31- Tuberculosis (versus MAC)
The typical symptoms of TB are low grade fever (38°-39°) once a day (often night time, with night sweats) + cough + loss of weight + the characteristic "TB color" (a tinge of dull gray?) + light green sticky sputum (more common than the classic "rust-colored" (scx007) or blood stained (scx006) sputum. In patients whose TB disease is not too advanced, the sputum does not mix well with saliva (like oil with water) (scx001) (scx002), (scx003) unlike banal bacterial sputum (scx004). TB can involve brain (See "19-§1-Symmetrical Neuro"), or abdomen (abdominal pain, diarrhea, abdominal lymph nodes...), or skin (ptx063), or lymph nodes ("cold abscesses") (pxx221) (pxx222)...
When you cannot diagnose a patient and cannot find any drugs active in reducing the symptoms of chronic disease, think about TB. TB can give many kinds of symptoms! TB treatment is the main cause of "miraculous recovery" of dying patients in our ward!
You can do a "TB test" with anti-TB drugs. Give treatment (see below) for at least 15 days before deciding if it is useful to continue or not. Often we see some effect after only 4-5 days, especially from the curve of the daily temperature chart. But if a patient gets worse after a few days, stop the drugs even if you still believe he/she possibly has TB. The patient's condition may be already too serious to start a TB treatment (see §3)
Persons with HIV infection are at an increased risk of tuberculosis resulting either from newly acquired disease or from reactivation of latent infections
Persons with HIV infection and cd4<50 are at an increased risk of 'MAC' (Mycobacterium Avium Complex) which give same clinic than tuberculosis (often like "abdominal TB") but not responding to classical TB drugs. In our hospice we consider MAC diagnosis for patient not responding to classic treatments including CAT2 treatment)... Treatment is too expensive and we do not treat except if patient is candidate for ARV treatment...
Drugs available & doses (Thailand's protocols):
Combi-drugs sometimes available in our ward:
How to choose the drug regimen:
1. IF you have a well-organized ward AND a good follow-up system for patients (i.e.: you know whether the patients take drugs or not) AND sputum examination (AFB) available:
2. IF the ward organization AND/OR the follow-up of patients is not good (cannot be sure that patients receive AND take all drugs) AND/OR sputum examination (AFB) is not available:
3. IF patient is untrustworthy/untruthful (non-compliance):
4. IF no treatments have been effective AND it is not possible to refer to larger hospital:
5. If patient is close to death AND/OR has serious cachexis (if only temporarily unable to take drugs see 1.)
Adjuvant treatment with corticosteroids in treating tuberculosis is controversial.
The administration of corticosteroids should be considered as a last challenge when patient seems to be suffering more from TB drugs than from TB...
Corticosteroids should be given only when accompanied by appropriate antituberculosis therapy and need experience of therapist...
A good TB flowchart form for use in the case history of patients allows close
Monitoring of treatment, which is crucial for a successful result:
To see an example of Category 1 form CLICK HERE
To see how to fill in the Category 1 form CLICK HERE
To download the 3 forms (wmf format) CLICK HERE
To download the 3 forms (cdr format) CLICK HERE
("cdr" and "wmf" format can be resized without loss of quality.)
(The 3 forms are adapted for photocopy in black and white)
Important notes for our edification... (Extract of the "Harrison's 15th Edition")
- Acquired drug resistance develops during treatment for drug-sensitive tuberculosis with regimens that are poorly conceived or poorly complied with, allowing the emergence of naturally occurring drug-resistant mutations.
- Resistant organisms from affected patients may subsequently infect other people who have not been infected with M. tuberculosis previously, resulting in primary drug resistance
- Resistance to antituberculosis agents can develop not only in the strain that caused the initial disease, but also as a result of reinfection with a new strain of M. tuberculosis that is drug-resistant
- Reinfection with a new multidrug-resistant M. tuberculosis strain can occur during therapy for the original infection or after completion of therapy.
- Multidrug-resistant tuberculosis also has been transmitted to persons without HIV infection in health care facilities
- Several studies have documented a high prevalence of extrapulmonary disease in HIV-infected patients with clinical tuberculosis disease, particularly in conjunction with pulmonary manifestations
- Preliminary data suggest that patients coinfected with human immunodeficiency virus (HIV) and mycobacteria (Mycobacterium tuberculosis or M. avium) have altered pharmacokinetic profiles for antimycobacterial drugs. In particular, malabsorption of these agents appears to occur frequently, and could seriously affect the efficacy of treatment.
We must consider first:
1. TB contagion does not concern the "TB negative" dying patients of the ward. They will not have time to have TB symptoms.
2. The danger of TB contagion concerns workers, and in that way TB resistance concerns the whole population!
3. TB drugs can sometimes make patient's lives very uncomfortable or even cause suffering worse than the TB itself. (Sometimes stopping TB drugs may give a patient a few extra months of more comfortable life)
4. TB can be a difficult diagnosis even with lab or X-ray… and without… our experience teaches us it is better to assume that all patients are TB positive.
5. In a hospice for dying HIV patients, drug resistance can result because patient do not take drugs regularly but also because of malabsorption of drugs due to "tired gut".
6. TB patients without drugs or with inactive drugs often have a typical temperature curve that experience will help you to recognize.
Given the above, we should work according to the following policy (some points are unfortunately rarely possible):
1.We must organize an efficient way to know if patients are taking the drugs(See 11-Drug Distribution) and organize an efficient temperature follow-up with one T°curve for each patient!
2.The only patients who are not dangerous are the TB positive patients who are still strong (intestine still able to absorb drugs) and who are regularly taking treatment… and for whom the drugs clearly have a positive effect.
3.It is better to stop TB drugs for patients who cannot adhere to the prescribed drug regimen.
5.Workers must always use a mask except when they are in an isolation room for TB positive patients who regularly take TB treatment.
6.Workers must have frequent TB checks in a hospital.
7.It is nonsense to try a protocol for "resistant TB" if a patient's condition is already very serious and/or if the patient did not take drugs regularly in the past.