INFECTIOUS DISEASE

Case:
• Jose Rodriguez is a 35-year-old Hispanic man who presents to the Emergency Department at the
county hospital in Chicago, Illois, with 3-4 week history of productive cough, which originally
productive of yellow sputum but is now accompanied by the presence of blood in the sputum for
the past 3 days. Along with the cough, the patients also complains of subjective fevers, chills, night
sweats, dyspnea, pleuritic chest pain, fatigue, and unintentional 10-lb loss over the past several
weeks. The patient moved to the United States from Mexico 4 years ago and has not recently
travelled.
His mother has DM and HTN and his father died of MI 6 months ago. He has 10 pack-year history
of smoking but quit several weeks ago when the current illness started. The patient denies elicit drug
use, but does report drinking alcohol on weekends. Patient is a laborer and is currently working for
cash on a new home construction project in close contact with the workers. Several of his co-workers
have recently moved to United States from Mexico and have similar respiratory symptoms. The
patient does not have any medical insurance. Patient is married and live with his wife and young
child, who are not currently experiencing the same symptoms.
Working diagnosis
• Tuberculosis -> is a serious chronic pulmonary and systemic disease cause most
often by Mycobacterium tuberculosis. Oropharyngeal and Intestinal tuberculosis
contracted by drinking milk contaminated with Mycobacterium bovis is rare in
countries where milk is routinely pasteurized, but it is still seen in countries that have
tuberculous dairy cows and unpasteurized milk. Can be airborne too.
• Site: alveoli

Mycobacteria
- they are slender, aerobic rods that grow in straight or branching chains.
- have a unique waxy cell wall composed of unusual glycolipids and lipids including mycolic
acid, which makes them acid-fast, meaning they will retain stains even on treatment with
mixture of acid and alcohol
- they are weakly gram positive
Pathophysiology
• The outcome of infection in previously unexposed, immunocompetent
person depends on the development of anti-mycobacterial T-cell
mediated immunity.
• Early in infection, M. tuberculosis replicates essentially unchecked within macrophages while later
in infections, the cell response stimulates macrophages to contain the proliferation of the bacteria.
The steps in infection are the following:

TH1 mediated Granulomatous Immunological

Entry of the macrophage
macrophages and killing of Inflam and state in active
bacteria tissue damage tuberculosis

Role of
Host
Replication in TH1 other
macrophages susceptibility
Response immune
to the disease
cells
Etiology
-Tuberculosis infection is caused by tubercle bacilli, which belongs to Mycobacterium.

THREE RELATIVE ARE OBLIGATE PARASITES THAT CAN CAUSE TUBERCULOSIS

DISEASE:
 Mycobacterium tuberculosis
 Mycobacterium bovis
 Mycobacterium africanum

-Infection with tubercle bacilli occurs in the vast majority of the cases by the respiratory route.
-The lung lesion caused by infection commonly heal, leaving no residual changes except occasional pulmonary or
tracheobronchial lymph node calcification.
-Infants, adolescents, and immunosuppressed people are more susceptible to the more serious forms of tuberculosis
such as military or meningeal tuberculosis.
Etiology
Pulmonary Tuberculosis (respiratory) is more common than Extrapulmonary Tuberculosis (non-respiratory).

SITES OF EXTRAPULMONARY TUBERCULOSIS:

• Pleura
• Lymph nodes
• Pericardium > membrane enclosing the heart.
• Kidneys
• Meninges
• Bones and joints
• Larynx
• Skin
• Intestine
• Peritoneum > serous membrane which forms a lining of the abdominal cavity.
• Eyes
Progressive pulmonary tuberculosis arises from exogenous reinfection or endogenous reactivation of
latent focus remaining from the initial infection. If untreated, about 65% of patients will die in 5 years, the
majority of these within 2 years. Completion of the chemotherapy using drugs to which the tubercle bacilli are
sensitive almost always result in a cure, even with HIV infection.
Clinical manifestations
 COUGH (productive)
 WEIGHT LOSS/ANOREXIA
 FEVER
 NIGHT SWEAT
 HEMOPTYSIS – coughing of blood
 CHEST PAIN
 FATIGUE
 RALES – Bronchial breathing sounds.
DIAGNOSTIC PROCEDURE
• TB CULTURE TEST
• TB SKIN TEST
MENDEL-MANTOUX TEST – one of the major tuberculin skin test
• TB Interferon gamma release assays (IGRAs)
• SPUTUM SMEAR
• FLUORESCENT MICROSCOPY
• CHEST X-RAY
• SERROLOGICAL TEST
• CHEST PHOTOFLUOROGRAPHY
• MICROSCOPIC OBSERVATION DRUG SUSCEPTIBILITY TESTING
TREATMENT
OBJECTIVES:
• To cure people with tuberculosis
• To control tuberculosis, by either preventing the development of the
infection or reducing the period of infectivity of people with
infectious disease.
STANDARD TREATMENT
• For INITIAL treatment of Tuberculosis, start patients on a 4-drug
regimen;
• Isoniazid
• Rifampicin
• Pyrazinamide
• Ethambutol/streptomycin
Once the TB isolate is known to fully susceptible, ethambutol or streptomycin
can be discontinued.
ISONIAZID
• AKA isonicotinylhydrazide (INH)
• An antibiotic used for treatment of tuberculosis
• ACTIVE TUBERCULOSIS, often used with rifampicin,
pyrazinamide, and either streptomycin or ethambutol.
• LATENT TB, often used itself.
• Taken orally or IM.

• Common side effects:

Increase blood levels of liver enzyme
Numbness of both hands and feet
Liver inflammation
RIFAMPICIN
• AKA rifampin
• Treats several types of bacterial infection, including tuberculosis, M. avium
complex, leprosy and legionnaires’ disease.
• Almost used together with antibiotics except when given to prevent
Haemophilus influenza type b and meningococcal disease.
• Before treating the patient for a long time measurements of liver enzyme
and blood counts are recommended.

• Common side effects

 Nausea and vomiting
 Diarrhea
 Loss of appetite
PYRAZINAMIDE
• A medication used to treat TB but for active tuberculosis only.

• Common side effects:

Nausea
Loss of appetite
Muscle pain
Rash
Gout
Liver toxicity
Sensitivity to sunlight
ETHAMBUTOL
• Primarily used to treat tuberculosis
• It treats active TB with rifampicin, isoniazid ,and pyrazinamide.

• Common side effects:

Problems with vision
Joint pain
Nausea
HA
Feeling tired
Liver problems and allergic reactions
STREPTOMYCIN
• Used to treat number of bacterial
infection, such as
 Tuberculosis
 M. avium complex
• Common side effects:
 Enocarditis Vertigo
 Brucellosis Vomiting
 Burkholderia infection Numbness of the face
 Plague Fever
 Tularemia rash
 Rat bite fever
• Administered via IV or IM.
Case Proper
A. Patient’s Demographic Data
• Age: 35 years old
• Gender: Male
• Race: Latin-America (Hispanic)
B. History
• Medical History
• None

• Family History
• His mother has Diabetes mellitus and Hypertension
• His father died of Myocardial Infarction 6 months ago

• Social History
• He has a 10 pack-year of smoking but quit several weeks ago when the current illness started.
• The patient denies illicit drug use, but does report drinking alcohol on weekends.
Chief complain/ROS
• Productive cough with hemoptysis
• Shortness of breath that worsens with exertion
• Pleuritic chest pain
• Subjective fevers
• Chills,
• Night sweats
• Fatigue
• 10-lb weight loss over the past several weeks.
E. Physical Examination
• Gen: Somewhat thin-appearing Hispanic male in mild respiratory distress.
• Vital Signs:
• BP: 131/70
• Pulse rate: 94 bpm
• Respiratory rate: 24 bpm
• Temperature: 38.8°C
• Weight: 68kg
• Height: 5’9’’
• Skin: No lesions
• HEENT: Pupils Equal, Round, React to Light, Accommodation, Extraocular Movements Intact, No scleral icterus
• Neck: Supple
• Chest: Bronchial breath sounds in Right Upper Lobe
• Cardio Vascular: Slightly tachycardic, full Range of Motion
• Abdomen: Soft, Non-tender, Non-distented; (+) bowel sounds; no hepatosplenomegaly or tenderness
• Ext: No CCE, pulse 2+ throught; full Range of Motion
• Neurology: Aware&Oriented; CN II-XII; reflexes 2+. Sensory and motor levels intact
Diagnostic
Pulmonary Tuberculosis
Laboratory Examination
RESULT NORMAL VALUE
Na 143 mEq/L 135-145 mEq/L Normal
K 3.7 mEq/L 3.5-5.0 mEq/L Normal
Cl 106 mEq/L 96-106 mEq/L Normal
CO2 22 mEq/L 23-29 mEq/L Abnormal
BUN 21 mg/dL 7-20 mg/Dl Abnormal
SCr 0.9 mg/dL 0.9-1.3 mg/dL (male) Normal
Glu 101 mg/dL 72-99 mg/dL Abnormal
Hgb 11.6 g/dL 13.5-17.5 g/dL Abnormal
Hct 34.8% 38.8-50% Abnormal
RBC 3.8 x 103 /mm3 5 - 6 million cells/mcl Abnormal
Plt 269 x 10 3/mm3 150 x 103/𝑚𝑚3 - 450 x Normal
103 /𝑚𝑚3
WBC 11.3 x 103/mm3 4.5 x 103 /𝑚𝑚3 - 10 x Abnormal
103 /𝑚𝑚3
Alk phos 120 IU/L 44-147 IU/L Normal
ALT 45 IU/L 10-40 IU/L Abnormal
AST 34 IU/L 7-56 IU/L Normal
 Treatment
DRUGS Indication Dosage MOA Alternative
Rifampicin Tx for tuberculosis 600 mg Inhibits DNA- dependent RNA
polymerase activity by forming
a stable complex with the
enzyme
Isoniazid Tx for tuberculosis 300 mg Inhibits inhA, the enoyl
reductase from Mycobacterium
tuberculosis, by forming a
covalent adduct with the NAD
cofactor.
Pyrazinamide Tx for tuberculosis 2.0 g Pyrazinoic acid acid was
through to inhibit the enzyme
fatty acid synthase (FAS) I ,
which is required by the
bacterium to synthesise fatty
acids.
Ethambutol Tx for tuberculosis 15 mg/kg Inhibits arabinosyl Streptomycin
transferases which
is involved in cell
wall biosynthesis.
By inhibiting the
enzyme , the
bacterial cell wall
complex production
is inhibited. This
leads to an increase
in cell wall
permeability.
Therapeutic Monitoring
Sputum examination and culture or
Drug susceptibility testing
Chest X-ray
Pharmacy Interventions
Subjective

Patient complains of a productive cough with hemoptysis for the past

few days. He also complains of shortness of breath that worsens with
exertion, pleuritic chest pain , subjective fevers, chills, night sweats,
fatigue, and a 10-lb weight loss over the past several weeks.
Objective
Laboratory Examination
Vital Signs:
• Na 143 mEq/L
BP: 131/70 mmHg
• K 3.7 mEq/L
P: 94 bpm
• Cl 106 mEq/L
R: 24 bpm
̊̊̊̊̊̊̊̊̊̊ • CO2 22 mEq/L
T: 38.8 ̊̊̊̊̊C ̊̊̊̊̊̊̊̊̊̊
• BUN 21 mg/Dl
Wt: 68 kg
• SCr 0.9 mg/Dl
Ht: 5’9
• Glu 101 mg/dl
• Hgb 11.6 g/Dl
• Hct 34.8%
• RBC 3.8 x 103 /mm3
• Plt 269 x 10 3/mm3
• WBC 11.3 x 103/mm3
• Alk phos 120 IU/L
• ALT 45 IU/L
• AST 34 IU/L
Assesment
oDue to the symptoms
experienced by the patient, my
assessment, the findings are
consistent with tuberculosis
infection.
PLAN
Administration of Rifampicin,
Isoniazid, Pyrazinamide,
Etambutol/Streptomycin.
Avoid drinking alcohol.