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Suggest Treatment For MDR TB

Posted on Mon, 14 Apr 2014

Question: my wife suffering from mdr tb, sputum for afb was 1+ on 23/10/2013 and ATT was started. subsequent drug sensitivity showed resistance to rifampcin and INH. ATT satrted on MDR regimen wef 18/11/2013. kanamycin 2ml IM, COXERIN 250mg, ETHINOMIDE 250mg, LEVOFLOX 750mg, ecox 800mg. pyrazinamyde 1250 mg(which is stopped for three months because of recurrent vomitings after intake of PZA.) sputom for AFB was negative on date 23/01/2014, 26/01/2014/, 28/01/2014 and 11/03/2014... Bronchoscopy and XXXXXXX was done on 12/03/2014 for some tests mentioned below XXXXXXX AFB stain: result no AFB seen on ZN smear XXXXXXX Modifeid AFB stain: negative XXXXXXX fungal examination: no fungal element seen XXXXXXX fungus culture: no growth of fungi after one week incubation XXXXXXX hains 1st line: AFB stain -ve, identification MTC, resistance to antibiotics rifampcin and isonized. cytology report: amears show bronchial epithelial cells, macrographic and fair number of leucocytes, no maligent cells seen. XXXXXXX GRAM stain: ocasional gram negative bacilli seen pus cell 10-12/lpf epithelial cells 2-3/lpf. this is the status. pease tell me wheter she is recovering or not? and gram -ve bacilli is harful or treatable? and what to do for pyrezinamide tablet is there any substitute for this?

Answered by Dr. Arnab Maji (29 minutes later)

Brief Answer: Your wife is probably improving Detailed Answer: Hello, Being a chest specialist i see a lots of MDR TB (multi-drug resistant TB) patient daily and its quite usual to have that much of wordiness and I am trying to help you as mush as I can. You have told so many of times your wife's sputum for Acid-fast bacilli (AFB) were negative but never mention any mycobacterial culture of sputum done or not? Ideally we need to have sputum BACTEC culture on 3rd, 4th, 5th, 6th, 7th, 9th, 12th, 15th, 18th, 21st, 24th month of treatment to assess the viability of tubercular bacteria which can not be detected by sputum for AFB alone. With the report you have provided if your wife shows the signs of clinical improvement like weight gain, general well being, increased appetite along radiological improvement of shadowing then your wife is probably improving. But above all you need to have sputum mycobacterial BACTEC culture to prove it definitely. If your wife cannot tolerate pyrazinamide it can be replaced with PAS (para-amino salicylic acid). If you have further queries you can write back to me. Thank You. Regards, Dr Arnab Maji

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Arnab Maji (51 minutes later)

Thanks for your advise sir. I had a sputom culture test on third month whose 6th week report is pending rest two and 4 week report was negative. Her weight is constant from last 4 month to 41 kgs. Followed by sevare joint pain. Pyrazinemyde causing her 5 to 6 times vomiting a day. So is stopped for one more month. Is there some more test which may tell me more about her improvement.? Constant weight and lack of apetite is a sign of worry? Is sputom culture -ve means no bactera is present now? Also clearyfy about gram stain -ve bacteria. It is treatable , harmful? Also can PAS may cause same problem like pyrazinemyde. Also suitable dose and taking method of PAS.

Answered by Dr. Arnab Maji (1 hour later)

Brief Answer: Culture is best, PAS needs to be added Detailed Answer: Hello, Thanks again for your queries. There is no better test other than culture of sputum to tell you more about her improvement. Culture is negative means she is definitely improving but culture needs to be consistently positive throughout the course of treatment. Sputum culture negative means no live bacteria causing harm to her is present. It can differentiate between live and dead bacteria whcih sputum AFB cannot and that's why culture is more reliable than sputum. Constant weight is never a bad sign, weight gain is a good sign, weight loss is worst of lot. Lack of appetite may be due to excessive drugs, may not because of disease per se. So it has less reliability, though increased appetite is a good sign. Gram negative bacteria in sputum is not a matter to be worried for sure. PAS can be tolerated well by her even though intolerability to Pyrazinamide and guideline always demonstrates better result with PAS replacement rather than omitting a drug totally. If you have further queries you can write back to me. If you are happy with my response kindly write review for me. Thank you

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar