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Dr. Andrew Rynne

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Have cough and losing weight. CT showed granulomatous nodes in lungs. Miliary TB?

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Dr. Aparna Amritsagar

Internal Medicine Specialist

Practicing since :1997

Answered : 274 Questions

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Posted on Fri, 1 Mar 2013 in Medicines and Side Effects
Question: Dear Dr,
My wife is feeling very tiresome and fatigued since last 4 weeks with some wait loss of 4-5 kgs and she had cough 1 month back. She also had pain on her ankle since last 1 month. She has some lab tests done and findings were : 117 ESR readings and all other readings were normal including kidney function and liver function test. Doctor got the CT chest done and she got a clue of some granulomous nodes in lungs, spleen and lever with necrosis. She has started taking TB medicines from december 15th. but she is still complaining for pain in ankle joint and knee joint. She feel better in the morning with less pain in Ankle and knee, but as the day progresses she feel very triesome and fatigued. She also had night sweats couple times in last one month. Doctor's prescription is attached with this and we also have lot many blood report and CT Chest report. I would like to know if the doctor has prescribed her TB drugs, why is the pain in knee and is not going. is she suffering from Miliary TB ? if yes then what is the treatment ?
doctor
Answered by Dr. Aparna Amritsagar 9 hours later
Hello,
Thanks for writing your query to me.

The symptoms which you mentioned, high ESR of 117 & CT report showing granulomatous nodes confirms that your wife has tuberculosis. Anti tuberculosis medicine has to be taken for a longer duration of time about 6 – 8 months. Since the treatment is started on 15th December it will take time (15 days to 1month) to show any improvement in symptoms.

Your doctor has started all first line anti tuberculosis medicines. Have faith in your doctor. Kindly take the medicines as prescribed & do regular follow ups with your treating doctor.
When taking tuberculosis medications, it is important to be aware of a few basic cautions:
• Report any side effects to the doctor immediately.
• Tell your doctor about any other medications if your wife is taking.
• Medication must be taken for long enough to kill all of the tuberculosis bacteria – a minimum of six months.
• Medications should not be stopped, even when if your wife feels better. Irregular use can lead to the tuberculosis bacteria becoming resistant to the medications.

Knee pain & ankle pain , weakness, tiredness can all be related to tuberculosis. Avoid standing for long time. Take proper sleep & most importantly have a balanced nutritious diet.

Protein deficiency may have a particular detrimental effect on the ability of the body to fight tuberculosis. Multiple micronutrient deficiencies are also common during tuberculosis. Try to improve the diet . Try to always have proteins, such as meats, poultry, fish, eggs, nuts and beans with every meal , make sure your wife is getting enough protein. It is very important to maintain adequate nutrition status so that can help body fight off the infection.

Miliary tuberculosis is a form of tuberculous infection in the lung leading to erosion of the infection into a pulmonary vein. Once the bacteria reach the left side of the heart and enter the systemic circulation, the result may be to seed organs such as the liver and spleen with said infection. Treatment for Pulmonary as well as Miliary tuberculosis is same. Only based on the improvement of patients' symptoms the duration is either short for 6 months or can be long for 9 months. So don’t worry, if medicines are taken regularly with a balanced diet , tuberculosis is 100% curable.

I hope I have answered your query. In case you have any further questions I will be happy to help you.



Above answer was peer-reviewed by : Dr. Shanthi.E
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Follow up: Dr. Aparna Amritsagar 16 hours later
Hello Dr. XXXXXXX

thanks for your answer.

My doctor has not prescribes ISozianid to me, I saw that most people take 4 medicines in TB reatment including refampcin, ethambutol and pyriz...

How do we track after taking medicines that there is some improvement internally. Do we need to get ESR checked regularly ? If ESR goes down does that mean the improvement ? How long generally it takes to see the change in ESR after the medication starts ?

How did you confirm from the CT that it is TB ? I still want to be confirmed that it is TB ? Does sarcoidosis also have the same problems ?

Please answer my further queries stated above.
doctor
Answered by Dr. Aparna Amritsagar 7 hours later
Hello,
I can understand your concern. Let me clear all your doubts.

Your doctor has started 4 drugs anti tuberculosis drugs – Rcinex, combitol (ethambutol), pyrizina. Rcinex is a combination medicine that contains both Isoniazide + Rifampcin. R-Cinex (Isoniazid/Rifampin) is an antibiotic that acts by interfering with bacterial reproduction to prevent its growth and stop the spread of infection. This will allow the immune system to fight and destroy it naturally to cure your condition. As tuberculosis treatment is long-term & to maintain the compliance of the medicines there are various combination available in market which makes taking tablets easier.

ESR is increased in any infection/ inflammatory condition. It is not specific for tuberculosis. But yes as the infection is coming in control, ESR shows a declining trend indicating that the medicines are working & patients is getting better. How long will it take for ESR to decrease varies from patient to patient & also on patients immunity. Your wife will also need to do repeat ESR test regularly just to see if the infection is coming in control. In addition her symptoms will be monitored regularly to check for improvement. There is feeling of wellbeing in patient; fever subsides; tiredness and weakness subsides - in all there is improvement in patient’s condition.

Most patients with Sarcoidosis present with the classic combination of bilateral hilar lymphadenopathy, parenchymal disease of the lung, and eye or skin lesions; however, virtually any organ in the body may be involved. Bilateral hilar lymphadenopathy is the most common radiographic finding.

Sarcoidosis & TB are granulomatous disease. But there are certain differentiating factors.
1. In TB, disease is progressive; in sarcoidosis disease shows remission & exacerbation.
2. In TB, Lymph node show necrosis, caseation; in sarcoidosis, lymph nodes can be non necrotic.
3. Pericardial and pleural effusion is more common in TB, where as in Sarcoidosis pleural effusion is less common.
4. A sure diagnosis can only be made by doing a lymph node biopsy as your doctor has advised.

But as mentioned on your prescription note that you had opted for empirical therapy so doctor has started tuberculosis treatment based on CT scan & clinical findings. Your wife’s X-ray & CT scan show a necrotic granuloma, pericardial effusion & upper zone lesion which go in favour of Tuberculosis, however a lymph node biopsy would be helpful to confirm tuberculosis & exclude sarcoidosis.

I hope I have answered your query. In case you have any further question, I will be happy to help.
If you do not have any queries, please close this discussion.

Best Regards
Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Aparna Amritsagar 35 hours later
Dear Dr. XXXXXXX

thanks for your further response.

Today we got the ESR test repeated with Liver function test. Results show ESR reading as 55 which seems lesser then 103 which was 10 days back. before starting the TB medicines.

Liver function test were in normal range. What is your view on finding and the disease situation ?

Regards, XXXXXXX
doctor
Answered by Dr. Aparna Amritsagar 1 hour later
Hello,

Good to know that ESR has come down. That means your wife is responding to the antituberculosis treatment. Kindly continue it. Normal ESR is 1 -20mm/hour.
As I had mentioned before also, tuberculosis treatment is long standing. It is usually for duration of 6 - 9 months. So even though ESR has decreased that does not mean that disease is cured. But it is a positive sign that patient is responding.
Antituberculosis medicines have side effects. They can increase liver enzymes. Since Medicines are started since few days only, LFT is usually normal in early days for treatment. What is more important is that it should remain normal throughout the course of treatment. The dose of the medicine can be adjusted as per the LFT findings; so you need to regularly follow up with your doctor & do blood test as advised.

I hope I have answered your query. In case you have any further question I will be happy to help you.

Regards

Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Aparna Amritsagar 2 days later
Hi Dr. XXXXXXX

Greetings on Christmas.

All readings of LFT was normal but total bilirubin is .27 which is marginally lower then the normal rage of .30

It it ok ?

regards, XXXXXXX
doctor
Answered by Dr. Aparna Amritsagar 26 minutes later
Hello,
Thanks for your greetings.
Total bilirubin is ok. Low level are not of much concern. TB medicines tend to increase LFT which is not good, so don't worry. Do regular follow up with your doctor & continue taking medicines for full course. Tuberculosis is totally curable if you follow your doctor's advice.
Take care.
Above answer was peer-reviewed by : Dr. Aparna Kohli
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