Case of the day

Brochiectasis or Koch's

35/m having mild blood with morning sputum during cough reflex, he had completed Koch's treatment before 4 months nd completely cured, afb -neg, esr 30. But today cbc normal, esr 115, sputum send, no fever, no any other complain, only blood with sputum in morning. In Starting of Koch's Rx AKT4 +levo+ streptomycin750 IM, Fir 3 months, AfB neg, Then 2 course of AKT3 Fir 5 months And he already taken previous Koch's in 2005, Then 2time above mention, plz suggest now for blood with sputum Hrct below CT shows no lymphadenopathy, only bronchiactasis changes, then How it could be MDR Koch's Plz elaborate

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This is a very interesting case This case throws open difficulties in treatment of tuberculosis This patient has taken antitubercular treatment in 2005, after that there was recurrent tuberculosis about 1 year back At this point of time comes most important decision. We must send Sputum for culture and sensitivity. It is very very important at this point of time to get culture of tuberculosis and test it for sensitivity pattern. Because recurrent tuberculosis is always likely to have drug resistant tuberculosis Now consider that we are treating this case blindly and this case of actually resistant to isoniazid and Rifampicin, then in this hypothetical scenario what happens? In continuation phase for 5 months we are giving isoniazid, Rifampicin and ethambutol. But this hypothetical scenario, organism is resistant to isoniazid and Rifampicin. Therefore we are giving only one effective medicine that is ethambutol. Effectively this patient is receiving single drug therapy of ethambutol because other two drug are not working. Very soon the organism becomes resistant to ethambutol as well. Now the organism has become resistant to three drugs isoniazid Rifampicin and ethambutol. This we contribute to increasing resistance of tuberculosis It is very best important to get tuberculosis culture and sensitivity. Some time I have sent three samples for tuberculosis culture in order to get culture positive result Now coming back to this case HRCT chest IS showing multiple cavitatory lesion, with parenchymal nodule it is highly suggestive of tuberculosis upper lobe cavitary disease is commonly seen in immunocompetent adults, while lower lung zone disease, adenopathy, and pleural effusions are commonly found in immunocompromised patients In this case there is lower lobe affection, which may indicate immunocompromised status, if immunocompromised status exist then there is no defence against organism. That may explain no lymphadenopathy In very rare circumstances atypical mycobacterium tuberculosis can give rise to cavitatory lesion with no lymphadenopathy Adv Sputum for Gene Xpert, TB culture Repeat TB culture on multiple occasions, if required bronchoscopy lavage and culture can be sent, because it is very very important Check for immunocompromised status, viral marker, diabetes Treatment based on reports only

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It can be MDR tuberculosis which is resistant to Rifampicin and INH OR It could be XDR tuberculosis which is resistant to even category 2 Anti - tubercular drugs . But to duagnose MDR- TB - GenXpert MDR/ RIF molecular assay is important. In this case - parenchymal nodule with cavitation in superior segment of right upper lobe goes in favour of active tuberculosis. But till the test for MDR / XDR tuberculosis is not done label it as BRONCHIECTASIS WITH SECONDARY SUPPURATION as the cause of hemoptysis which can be due to erosion of a vessel. So - initial treatment is Inj Piperacillon 4 gm + tazobactum 500 mg × 6 hourly for 1 week . We have seen - post tubercular trested patient with secondary btonchiectasis and hemoptysis

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Post tubercular bronchiectasis Go for AFB c/ S Regular monitoring and constant evaluation required. Continue same treatment. Give BS antibiotics iv bd slowly for 5days. Good nutritious balanced diet. Ask pt to avoid the food precipitated morning blood.

Thanks Dr Sandeep Ghodekar
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Post tubercular bronchiectasis. Possibly the site of hemoptysis is bronchiectatic segment. If sputum production is there , go for sputum -AFB culture and sensitivity test. Continue same treatment at present.

Valuable opinion
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May be MDR tuberculosis or bronchitectis

Congratulations! Your case has been selected as Case of the day and you have been awarded 5 points for sharing the case. Keep posting your interesting cases, Happy Curofying!

Bronchiectasis can occur due to any infection including TB. And CT can't diagnose whether it's a MDR TB case or not. Kindly send the sputum or other samples for CBNAAT.

Hrct cavitory lesion with hemoptysis with esr high do cbnat looks MDR TB streptomycin now out dated

Look to me is post tubercular bronchiactesis Or MDR TB Adv : CBNAAT and KPA

Agreed with Dr.Jayesh K

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