Patient Presentation

 A previously healthy 33-year-old woman was admitted to the acute medical care

unit with a two day history of feeling lethargic and unwell.

History

 A 33-year-old woman developed severe continuous pain in the right upper limb

with no specific aggravating or relieving factors and associated with severe

weakness. On the morning of the day of admission she had noticed that her lips

and tongue were swollen, and she felt short of breath. She was given

intramuscular adrenaline by the ambulance staff for a threatened airway and was

transferred to the acute medical unit for further evaluation and management.

Past Medical History

 She was a non smoker and

Birth History

 The patient was delivered through normal vaginal delivery with no complications

Family History

 Parents and siblings had no history of tuberculosis

Social History
  The patient lives in a small, open house in Cabanatuan City. There are 3 adults

and 3 children, aged 5, 9, and 12. He is the only employed adult and supports the

household. Water and electricity are available in the home.

 No one in the household, other than him, have been diagnosed with tuberculosis

Vaccinations

 Patient had Bacillus Calmette-Guerin vaccination

Medication

 Patient was given medication regimen of 3 tablets of ethambutol a day during the

first stage of treatment of his previous tuberculosis diagnosis.

Allergies

 Patient is allergic to metal and noted that he avoids using accessories like watches

and belts.

Differential Diagnosis

 Pneumonia – infection in the air sacs of the lungs. (other symptoms include

fever, sputum production, chest pain and dyspnea)

 Bronchitis – infection in the bronchial tubes of the lungs (other symptoms

include fever, sputum production, chest pain and dyspnea)

 Bronchiectasis – condition where airways of the lungs are widened, leading to

build up of excess mucus which makes lungs more vulnerable to infections.

  Tuberculosis – contagious infection that attacks the lungs (other symptoms

include night sweats, weight loss, and fatigue)

 Pulmonary embolism – occur when an artery in the lungs gets blocked by a

blood clot. (other symptoms include chest pain, dyspnea, leg pain, leg swelling)

 Goodpasture Syndrome – serious autoimmune disease that attacks the lungs and

kidney. It occurs when body’s immune system produces antibodies against

collagen in lungs and kidney. (other symptoms include hematuria)

 Granulomatosis with polyngiitis – causes inflammation of blood vessels in our

nose, sinuses, throat, lungs, and kidneys. It causes slow blood flow and therefore,

develops inflammation in the organs affected called granuloma. (other symptoms

include bloody nasal discharge)

Vitals

 Heart Rate: 110 beats per minute

 Blood Pressure: 110/80 mmHg

 Respiratory Rate: 20 breaths per minute

 Temperature: 37.1°C

Anthropometry

 Height: 5 ft 7 in

 Weight: 48 kg

 Patient visibly looks thin and underweight

Examination

 General

o Adult male, looks visibly thin and underweight

 Skin, Hair, Nails

o No discolorations

o No lesions

o No edema

o Skin is smooth and even

o Skin is warm

o Skin has good turgor

o Terminal hair and velus hair are appropriately distributed

o No patches

o Nails have pink tones

o No clubbing

o Nails are hard and relatively immobile

o Good capillary refill

 HEENT

o No involuntary head movement

o No lesions (HEENT)

o Patient doesn’t suffer from limited movement of temporomandibular joint

o Neck is symmetric

o Trachea is midline
 o No bruits

o No tenderness

o No enlargement

o Normal vision

o Pupils are round and reactive to light and accommodation

o Eye movements are symmetric

o No swelling or Redness

 Respiratory

o Regular respiratory rate

 Cardiovascular

o Regular rate and rhythm

o No murmurs

 Chest

o Symmetric

o No tenderness

o No lesions

o Not in respiratory distress

 Abdomen

o No tenderness

o No organomegally

 Neurological

o No abnormalities
Investigation

 Patient’s blood laboratory results could not be retrieved due to confidentiality

however, he noted that there was no abnormal finding. All parameters are within

normal range

Figure 1. Chest X-ray of patient with pulmonary tuberculosis

 Chest X-ray results:

o Lungs: Reticular and hazy opacities are noted in the upper right lobe

o Mediastinum: Unremarkable and not displaced

o Heart: Not enlarged

 o Vessels: Within normal limits

o Aorta: Unremarkable

o Diaphragm: Intact

o Osseous structures: Unremarkable

o Soft Tissue: Unremarkable

o Impression: Pulmonary Tuberculosis in the Right Lung

 Xpert MTB/RIF Assay

Table 1. Result of the Xpert MTB/RIF Assay prior to diagnosis and treatment

Visual Appearance Mucopurulent

Reading Mycobacterium is detected, but low
Laboratory Diagnosis RIF resistance not detected

Final Diagnosis

 Pulmonary embolism, Good pasture syndrome, and Granulomatosis with

polyngiitis are ruled out because these diagnoses present physical manifestations

and other symptoms that were not observed in the physical examination.

 Chest x-ray showed reticular and hazy opacities in the upper right lobe of the

lungs. The x ray findings were further established by the Xpert MTB/RIF Assay

which tested positive for the presence of Mycobacterium tuberculosis with no

drug resistance. This led to the final diagnosis of pulmonary tuberculosis.

Discussion

What is Pulmonary Tuberculosis?

Pulmonary tuberculosis is a communicable disease, usually chronic but

occasionally acute, caused by Mycobacterium tuberculosis specifically, when the agent

primarily attacks the lungs.

Etiology of Mycobacterium tuberculosis

 Domain: Bacteria

 Phylum: Actinobacteria

 Class: Actinobacteria

 Order: Actinomycetales

 Family: Mycobacteriaceae

 Genus: Mycobacterium

 Species: M. tuberculosis

Mycobacterium tuberculosis is an aerobic, non-motile, non-spore-forming, and acid-

fast Gram-negative microorganism. It has a generation time of 15 - 20 hours which is

extremely slow.

Pathophysiology
 Mycobacterium tuberculosis is an aerobic Gram-negative bacterium. It makes its

way to the lungs and into the pulmonary alveoli. This site of the lungs provides optimal

growth for this bacterium because this is where multiple gas exchange processes takes

place. Hence, oxygen is rich in this site.

Mycobacterium tuberculosis enters alveolar macrophage via phagocytosis.

Encapsulated Mycobacterium are now called phagosomes. Lysosomes fuse with

phagosomes and form phago-lysosomes where degradation of Mycobacterium

tuberculosis occurs. Mycobacterium tuberculosis bypasses this process and inhibits

fusion with lysosome. Ultimately, Mycobacterium tuberculosis may now freely replicate

within alveolar cells which causes primary infection.

3 weeks after primary infection, cell mediated immunity surround the site of

infection with immune cells and forms granuloma. With the formation of granuloma,

there is necrosis of tissue in the site of infection which is called Ghon Focus. When

nearby lymph nodes are infected, it is called Ghon complex. Ranke Complex is when

there is fibrosis and calcification of Ghon complex. By this stage, there could be

elimination of the infection or the causative agent may be dormant which is called latent

tuberculosis.

Pathogenesis

Mycobacterium tuberculosis has multiple mechanisms of action that allow for their

replication and cause infection, they are as follows:

 Inhibition of Phagosome Maturation

 Under normal circumstances, V-ATPase pump proton into phagosome in order to

increase its acidity. Essentially inhibiting its maturation and denaturing it. However,

Mycobacterium tuberculosis produces Protein Tyrosine Phosphatase Protein which

binds onto subunits of V-ATPase. The PTP protein inhibits the acidification of

phagosome and prevents denaturation of phagosomes.

 Inhibition of Phago-Lysosome Formation

For the formation of phago-lysosome, phagosomes must exchange their RAB5

protein for RAB7 protein which marks them for fusion with lysosome. However,

Mycobacterium tuberculosis exchanges for RAB22a protein which inhibits its fusion

with lysosome.

 Inhibition of Interferon Production

Cyclic GMP-AMP Synthase (cGAS) detects foreign DNA and activates STING

pathway. The STING pathway ensures interferon production in macrophages.

However, Mycobacterium tuberculosis uses immune system cells for its processes

and therefore is not recognized as foreign DNA.

How can pulmonary tuberculosis be acquired?

Tuberculosis is an airborne disease. Therefore, a person may acquire tuberculosis

by breathing in exhaled air by an infected person. Mycobacterium tuberculosis can

survive in the air for hours. A person may acquire the disease or agent even if no infected

person is in the vicinity.

Symptoms of pulmonary tuberculosis

  Breathing difficulty  Fatigue

 Chest pain  Fever

 Cough (usually with mucus)  Weight loss

 Coughing up blood  Wheezing

 Excessive sweating

Laboratory aids to diagnosis

 Sputum Examination - finding the bacillus in sputum, so called positive sputum

definitely or strongly suggests tuberculosis

 X-ray - important in establishing diagnosis and determining severity of disease

 Tuberculin Skin Test - tests that show whether the patient was in contact with an

active case of tuberculosis

Other exams used to detect pulmonary tuberculosis

 CT scan - an imaging test to check lungs for signs of an infection

 Bronchoscopy - procedure that involves inserting a scope through your mouth or

nose to allow your doctor to see your lungs and airways

 Thoracentesis - procedure that removes fluid from the space between the outside

of your lungs and the wall of your chest

 Lung biopsy - procedure to remove a sample of lung tissue

New method for tuberculosis diagnosis

The Xpert MTB/RIF assay is a test that detects Mycobacterium tuberculosis

complex and its resistance to rifampin. The advantage it has over other tests is that it
takes less than 2 hours while conventional culturing of a sample can take 2 to 6 weeks

and 3 additional weeks to test for its resistance to drugs.

Medication(s)

These four medications are most commonly used for treatment:

 Ethambutol – bacteriostatic, inhibits cell wall synthesis

 Isoniazid – bactericidal, inhibits mycolic acid synthesis which are required of

mycobacterial cell wall

 Pyrazinamide – may be bacteriostatic or bactericidal depending on

concentration, diffuses pyrazinamidase which converts pyrazinamide into active

pyrazinoic acid which increases acidity within bacterial cell

 Rifampin – may be bacteriostatic or bactericidal depending on concentration,

inhibits DNA-dependent RNA synthesis by inhibiting bacterial DNA-dependent

RNA polymerase

There are two stages in tuberculosis treatment. In the first two months, several anti-

tuberculosis drugs are used in order to kill as much bacteria as possible. In the next four

months, some medicines are stopped and others, usually rifampicin and isoniazid, are

continued in order to kill any remaining bacteria. Ethambutol is used only in the first
stage of the treatment regimen. In some cases, Mycobacterium tuberculosis may develop

resistance to these medications

Medication for drug-resistant tuberculosis

The following are medications administered to drug-resistant TB:

 Antibiotics called fluoroquinolones

 An injectable antibiotic, such as amikacin, kanamycin, and capreomycin

Other drugs used for tuberculosis treatment

Aminoglycosides, specifically streptomycin, are used in tuberculosis treatment

because they have excellent activity against aerobic, gram negative bacteria. Once inside

bacterial cell, they bind to the 30S ribosomal sub unit which causes misreading of genetic

code. This leads to interruption of normal bacterial protein synthesis.

Treatment

 In the first stage of the treatment (first two months), the patient was given

medication of 3 tablets of ethambutol once a day and 1g of streptomycin every

day.

 After the first stage of treatment the patient was scheduled for another Xpert

MTB/RIF Assay test. The following are the results from the test:

Table 2. Result of the Xpert MTB/RIF Assay after the first stage of treatment

Visual Appearance Salivary

Reading 0
Laboratory Diagnosis Negative
  Patient has now been cleared with pulmonary tuberculosis but is still taking

medications under doctor’s supervision to ensure that all bacteria have been

killed.

 In the second stage of tuberculosis treatment, the patient was given medication of

4 tablets of rifampicin+isoniazid drug once a day.

Final Outcome

 The patient’s weight increased from 48 kg to 57 kg.

 Xpert MTB/RIF Assay test after the initial treatment show that previous

Mycobacterium tuberculosis complex are now killed or at little amount.

 Patient is now doing well and asymptomatic and continuing medication.

Management and Prevention

General Care of Patient

 Always have patient wear clean pajama, a change of linen, and bathe. Night

sweats are common in tuberculosis. If they do, they should bath or have alcohol

rub on site of sweating and have linen changed

 Proper oral and hair hygiene.

 Well-balanced diet is advised. Special diets are given to extremely ill patients.

 Room should be well ventilated.

 Patient should be informed should he/she have an operation

 Patient's family should be informed of patient's condition, visiting hours, and how

to avoid being infected

Nursing care in tuberculosis

 Isolation of Patient

o wash hands with soap before and after contact with patient especially,

before leaving hospital

o wear gloves, mask, and gown to avoid contact with contact with infected

patient and disease causing agent

o Patient's dishes, utensils, and linens should be sterilized and not be used

by anyone other than the patient

o After tests, cups containing sputum or any sample from the patient should

be wrapped several layers and incinerated

o Visitors should wear masks and be of safe far distance from the patient.

Physical contact, even the slightest, should be avoided.

o Room should be disinfected

 Key notes to remember when administering medication:

o Wear mask, gloves, and glasses

o Do not permit the streptomycin to come in contact with hands

o Rinse syringe and needle under running water immediately after use.

Washing should be done before removing gloves

o Do not touch your own skin when administering medication

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