Pulmonary Tuberculosis: A case study and clinical perspectives

Suganya1, Lucy Grace. T2, Jaya Menon3

1ICN Nurse, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

2Nurse Educator, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

3Nursing Superintendent, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

Introduction

Pulmonary tuberculosis (TB) a contagious bacterial lung infection caused by Mycobacterium tuberculosis, which spreads through the air if someone with active TB coughs, speaks or sings.

Most people recover from primary TB infection without further evidence of the disease. The infection may stay inactive (dormant) for years or for some people it becomes active again (reactivates).

Most people who develop symptoms of TB infection would have been infected in the past. In some cases, the disease becomes active within weeks after the primary infection.

Incidents

The incidence rate of TB in India shows a 17.7% decline from 237 per 100,000 population in 2015 to 195 per 100,000 population in 2023. TB deaths has reduced by 21.4% from 28 per lakh population in 2015 to 22 per lakh population in 2023.

The global incidence of pulmonary tuberculosis (PTB) was estimated as 133 cases per 100,000 populations in 2022 The prevalence was higher among males than females and more in rural areas compared to urban areas.

In India the standard treatment for drug-sensitive pulmonary tuberculosis involves a 6-month regimen of four drugs (Isoniazid, Rifampicin, Pyrazinamide and Ethambutol followed by a continuation phase with three drugs (Isoniazid, Rifampicin, and Ethambutol).

TB resistant to isoniazid can be treated with rifampin, pyrazinamide, and ethambutol for 6 months. Therapy should be extended 9 more months if the patient remains culture-positive after 2 months of treatment.

The first-line therapeutic drugs are the most effective and least toxic for use in the treatment of TB, while the second-line therapeutic drugs are less effective, more expensive and have higher toxicities. They are however, essential for the treatment of drug resistant forms of the bacteria (MDR-TB).

Case Presentation

A 65 years’ male was admitted with C/o cough for past 3 months, fever and shortness of breath for 4 days associated with loss of appetite and loss of weight. On examination, patient was hypoxic, hypotensive and had tachypnea (Temp: 101.6žF, PR: 102/min, BP: 100/60 mm Hg, Spo2: 90% on room air , 99% with 6 litres O2, CVS: S1 S2 (+), RS: BAE (+) / decreased air entry left side, P/A: Soft).

Patient had wheeze while on admission which was treated with bronchodilator and nebulization. Patient is a known case of type 2 Diabetes Mellitus, on irregular medication.

CT chest showed left loculated hydropneumothorax with left lung consolidation.

His Trop I was positive. Cardiologist opinion was obtained. Echo showed no regional wall motion bbnormality (RWMA,) hence trop I was repeated which showed decreasing trend and treated with statins.

Sputum for Acid fast Bacilli (AFB) / TB (polymerase chain reaction) PCR were positive. His albumin was less (2.8).

Lab Values

In view of hypoalbuminemia, Pyrazinamide was replaced with Levoflox and continued along with Rifampicin, INH & Ethambutol.

Patient had sudden shortness of breath. Repeat CT chest showed increased left hydropneumothorax.

Repeat CT Image

Pigtail was placed. Frank pus drained. Pus TB PCR was positive.

Enterococcus – Microscopy Image

Pus C/S showed MDR Enterococcus and treated with Vancomycin. Physician opinion was obtained for DM and treated with insulin. His ICD drain started decreasing, consistency changed to serous nature. ICD removed.

Nursing Actions

1. Assessment and Monitoring:

  • Monitored vital signs regularly, especially respiratory rate and oxygen saturation.
  • Assessed for symptoms like persistent cough, fever, night sweats, and weight loss.

2. Infection Control Measures:

  • The staff followed airborne precautions.
  • Ensured proper hand hygiene and use of personal protective equipment (PPE).
  • Educated the patient about cough etiquette and proper disposal of sputum.

3. Medication Management:

  • Administered anti-tubercular therapy (ATT) as prescribed.
  • Monitored for drug side effects.

4. Nutritional Support:

  • Provided high-protein, high-calorie diet to improve immunity.
  • Monitored weight and nutritional status regularly.
  • Encouraged adequate hydration to prevent dehydration.

5. Patient Education and Counselling:

  • Educated about treatment adherence to prevent drug resistance.
  • Advised on the importance of follow-up sputum tests for treatment response.
  • Provided emotional support as TB carries social stigma.

Discharge status

Patient improved well, Vitals were stable and discharged in stable condition.

Conclusion

Pulmonary tuberculosis a serious lung infection remains a global health challenge but with early diagnosis and effective treatment it is curable. However long-term effects and the emergence of drug resistance pose ongoing challenges.

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