case mdr tb journal nejm
TRANSCRIPT
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Case 18-2009: A 24-Year-Old Woman
with AIDS and T!er"losis with
#ro$ressi%e Co$h& D's(nea& andWastin$
Oleh:
)I*A +A)DI,I
0010101000.
#em!im!in$:
dr. T . Zulfikar, Sp.P
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#resentation o/ Case
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Dr. Anne Griffin edi"ine and #ediatri"s: A 24-'ear-old woman with the a"3ired
immnode/i"ien"'
s'ndrome AIDS and (lmonar' t!er"losis was admitted to ahos(ital in Soth A/ri"a that is a//iliated with this hos(ital& !e"ase o/ (ro$ressi%e
"o$h& d's(nea& and wastin$
A dia$nosis o/ (lmonar' t!er"losis was made months earlier& when she
(resented at another /a"ilit' with a (rod"ti%e "o$h& and a s(tm s(e"imen was
(ositi%e /or a"id-/ast !a"illi on s(tm-smear mi"ros"o(' ,o "hest radio$ra(h was
o!tained She had no 5nown histor' o/ a"ti%e t!er"losis The (atient was enrolled
in a lo"al Dire"tl' O!ser%ed Treatment DOTS (ro$ram& and antim'"o!a"terialthera(' isonia6id& ri/am(in& etham!tol& and ('ra6inamide /or 2 months& /ollowed
!' isonia6id and ri/am(in /or 4 months was administered a""ordin$ to the Soth
A/ri"an ,ational T!er"losis Control #ro$ramme $idelines The ne7t month&
a test /or hman immnode/i"ien"' %irs I in/e"tion was (ositi%e the CD4;
T-l'm(ho"'te "ont was 102 "ells (er "!i" millimeter
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A/ter < months o/ thera('& the (rod"ti%e "o$h (ersisted and
stained s(e"imens o/ s(tm remained (ositi%e /or a"id-/ast
!a"illi Isonia6id and ri/am(in were "ontined A((ro7imatel' <
wee5s !e/ore admission& the (atient=s "o$h worsened andd's(nea de%elo(ed and worsened& with /e%ers& ni$ht sweats&
and wei$ht loss She !e"ame (ro$ressi%el' de!ilitated and was
admitted to the hos(ital
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2 Di//erentialDia$nosis
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Dr. Subba Digumarthy: There are mlti(le "a%ities and air-s(a"e
o(a"ities in the le/t ln$ in%ol%in$ the ((er lo!e >i$ 1& the lin$la& and
the lower lo!e There is loss o/ %olme in the le/t ln$& with a sli$ht shi/t o/the mediastinm to the le/t The le/t heart !order and the mediastinm
are (artiall' o!s"red !' the o(a"ities in the le/t ln$ There is also /o"al
"onsolidation in the ri$ht ((er lo!e ad?a"ent to the minor /issre There
is (leral thi"5enin$ or a small (leral e//sion on the le/t side
lti/o"al as'mmetri" in%ol%ement o/ the ln$s
This (atient& who was in/e"ted with !oth I and t!er"losis&
was re/erred to or hos(ital !e"ase o/ e%iden"e o/
(ro$ressi%e t!er"losis& des(ite a((ro(riate treatment
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Kategori Sistolik
(mmHg)
Diastolik
(mmHg)Normal < 120 < 80
Pre Hipertensi 120 – 139 80 – 89
Hipertensi
Derajat I140 – 159 90 – 99
Hipertensi
Derajat II≥ 160 ≥ 100
FIGURE transFigure
1. Radiograph of the Chest.There are mlti(le "a%ities and air-s(a"e o(a"ities in the le/t ln$in%ol%in$ the ((er lo!e& the lin$la&and the lower lo!e There is loss o/%olme in the le/t ln$& with a sli$ht
shi/t o/ the mediastinm to the le/tThe le/t heart !order and themediastinm are (artiall' o!s"red!' o(a"ities in the le/t ln$ There is(leralthi"5enin$ or a small (lerale//sion on the le/t side There is /o"al
"onsolidation in the ri$ht ((er lo!ead?a"ent to the minor /issre
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Kategori Sistolik
(mmHg)
Diastolik
(mmHg)Normal < 120 < 80
Pre Hipertensi 120 – 139 80 – 89
Hipertensi
Derajat I140 – 159 90 – 99
Hipertensi
Derajat II≥ 160 ≥ 100
Dr. Wilson: I am aware o/ the dia$nosis in this
"ase& whi"h illstrates man' o/ the dia$nosti" and
thera(eti" "hallen$es en"ontered in resor"elimitedsettin$s in sothern A/ri"a This 'on$
woman with I in/e"tion was in a DOTS (ro$ram
that shold ha%e ensred adheren"e to /irstline
thera(' /or t!er"losis& !t she had s(tm
smears that were (ersistentl' (ositi%e /or a"id-/ast!a"illi there is a (a"it' o/ other la!orator' in/ormation&
s"h as "ltre reslts and dr$-sensiti%it'
testin$ Common "ases o/ s(tm smears that
are (ersistentl' (ositi%e /or a"id-/ast !a"illi in Iin/e"ted
adlts are shown in Ta!le 2& and "aseso/ nonres(onse to antit!er"losis thera(' are
shown in Ta!le .
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A re%iew o/ this (atient=s !lood-test reslts shows
se%eral a!normalities er normo"'ti" anemia is
most li5el' anemia o/ "hroni" disease& de to !oth
ntreated I in/e"tion and t!er"losis& and
wold !e e7(e"ted to im(ro%e with e//e"ti%e treatment
o/ the nderl'in$ "ase )otine iron s((lementation
/or anemi" (atients with t!er"losis
is not re"ommended1 ild-to-moderate
throm!o"'to(enia is /re3entl' o!ser%ed in (atients
with ad%an"ed I in/e"tion it is sall'
attri!ted to marrow s((ression !' I !t ma'!e de to atoimmne throm!o"'to(enia sall'
seen earl' in the "orse o/ the disease or to
(latelet "onsm(tion in a (atient with "oa$lo(ath'
Throm!o"'to(enia "an also !e "ased !'
ri/am(in
A!or"al laorator#$test results
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Su""ar#
In this (atient with e7tensi%e ln$ disease& (ositi%e
s(tm smears& and "lini"al deterioration&
(ro$ressi%e t!er"losis was the most li5el' dia$nosiser la"5 o/ a res(onse to /irst-line antit!er"losis
thera(' "old ha%e !een de to an'
o/ se%eral /a"tors Ta!le .& !t the (redominant
"on"ern shold !e a!ot either mltidr$-resistant
or e7tensi%el' dr$-resistant t!er"losis '"o!a"terial
"ltre and testin$ /or dr$ sensiti%it'with the se o/ "on%entional methods "an ta5e
months )es(ondin$ to the (ossi!ilit' o/ mltidr$-
resistant t!er"losis in this seriosl' ill (atient
is di//i"lt and "ontro%ersial
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Clini"al Dia$nosis
#lmonar' in/e"tion with dr$-resistant M. tuberculosis&
either mltidr$ resistant or e7tensi%el' dr$
resistant& in a (atient with I in/e"tion
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#atholo$i"al Dis"ssion
Dr. Wilson: Three months a/ter the (atient=s death&
a s(tm "ltre that had !een o!tained drin$
her hos(itali6ation was re(orted to show M. tuberculosis
that was resistant to isonia6id& ri/am(in&
etham!tol& stre(tom'"in& 5anam'"in& and "i(ro/lo7a"in
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T%A&'S