Are shortness of breath, bronchovascular lung markings and little pleural effusion indicative of latent TB Re-activation?
In last two years, her flares have become more frequent and severe. Therefore, her rheumatologist started her on biologics injection of Etanercept weekly. She was screened for Tuberculosis before starting her treatment. However, all her tests came normal. She completed a course of 12 injection recently.
After 10th injection, she started feeling shortness of breath. There was no other symtom. On our visit of Rheumatologist, when we told about her symtom, he ordered a chest X-Ray. There were prominent bronchovascular markings on her lungs and little pleural effusion found on her right lung. However, fluid was so little that it could not be extracted during ultrasound. There was no symptom of cough, fever etc.
Only the basis of X-Ray, her doctor diagnosed it as a case of latent TB Re-activation and started her on following TB Medication immediately:-
1. Cap R-cinex-600 – 1 daily (empty stomach) for 6 months.
2. Tab Benadon (40 mg) ½ daily after breakfast for 6 months.
3. Tab P-zide (750 mg) – 2 daily after lunch – 2 months.
4. Tab Mycobutol (1000 mg) after dinner – 2 months
Doctor ordered LFT test one week after taking the medicines and it all came out to be fine.
He also added following medications for Rheumatoid Arthritis:
1. Omnacortal – 2.5 mg daily and HCQS – 200mg
2. Calcirol XXXXXXX once a month
3. Crocin for pain - 650 mg SOS
After taking above medicines for 10-15 days, she suffered side effects such as nausea, weakness, gas, heartburn etc. , she felt extremely uncomfortable and also suffered a severe RA flare. Hence, her rheumatologist recently changed the medicines to following:-
1. Tab Isonex – 300 mg – 1 daily (empty stomach)
2. Tab Benadon (40 mg) - ½ daily after breakfast
3. Tab Zanocin (400 mg) – 1 daily (after breakfast)
4. Tab P-zide (750 mg) – 2 daily after lunch
5. Tab Mycobutol (1000 mg) after dinner
6. Injection Depomedrol- 80 mg for RA
In total, she has taken one month of tb treatment already. My query is as follows:-
1. Is it a right diagnosis of Tuberculosis in her case.
2. Is her treatment of Tuberculosis right? If not, what will you prescribe.
Please help and guide in her case.
Yes, diagnosis of tuberculosis is right.
Reactivation TB is very common in RA patients who are taking immunosuppressive drugs.
So there is a high possibility of tuberculosis in her case.
But I would further confirm TB by doing TB Gold test. If TB gold test was positive then TB is sure.
So please let me know if this test was done or not.
I also order repeat Liver function test to rule out AKT induced hepatitis.
Sometimes this complication can be seen after 3 weeks of treatment initiation.
So get done fresh LFT (liver function test).
Also start good antacid (pantoprazole or rabeprazole) and anti emetic (domperidone or levosulperide) combination on empty stomach twice daily.
This will help her in nausea, gas and heartburn.
Protein supplement (protein powder) along with antitubercular drugs is also recommended to improve a weakness.
I don't know why Rifampicin is stopped.
If fresh LFT is normal then Four drug AKT (rifampicin, isoniazid, pyrazinamide and ethambutol) should be started.
Hope I have answered your query. Let me know if I can assist you further.
Rifampicin was stopped after 15 days of starting the treatment because of extreme nausea, gas etc even though she was taking Pan -40 twice daily with it. Her symtoms improved after stopping Rifampicin.
LFT was done one week after starting the treatment which was normal. No fresh LFT has been done. Her doctor suggested that we get her CBC, SGPT, SGOT, ESR and CRP done one month after starting the treatment and we will be getting it done soon.
Should we start her Rifampicin. What is the right regimen for her. Please suggest.
What are the symptoms to watch out for in case of drug induced hepatitis.
Yes, rifampicin should be started if hepatitis is ruled out.
You should first get done those reports.
If LFT is normal then Rifampicin should be started.
Ideal regimen for TB is four drugs (rifampicin, isoniazid, pyrazinamide and ethambutol) for 2-3 months and three drugs (rifampicin, isoniazid and ethambutol) for the next 4-5 months.
And better to give a combination of pantoprazole and Levosulpiride or pantoprazole and domperidone instead of plain Pantoprazole.
This will help in nausea, vomiting and heartburn.
Symptoms like nausea, vomiting, right abdominal pain, Yellowish discolouration of urine and eyes etc are suggestive of hepatitis.
Hope I have answered your query.
Dr Kaushal Bhavsar, Pulmonologist
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