Brief Answer: Possibilities of fever recurrence need evaluation Detailed Answer: Hi XXXXXXX Thanks for your query. It is common to have irregular fever while on anti-tuberculosis therapy. However, recurrence of fever indicates either, introduction of a bacteria while the fluid was tapped; or, drug-resistance (a common phenomenon in India). Cough is due to friction between inflamed walls of the fluid-filled cavity. Hence, the BEST course of action should be :- 1. Culture (of TB bacteria) and sensitivity test which will give information whether all anti-tubercular drugs- prescribed to your husband- are sensitive to the TB Bacteria. 2. An empirical course of a broad-spectrum antibiotics for the secondary bacterial infection of the fluid . 3. To keep in mind, a possibility of drug-induced fever. Consult your doctor and apprise him of my opinion. I am certain that he will agree with my opinion; order required tests, and- based on the reports- will arrive at a certain diagnosis and prescribe suitable treatment as advised. Hope I have addressed to your concerns to your complete satisfaction and you find my response helpful and informative. I will be happy to answer further queries, if any. Fond regards and have a nice day, Dr. Rakesh Karanwal

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Brief Answer: Continue with levoflox. Get test for malaria done Detailed Answer: Hi XXXXXXX Nice to hear back from you. I fully agree with your doctor's advice. Fever at this stage is not normal. As earlier mentioned, causes can be malaria, secondary bacterial infection, resistance to TB medicines. Firstly, other causes of fever need to be ruled out before attributing it to a drug. Further, it is indeed, too early to stop anti-tubercular medicine causing fever. Usually, Pyrazinamide causes fever. But it is one of the most effective drugs. Hence, should ideally not be stopped for at least 2 months of starting the treatment. (Pyrazinamide and Ethambutol are conventionally given only for 2 months, and stopped thereafter.) Continue with Levoflox for 1-2 weeks and see the response. MOST IMPORTANTLY, tuberculosis reduces the body immunity. Also, since Malaria is occurring at this time of the year, it needs to be ruled out (the presentation of fever is typical of malaria). Get malarial antibodies test done. If positive, an anti-malarial course will terminate the fever. If the fever doesn't come down even after 1 week of Levoflox and anti-malarial treatment, get a sensitivity test for all four TB drugs, to detect resistance (if any) to either of these drugs. Take care Dr. Rakesh Karanwal

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Brief Answer: Low probability of typhoid. Detailed Answer: Hi XXXXXXX Your husband has been having intermittent fever- lasting for just few hours at the same time of the day (noon)- since last about 10 days. The causes of this trend of fever, as already brought out earlier, are :- 1. Resistance to anti-Tubercular drugs 2. Drug-induced fever 3. Malaria Further, I have strong reasons to doubt the diagnosis of typhoid fever for the following reasons:- # Typhoid fever is PERSISTENT (that is, continuous, without touch normal). # Typhidot test is NEGATIVE (that is, no IgG or IgM antibodies to typhoid bacteria have been detected, EVEN after 10-days of SO-CALLED Typhoid Fever. # Widal's test is non-specific : false-positive test is seen in numerous other conditions, including malaria. # Widal's- test done after 10 days' of fever- TO titers of 1:80 is NOT diagnostic of typhoid. If I were your husband's treating Physician, my course of action would have been :- (a) First, get test for malarial antibodies done : give a course of anti-malarial treatment on the presumption of fever being due to malaria. (b) If fever does not subside on completion of anti-malarial course, send a sample of fluid from the pleural cavity, for culture and sensitivity test, to see for secondary bacterial infection and, for evidence of drug-resistance, if any. The report would have been available within a few days. (c) If the culture and sensitivity report showed resistance to one or more drugs, modified treatment for drug-resistant tuberculosis would be started. (d) But, if the tubercular bacilli are found to be sensitive to all four drugs (I presume that your husband has been prescribed Ethambutol, Isoniazid, Rifampicin and Pyrazinamide), I would have concluded it as Drug-induced fever. (e) In that case, Pyrazinamide would have been stopped, but other three drugs would have been continued for at least 3 months or more. (g) If some other bacteria are isolated, specific treatment for the same would be initiated. (h) Lastly, screening for HIV in a case of tuberculosis, is a Standard practice. I would have strongly advised HIV test, at the first instance. May I- at this juncture- hasten to add that no aspersion is being cast on your husband. I have merely stated the Standard Practice. As for your query regarding impact of TB and Typhoid together, there is no impact. Typhoid (if at all, it is typhoid) will get cured with a course of antibiotics, without affecting the efficacy of anti-tubercular drugs. I can fully understand your dilemma, receiving conflicting opinions from different doctors. However, the final decision is yours. Take care, Dr. (Col) Rakesh Karanwal

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Brief Answer: Give Empirical course of anti-malarial treatment Detailed Answer: Well XXXXXXX No comments on the Peripheral smear 'report'! Everyday, I get several patients in my Clinic, whose peripheral smear report says "malarial parasites not seen", but respond promptly to anti-malarial course. I suggest that you buy 12 Tabs of Falcigo : give 2 tablets twice a day on first day; thereafter, one tablet twice a day for next four days (a 5 day-course)(This is called Empirical therapy) If fever doesn't come down on completion of the course, proceed with Steps (b) to (h) as penned above. Do be in communication with me, if you wish to do so. I wish your husband a speedy recovery. Take care Dr. Rakesh Karaneal

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