CASE PRESENTATION

OF

ON

TB

ANKLE JOINT

By R.S.Pavani

SYMPTOMS Inflammation & Swelling of joints Fever and weight loss Difficulty walking and muscle spasms Pain starts in certain spots like spine, hip, and knee Bones become weak leading to fractures and deformites

COMPLICATIONS

Bones. Spinal pain and joint destruction may result from TB that infects your bones. In many cases, the ribs are affected. Brain. Tuberculosis in your brain can cause meningitis, a sometimes fatal swelling of the membranes that cover your brain and spinal cord. Liver or kidneys. Your liver and kidneys help filter waste and impurities from your bloodstream. These functions become impaired if the liver or kidneys are affected by tuberculosis. Heart. Tuberculosis can infect the tissues that surround your heart, causing inflammation and fluid collections that may interfere with your heart's ability to pump effectively. This condition, called cardiac tamponade, can be fatal.

RISK FACTORS

PATIENT DETAILS
Age Gender Weight Unit 45 yrs Female 35 kgs Ortho-III

REASON FOR ADMISSION

c/o pain and swelling in left ankle of left dorsum of foot from past 6 months which increased in intensity past 10 days C/0 Pain increased on walking & decreased on rest

PAST MEDICAL HX :
She got admitted in a private hospital , diagnosed as synovitis of left ankle and joint debridement Synovial biopsy was done. Biopsy showed possibility of TB for which she was started on AntiTB drugs from past 1 1/2 month which she stopped taking from 2 weeks

PROVISIONAL DIAGNOSIS
? TUBERCULOSIS OF ANKLE JOINT

DAY1 (25/7/13)
BP:130/80mmHg Pulse:80bpm

Patient has no fresh complaints General condition fair and vital stable ADV: Hb , TC , DLC, ESR, RBS , Uric acid , CRP,RA Test , Synovial Biopsy.
Drug T. Aceclofenac T. Ranitidine Inj.Diclofenac Dose 100mg 150mg 50mg Route Po Po iv frequency 1-0-1 1-0-1 Sos

LAB DATA
Hb :11.7g/dl TC :9,000cells/cumm DLC:N:54% E:06% B:00% L:40% M:00% ESR:70mm/hr PCV:35.7%

RBS:96mg/dl Uric acid: 5.0 mg/dl CRP: 0.00 mg/dl RA test: negative

DAY 2 (26/7/13)
BP:120/80mmHg Pulse:80bpm Patient has no fresh complaints General condition fair and vital stable Adv: Treatment as per chart. T. AKT4 from today Chest X-Ray Pulmonologist opinion

DAY 3(27/7/13)
BP:120/80mmHg Pulse:90bpm

Patient c/o chills and rigors and gastric irritation after taking AKT4.

ADV: syp.aluminium hydroxide 1tsp 1-0-1 Stopped AKT4 drugs Pulmonologist reference

DAY4 (28/7/13)
BP:110/60mmHg No fresh complaints Toe movements present Distal pulses- present ADV: CST Patient will be shifted to pulmonology Pulse:90bpm

DAY 5,6 (29,30/7/13)

O/E: Patient has no fresh complaints General condition fair, vitals stable Adv: CST

DAY 7 (31/8/13)
BP:110/90mmHg O/E: vitals stable stopped AKT4 since 3 days Adv : CST Pulse:80bpm

DAY 8 (1/8/13)
BP:120/70mmHg o/e: Patient General condition fair Vitals stable stopped AKT4 since 4 days

Pulse:80bpm

Adv : CST

DAY 9,10 (2 & 3/8/13)

Pulse:80bpm

Adv : CST

TREATMENT CHART
Drug T. Aceclofenac T. Ranitidine Inj.Diclofenac Tab.INH+RFM+PYR +ETH Dose 100mg 150mg 50mg 300+450 +750+80 0mg Route frequency Po Po Po Po 1-0-1 1-0-1 Sos 1-0-0 Day of Start D1 D1 D1 D2 Day of Stop Cont Cont Cont D3

RECHALLENGE THERAPHY
DRUG DOSE frequency day 11 (4/8/13) Day 12 (5/8/13) Day 13 (6/8/13) Day 14 (7/8/13)

T.Ethambutol

800mg

1-0-0

-0-0 -0-0 1-0-0

T.Pyrazinamide

750mg

1-0-0

-0-0 -0-0 1-0-0

+ -0-0 -0-0 1-0-0

T.Isoniazid T.levofloxicin

300mg

1-0-0

_ -0-0 -0-0 1-0-0

500mg

1-0-0

T.Rabeprazole T.silybin phospholipid

20mg 1-0-0) 120mg

1-0-0 0-1-0

+ +

+ +

+ + +

PHARMACEUTICAL CARE PLAN

SUBJECTIVE Swelling of joints Pain in the joints

OBJECTIVE Synovial biopsy X-ray

FINAL DIAGNOSIS
Based subjective and objective evidence of patient she was diagnosed as tuberculosis of ankle joint

GOALS OF TREATMENT
To reduce the signs and symptoms. To prevent further progression of the disease To reduce the complications of the disease To improve the health related quality of life

TREATMENT OPTIONS

Anti TB drugs Isoniazid Rifampicin Pyrazinamide Ethambutal Non pharmacological treatment Orthosis Below knee plaster cast

GOALS ACHIEVED

Nil

MONITORING PARAMETERS

Disease specific Chest x-ray Total blood count PLT ESR synovial biopsy AFB culture sensitivity

Drug specific Potts-cozart test Opthalmic examination Liver function tests

PROBLEMS IDENTIFIED

ADR-Drug induced chills & rigors and gastric irritation. Pyridoxine was not prescribed.

PATIENT COUNSELLING

About the disease: Tuberculosis (TB) is an infectious disease that is caused by a bacteria. It spreads from person to person through airborne particles. Symptoms include unexplained weightloss , tiredness, fatigue, shortness of breath, fever, night sweats , chills, and a loss of appetite. Symptoms specific to the lungs include coughing that lasts for 3 or more weeks, coughing up blood, chest pain, and pain with breathing or coughing

ABOUT THE MEDICATION

Isoniazid : Advice the patient about the signs/symptoms of hepatotoxicity. If taking antacids, patient should take antacid at least 1h before oral INH. Patient should take medication on empty stomach 1h before or 2h after food. Patient should report sign/symptoms of peripheral neuropathy and thrombocytopenia.

RIFAMPICIN

It decreases the effectiveness of oral contraceptives. Drug causes red-orange discolouration of urine, feces, saliva ,sweat& tears. It causes flu-like symptoms. Advice patient to take this drug 1h before & 1h after a meal with a full glass of water.

PYRAZINAMIDE
This drug may cause nausea,vomiting. Advice the patient to report signs/symptoms of hepatotoxicity. ETHAMBUTOL Instruct the patient to promptly report any visual changes.

LIFESTYLE MODIFICATIONS

Dietary Tips for Tuberculosis Patients Eat a variety of fruit and vegetables each day. (dark green, orange, legumes, starchy vegetables) several times a week. Drink pasteurized milk and warm water. Bake, broil, or grill food should be consumed. Eat a variety of protein rich foods, with more fish, beans, peas, nuts and Choose low-sodium foods, and do not add salt when cooking.

LIFESTYLE MODIFICATIONS

Hand hygiene :

Cleaning hands with soap and water or an alcohol-based hand rub to prevent transmission of germs to others.

Personal protective equipment :

Use a mouthpiece, resuscitation bag, or other ventilation devices to prevent contact with mouth and oral secretions.

Respiratory hygiene :

Cover mouth/nose when coughing/sneezing. Use tissues and promptly dispose of them in trash. Perform hand hygiene after soiling hands with respiratory secretions.

Environmental cleaning :

Develop procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient/resident-care areas.

DOTS

TB DOT providers should document reasons for both refusal of DOT and discontinuation of DOT by TB clients who are or have been offered this treatment option. It ensures that the patient completes an adequate regimen. It lets the health care worker monitor the patient regularly for side effects and response to therapy. By ensuring that patient takes every dose of medicine, it helps the patient become non-infectious sooner and adherent to medication. Health-care providers of TB services will take the time to explain to patients, in simple language . DOT should take place anywhere the patient and health care worker agree upon provided the location is convenient and safe for both parties

BCG VACCINATION

The live attenuated strain of Mycobacterium bovis known as bacillus Calmette-Gurin (BCG) uses shared antigens to stimulate the development of cross-immunity to Mycobacterium tuberculosis. 1mL percutaneous.

 VACCINE

ADMINISTRATION

The single dose of BCG vaccine is administered intradermally, into the lateral aspect of the abducted left upper arm. Patients should be advised not to cover the site with tight clothing or sealed dressings. The BCG can be given simultaneously with other live vaccines but, if not given at the same time, further immunisations should be delayed for at least 4 weeks. No other immunisations should be given in the same arm for 3 months because of the risk of lymphadenitis..

CONTRA-INDICATIONS
A past history of TB. A positive pre-immunisation tuberculin test. A previous anaphylactic reaction to vaccine component. Compromised immunity due to treatment or disease. Generalised septic skin conditions. Acute illnesses with fever or systemic upset.

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