/e /ost. Primary -isease Amon% t/e a))ro6imately 10 )er cent o, in,ected indi5iduals +/o de5elo) acti5e disease1 about /al, +ill do so +it/in t/e ,irst t+o to t/ree years and are described as de5elo)in% ra)idly )ro%ressi5e or )rimary disease. T/e tubercle bacilli establis/ in,ection in t/e lun%s a,ter t/ey are carried in dro)lets small enou%/ A& to 10 micronsB to reac/ t/e al5eolar s)aces. !, t/e de,ense system o, t/e /ost ,ails to eliminate t/e in,ection1 t/e bacilli )roli,erate inside al5eolar macro)/a%es and e5entually 2ill t/e cells. T/e in,ected macro)/a%es )roduce cyto2ines and c/emo2ines t/at attract ot/er )/a%ocytic cells1 includin% monocytes1 ot/er al5eolar macro)/a%es and neutro)/ils1 +/ic/ e5entually ,orm a nodular %ranulomatous structure called t/e tubercle. !, t/e bacterial re)lication is not controlled1 t/e tubercle enlar%es and t/e bacilli enter local drainin% lym)/ nodes. T/is leads to lym)/adeno)at/y1 a c/aracteristic clinical mani,estation o, )rimary tuberculosis AT"B. T/e lesion )roduced by t/e e6)ansion o, t/e tubercle into t/e lun% )arenc/yma and lym)/ node in5ol5ement is called t/e $/on com)le6. "acteremia may accom)any initial in,ection. T/e bacilli continue to )roli,erate until an e,,ecti5e cell?mediated immune A.M!B res)onse de5elo)s1 usually t+o to si6 +ee2s a,ter in,ection. Failure by t/e
13

/ost to mount an e,,ecti5e .M! res)onse and tissue re)air leads to )ro%ressi5e destruction o, t/e lun%. Tumour necrosis ,actor ATNFB?al)/a1 reacti5e o6y%en and nitro%en intermediates and t/e contents o, cytoto6ic cells A%ran4ymes1 )er,orinB may all contribute to t/e de5elo)ment o, caseatin% necrosis t/at c/aracteri4e a tuberculous lesion. 8nc/ec2ed bacterial %ro+t/ may lead to /aemato%enous s)read o, bacilli to )roduce disseminated T". Disseminated disease +it/ lesions resemblin% millet seeds is termed miliary T". "acilli can also s)read by erosion o, t/e caseatin% lesions into t/e lun% air+ays ?and t/e /ost becomes in,ectious to ot/ers. !n t/e absence o, treatment1 deat/ ensues in <0 )er cent o, cases. T/e remainin% )atients de5elo) c/ronic disease or reco5er. ./ronic disease is c/aracteri4ed by re)eated e)isodes o, /ealin% by ,ibrotic c/an%es around t/e lesions and tissue brea2do+n. .om)lete s)ontaneous eradication o, t/e bacilli is rare. Rea)ti6ati$n -isease Reacti5ation T" results ,rom )roli,eration o, a )re5iously dormant bacterium seeded at t/e time o, t/e )rimary in,ection. Amon% indi5iduals +it/ latent in,ection and no underlyin% medical )roblems1 reacti5ation disease occurs in & to 10 )er cent. !mmunosu))ression is associated +it/ reacti5ation T"1 alt/ou%/ it is not clear +/at s)eci,ic /ost ,actors maintain t/e in,ection in a latent state and +/at tri%%ers t/e latent in,ection to become o5ert. 0ee )re5ious article ,or immunosu))ressi5e conditions associated +it/ reacti5ation T". T/e disease )rocess in reacti5ation T" tends to be locali4ed Ain contrast to )rimary diseaseB: t/ere is little re%ional lym)/ node in5ol5ement and less caseation. T/e lesion ty)ically occurs at t/e lun% a)ices1 and disseminated disease is unusual unless t/e /ost is se5erely immunosu))ressed. !t is %enerally belie5ed t/at success,ully contained latent T" con,ers )rotection a%ainst subse3uent T" e6)osure.

14

ET O+O/5 #ulmonary tuberculosis AT"B is caused by t/e bacteria Mycobacterium tuberculosis (M. tuberculosis).

S51PTO1S A0D D A/0OS S T/e )rimary sta%e o, T" does not cause sym)toms. )ulmonary T" occur1 t/ey can include:

/en sym)toms o,

.ou%/ Ausually +it/ mucusB .ou%/in% u) blood 76cessi5e s+eatin%1 es)ecially at ni%/t Fati%ue
1&

Fe5er ei%/t loss "reat/in% di,,iculty ./est )ain /ee4in% At t/e local le5el1 dia%nosis is best ac/ie5ed t/rou%/ microsco)ic

(t/er sym)toms t/at can occur:

detection o, bacillus in a s)utum smear. .ulturin% bacillus is e6)ensi5e and im)ractical as it ta2es 9 +ee2s ,or results1 and 6?rays can be misleadin%. 02in testin% is recommended by t/e *(1 but it is not a test s)eci,ic to /uman T"

bacillus. Additionally1 t/e si4e o, t/e reaction is not al+ays /el),ul1 as stron% reactions may occur in /ealt/y )eo)le +it/ re)eated occu)ational e6)osure and )eo)le cured o, T". !t /as been reco%ni4ed t/at males in t/e 2& to 34?year old a%e %rou) are t/e most common transmitters o, t/e T" bacillus. An in,ectious case +ill ty)ically in,ect u) to ten ot/er )eo)le in a year. !n case?,indin%1 t/e %eneral rule is t/at anyone +/o /as /ad a cou%/ ,or more t/an 3 +ee2s s/ould /a5e a s)utum smear. .ro+ded dar2 )laces are ideal areas ,or t/e s)read o, T"1 as direct sunli%/t +ill

19

2ill t/e bacillus in a ,e+ minutes but it can li5e in dar2 and dusty areas u) to 20 years. Tu,er)u&in testin. T/ree tuberculin tests are used !n !ndonesia:

*ea, test

T/is uses a multi)le )uncture K%unK +it/ rin%s o, s)i2es to in>ect a )uri,ied )rotein deri5ati5e A##DB ,rom t/e tuberculin mycobacteria. !t /as ,allen out o, %eneral use1 as t/e same s)i2e rin%s are used re)eatedly +it/ sterili4ation bet+een )atients and t/e A7A does not recommend it as a screenin% )rocedure.

Mantou6 test

0.1 ml o, ##D is in>ected intradermally into t/e ,orearm. T/e in>ection s/ould raise a +eal about ' mm in diameter. T/e in>ection site is usually e6amined a,ter '2 /ours and t/e diameter o, any induration A/ardenin%B on li%/t )ressure is measured. Results:
1'

Ne%ati5e: less t/an &mm diameter ea2ly )ositi5e: &?9mm diameter !ntermediately )ositi5e: 10?14mm diameter 0tron%ly )ositi5e: 1&mm diameter or more +it/ sores or s)ots

Tine test

.om)arable to t/e *ea, test in t/at it in5ol5es inoculation o, ##D ,rom t/e tuberculin mycobacteria by means o, similar s)i2es1 but t/ey are only used once. D ''ERE0T A+ D A/0OS S 1. #neumonia 2. #ulmonary Mycosis 1A0A/E1E0T No matter t/e treatment re%ime used1 t/e ,ollo+in% basic rules must be obser5ed:

Any dru% inta2e must be su)er5ised. Dru% inta2e must continue until ot/er+ise directed1 +/ic/ may be many mont/s. T/ere needs to be an uninterru)ted dru% su))ly to )re5ent emer%ent dru% resistance.

.ommonly used dru%s include A,irst linesB:

1<

!sonia4id

Ri,am)in

#yra4inamide

7t/ambutol

0tre)tomycin

(t/er dru%s t/at may be used to treat T" include:

Ami2acin

7t/ionamide

Mo6i,lo6acin

#ara?aminosalicylic acid

Dru. ntera)ti$ns Ad5erse e,,ects1 es)ecially %astrointestinal u)set1 are relati5ely common in t/e ,irst ,e+ +ee2s o, antituberculosis t/era)yL /o+e5er1 ,irst?line antituberculosis dru%s1 )articularly R!F1 must not be discontinued because o, minor side e,,ects.

19

Alt/ou%/ in%estion +it/ ,ood delays or moderately decreases t/e absor)tion o, antituberculosis dru%s1 t/e e,,ects o, ,ood are o, little clinical si%ni,icance. T/us1 i, )atients /a5e e)i%astric distress or nausea +it/ t/e ,irst?line dru%s1 dosin% +it/ meals or c/an%in% t/e /our o, dosin% is recommended. Administration +it/ ,ood is )re,erable to s)littin% a dose or c/an%in% to a second?line dru%. Dru%?induced /e)atitis1 t/e most serious common ad5erse e,,ect1 is de,ined as a serum A0T le5el more t/an t/ree times t/e u))er limit o, normal in t/e )resence o, sym)toms1 or more t/an ,i5e times t/e u))er limit o, normal in t/e absence o, sym)toms. !, /e)atitis occurs !N*1 R!F1 and #MA1 all )otential causes o, /e)atic in>ury1 s/ould be sto))ed immediately. 0erolo%ic testin% ,or /e)atitis 5iruses A1 "1 and . Ai, not done at baselineB s/ould be )er,ormed and t/e )atient 3uestioned care,ully re%ardin% e6)osure to ot/er )ossible /e)atoto6ins1 es)ecially alco/ol. T+o or more antituberculosis medications +it/out /e)atoto6icity1 suc/ as 7M"1 0M1 ami2acin=2anamycin1 ca)reomycin1 or a ,luoro3uinolone

Ale5o,lo6acin1 mo6i,lo6acin1 or %ati,lo6acinB1 may be used until t/e cause o, t/e /e)atitis is identi,ied. (nce t/e A0T le5el decreases to less t/an t+o times t/e

20

u))er limit o, normal and sym)toms /a5e si%ni,icantly im)ro5ed1 t/e ,irst?line medications s/ould be restarted in se3uential ,as/ion. .lose monitorin%1 +it/ re)eat measurements o, serum A0T and bilirubin and sym)tom re5ie+1 is essential in mana%in% t/ese )atients. Ta,&e 1: *e)atoto6ic )otential o, ,irst line ATT dru%s *e)atoto6ic )otential *i%/ :ess Dru%s !N*1 Ri,am)icin1 Ri,abutin1 #yra4inamide 0tre)tomycin1 7t/ambutol

s$nia7i- ( 0#" A))ro6imately 10?20C o, )atients durin% t/e ,irst 4?9 mont/s o, t/era)y /a5e a mild /e)atic dys,unction s/o+n by mild and transient increase in serum A0T1 A:T and bilirubin concentration. "ut in some )atients t/e /e)atic dama%e may be )ro%ressi5e and cause ,atal /e)atitis. Acetyl /ydra4ine1 a metabolite o, !N* is res)onsible ,or li5er dama%e. !N* s/ould be discontinued i, t/e A0T increases to o5er & times t/e normal 5alue. A )ros)ecti5e co/ort study o, 111141 )atients recei5in% !N* )re5enti5e t/era)y re)orted a rate o, /e)atitis lo+er t/an

21

t/at )re5iously re)orted. (, t/ese1 11 )atients A0.10C o, t/ose startin%1 and 0.1&C o, t/ose com)letin% t/era)yB de5elo)ed clinical /e)atitis. From January 1991 t/rou%/ May 19931 li5er trans)lant centres in Ne+ Nor2 and one in #ennsyl5ania collected data on )atients +/o /ad /e)atitis attributed to !N* t/era)y. 7i%/t )atients +ere on !N* monot/era)y on t/e usual dose o, 300 m% daily Ato )re5ent T"B at t/e time o, onset o, /e)atitis. *istolo%ical e5aluations s/o+ed massi5e or sub massi5e /e)atic necrosis1 +it/ c/olestasis in 2 )atients. *e)atoto6icity is rare in c/ildren recei5in% !N*. !n a 10?year

retros)ecti5e analysis1 t/e incidence o, /e)atoto6icity in &94 c/ildren recei5in% !N* A10 milli%rams )er 2ilo%ram )er day Am%=2%=dayB to a ma6imum o, 300 m%=dayB ,or t/e )ro)/ylactic treatment o, tuberculous +as 0.1<C. *o+e5er1 t/e incidence o, /e)atoto6icity in c/ildren recei5in% !N* and ri,am)icin ,or T" +as 3.3C in anot/er retros)ecti5e study A14 o, 430 c/ildrenB.

Ri%am4i)in Transient abnormalities in li5er ,unction are common in t/e initial sta%es o, t/era)y. "ut in some cases it may cause se5ere /e)atoto6icity1 more so in t/ose
22

+it/ )re?e6istin% li5er disease1 ,orcin% t/e )/ysician to c/an%e treatment and o)t ,or li5er ,riendly treatment. Ri,am)icin causes transient ele5ations in /e)atic en4ymes usually +it/in t/e ,irst < +ee2s o, t/era)y in 10C to 1&C o, )atients1 +it/ less t/an 1C o, t/e )atients demonstratin% o5ert ri,am)icin?induced /e)atoto6icity. T/e occurrence o, mortality associated +it/ /e)atoto6icity /as been re)orted to be 19 in &001000 )atients recei5in% ri,am)icin. A /i%/er incidence o, /e)atoto6icity /as been re)orted in )atients recei5in% ri,am)icin +it/ ot/er anti T" a%ents1 and is estimated to be ,e+er t/an 4C. A /i%/er incidence o, /e)atoto6icity /as also been re)orted in )atients recei5in% ri,am)icin in combination +it/ )yra4inamide ,or t/e treatment o, latent T". T/is data /as led to t/e recommendation t/at t/is re%imen s/ould %enerally not be o,,ered ,or t/e treatment o, latent tuberculosis.

Pyra7inami-e T/e most common ad5erse e,,ect o, t/is dru% is /e)atoto6icity. *e)atoto6icity is dose related and may occur any time durin% t/era)y. !n t/e
23

.entre ,or Diseases .ontrol A.D.B u)date1 4< cases o, /e)atoto6icity +ere re)orted in association +it/ a 2?mont/ re%imen o, Ri,am)in?)yra4inamide ,or t/e treatment o, latent tuberculosis bet+een (ctober 2000 and June 2003. T/irty? se5en )atients reco5ered and 11 died o, li5er ,ailure. (, t/e 4< re)orted cases1 33 A99CB occurred in t/e second mont/ o, t/era)y.

Et(am,ut$& T/ere are ,e+er re)orts o, /e)atoto6icity +it/ 7t/ambutol in t/e treatment o, T". Abnormal li5er ,unction tests /a5e been re)orted in some )atients ta2in% et/ambutolL /o+e5er1 t/ese )atients +ere also ta2in% ot/er antiT" dru%s 2no+n to cause li5er dys,unction.

Stre4t$my)in No /e)atoto6icity /as been re)orted.

24

CASE A0A+5S S

A +oman identi,ied as Mrs. # &' ?year ?old 1 admission at January 201 2014 +it/ a c/ie, com)laint o, s/ortness o, breat/ since 2 +ee2s a%o. (, t/ese com)laints 1 +e can t/in2 o, is a disorder in t/e res)iratory system = lun%s 1 /eart ,ailure 1 and 2idney disorders . A))ro6imately 4 mont/s be,ore admission1 os com)lained o, cou%/1 s)utum A@B1 s)utum color %reen1 os ,eels decreased a))etite1 +ei%/t loss and e6cessi5e s+eatin% es)ecially at ni%/t. Normal bladder and bo+el mo5ements A@B . "e,ore came to R08AM1 )atient /a5e been treated at /ealt/ center1 in t/ere t/e )atient /as c/ec2 s)utum and stated /a5e to under%o treatment ,or 9 mont/s. 0/e /as been ta2in% it ,or 1 +ee2. T/e com)laint can be seen ,rom t/e )resence o, c/ronic cou%/1 +/ic/ could be due to )ulmonary tuberculosis or c/ronic bronc/itis. !n t/is case1 it can be sus)ected tuberculosis ,rom s)utum color is %reen. 76cessi5e s+eatin%1 a))etite and +ei%/t do+n s/o+ )rodromal sym)toms are o,ten seen in )ulmonary tuberculosis.

2&

(s /a5e /istory o, diabetes mellitus. !t may cause os susce)tible )ulmonary tuberculosis. *istory o, /i%/ blood ill indis)utably1 /istory o, t/e disease +it/ t/e same com)laint is a cou%/ lon%er in t/e ,amily is also re,uted by t/e os. (, )/ysical e6amination ,ound t/e )atient Ks %eneral condition seemed ill bein%1 and a+areness com)os mentis. "lood )ressure 90=90 mm*%1 )ulse '26=minute1 2<6= minute res)iratory1 and tem)erature 391< ..
0

it/ t/e )/ysical

e6amination result it s/o+ t/at os +as in unstable condition and %eneral state o, im)ro5ement must be done. 76amination o, t/e eyes icteric are ,ound at bot/ sclera. (n lun% e6amination ,ound .rac2les o, t/e ri%/t lun%1 and normal 5esicular obtained in bot/ lun% ,ield. (n abdomen e6amination ,ound )ress )ain at ri%/t /y)oc/ondriac1e)i%astric1le,t /y)oc/ondriac1 le,t lumbar and umbilical. (n e6amination o, t/e /eart1 %enital1 and limb abnormalities +as not ,ound. !n laboratory +e ,ind t/at 0$(T: &9 8=:1 0$#T: 14 8=:1 Total bilirubin: 91< m%=dl and direct bilirubin: 91& m%=dl. "ased on )/ysical e6amination and laboratory

29

,indin%1 a dia%nosis can be establis/ed )ulmonary tuberculosis +it/ dru% induced /e)atitis. Dru%?induced /e)atitis is de,ined as an increase in A0T or A:T G 3 times t/e u))er limit o, normal in t/e )resence o, sym)toms or O & times t/e u))er limit o, normal in t/e absence o, sym)toms and bilirubin le5el risin% to t+o times or abo5e t/e u))er limit o, normal. !N*1 #MA and less commonly1 R!F can cause dru%?induced /e)atitis. !, /e)atitis occurs !N*1 R!F1 and #MA1 all )otential causes o, /e)atic in>ury1 s/ould be sto))ed immediately but1 i, t/e lesion ,rom c/est radio%ra)/s +as +idely a5ailable t/ey must be %i5en etambutol and stre)tomycin i, t/ere renal insu,,iciency can be subtitled by ot/er dru%s ,rom second line suc/ as mycrolite and 3uinolon. Treatment +as %i5en a bed rest1 o6y%en 2:=minute1 trans,usion #R. until *b G 10 %r=dl and monitorin% sym)toms o, D!*. For )/armacolo%ical inter5ention +as %i5en ATT in intensi, treatmentL etambutol 1000 m% and

o,lo6acin 200 m% ,or 2 mont/1 antibioticsL ci)ro,lo6acin 200 m%=12 /ours ,or &?' days1/e)ato)rotectorL curcuma 361tab and mucolyticL ambro6ol 36.1. T/e

2'

)ro%nosis ,or t/is )atient is dubia ad malam because )atient +as %oin% out ,rom R08AM be,ore treatment is com)leted.

2<

RE'ERE0CES

1. -is/ore1at

all.

200'.

Dru%

induced

/e)atitis

+it/

anti?tubercular -at/mandu

c/emot/era)y:

./allen%es and di,,iculties in treatment.

8ni5ersity Medical Journal 2. PPPPP. 2003. Treatment o, Tuberculosis. .D. 3. PPPPP. 2003.$uidelines ,or t/e Treatment o, Acti5e Tuberculosis Disease. .D*0=.T.A Joint $uidelines 4. PPPPP. 2002. Monitorin% For *e)atoto6icity Durin% Antituberculosis Treatment. A consensus statement o, t/e Tuberculosis .ontrol .oordinatin% .ommittee o, t/e *on% -on% De)artment o, *ealt/ and t/e Tuberculosis 0ubcommittee o, t/e .oordinatin% .ommittee in !nternal Medicine o, t/e *os)ital Aut/ority1 *on% -on% &. /tt):==+++.e6)at.or.id=medical=tuberculosis./tml: at January 3012014

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