Summary 7

Mr. KMS, a 22 years old Chinese gentleman, fresh university graduate with no known medical illness, referred from Hospital Putra with prolonged productive cough with whitish sputum for 4 weeks and fever for 3 weeks. He also had weight loss of 8 kg in one month time and occasional night sweat.

Question: What is the clinical significance of night sweats?

On examination, he appeared lethargic and cachexic with temperature of 37.5oC. There was reduced chest expansion, presence of stony dullness on percussion, reduced breath sound and vocal resonance over the left lower zone of the lung upon examination of the respiratory system.

Question: What are the respiratory findings suggestive of?

Full blood count, renal profile, liver function test were normal. Mantoux test reading was 18 mm and quantiferon TB gold plus was positive.

Question: What does the Mantoux test measure? What does the Quantiferon test measure?

Chest X-ray showed left fibrotic lesion on upper zone and pleural effusion of the left lung. Pleural fluid was exudative with gram positive bacilli and TB DNA PCR of the pleural fluid was negative. Ultrasound of left hemithorax revealed left complex pleural effusion with multiple septations and CECT thorax revealed bilateral upper zone fibrotic changes. Sputum TB culture and sensitivity is still pending.

Question: What does an exudative pleural effusion due to gram positive bacilli suggest to you?

He was first treated as community-acquired pneumonia with left parapneumonic effusion. The diagnosis was changed to smear negative reactivation of pulmonary tuberculosis with left complex tuberculous pleural effusion after investigations. He was treated with akurit-4 3 tablets OD and tablet pyridoxine 10 mg OD.

Question: What are the doses of the four medicines (according to body weight) given for treatment of TB in adults?

He was admitted for 9 days and recovered well in the ward. He was discharged with a memo to Klinik Kesihatan to attend the chest clinic for directly observed therapy, family TB screening and repeat liver function test 2 weeks after discharged. He will come back to follow up in MOPD after 2 months to review his sputum TB culture and sensitivity and to repeat liver function test and renal profile.

Question: What parameters should be observed in this patient as pointers to successful treatment?

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