6. A patient with low grade fever, cough and weight loss.

Case history– A 28 year’s old male presents with low grade irregular fever, cough and significant weight loss for 2 months.

What is the diagnosis striking in your mind?

Pulmonary tuberculosis

What key questions would you ask?

• Pattern of fever- low grade irregular fever, evening rise of temperature with profuse night sweating.
• Cough- may be dry or productive with scanty sputum. Coughing up blood is a common problem.
• Weight loss- 10 % weight loss or more than 3 kg loss in 6 months or 0.5kg per month.
• Associated symptoms- chest pain, haemoptysis (coughing up blood) and anorexia.

What will you examine?

General examination- Patient is ill looking, emaciated. Temperature may be raised.

Chest examination- may be normal, crepitations which disappears/alters after coughing, even may appear after coughing (post-tussive crepitation).

Features of cavitation/fibrosis ^* may be present.

Features of pleural effusion^** may be present.

Investigations-

CBC with ESR- ESR is expected to be high

X-ray chest PA view- patchy opacities (typical), may be cavitation, consolidation and pleural effusion

Sputum for AFB

MT

Pleural fluid study.

Treatment-

  Treatment Phase:

1. Initial or Intensive Phase- 2 months
2. Continuation Phase- 4 months

  Composition of FDC Tablets:

• 4FDC : Isoniazid 75 mg + Rifampicin 150 mg + Pyrazinamide 400 mg + Ethambutol 275 mg
• 2FDC : Isoniazid 75 mg + Rifampicin 150 mg

 Dosages of FDC Tablets:

Category I:

• If smear positive tuberculosis, add levofloxacin 500 mg daily for 6 months if weight <50 kg and 750 mg daily if weight >50 kg.

*Features of fibrosis- flattened chest, diminished movement, trachea and apex shifted to same side, percussion note impaired, low-pitched bronchial breath sound and crepitation.

**Features of pleural effusion- diminished movement, trachea and apex shifted to opposite side, percussion note stony dull, and breath sound diminished or absent.