Case Study 1

Tell your mentee that you will review a case study and ask some questions to help him/her improve skills in using the Algorithm for the Diagnosis of TB in A Presumptive TB Case with Unknown HIV Status.

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Zinyoro is a 20-year-old male student presenting in your clinic with a cough and weight loss for the past month. He tells you he thinks he is sick from staying up late studying for exams. He does not report any medical problems in the past. He does not know his HIV status.

Vital signs: Temperature: 36.3 C, HR: 82 and regular, RR: 20, B/P 123/78, Weight 73kg

Physical exam: Chest exam reveals right-sided anterior crackles

1. What are your next steps in evaluating Zinyoro’s symptoms?
   • Use the TB screening tool to further evaluate his risk for TB.
   • Ask about HIV status and if not known, provide pre-counseling and HTC.
   • Obtain spot sputum specimen and send to the laboratory immediately.
   • Provide patient education with each step of the evaluation.
   • Ask about TB contact.

Additional Information
Zinyoro’s spot sputum is negative and his HIV test is positive. When you tell him the results, he is visibly shaken and upset and tells you that the results must be wrong.

2. What are your next steps in evaluating Zinyoro’s symptoms?
   • Provide counseling and psychosocial support. Ensure patient understands information being given and allow for sufficient time for questions.
   • Proceed to Algorithm for Diagnosis of TB in HIV Positive Smear Negative Patient.
   • Give him a chest X-ray (if available).
   • Get a sputum for culture and DST (if available).
   • Perform a complete physical examination, if not already done, focusing on HIV related signs and symptoms such as enlarged lymph nodes and oral candidiasis.
   • Get HIV baseline laboratory tests.
   • Give an antibiotic but not a Fluoroquinolone or streptomycin. Amoxicillin for 5 days is one option. Close follow-up is needed to evaluate for improvement. If there is improvement, this would suggest that he may have PCP, bacterial pneumonia, or another respiratory condition; although TB should remain one of your differential diagnoses. It is important that the patient is closely monitored and returns to the clinic to be re-evaluated after antibiotics or sooner if his condition worsens.
   • Refer for comprehensive HIV care and support.
3. What will you do if Zinyoro returns after completing the course of antibiotics without improvement?
   • Assess further to rule out other potential diagnoses. If no improvement or continued worsening, reassess for possible TB.
   • Initiate CPT unless this has been started at the HIV clinic.
   • Coordinate TB care and treatment (if initiated) with initiation of ART.

Case Study 2

Tell your mentee that you will review a case study and ask some questions to help him/her improve skills in using the Algorithm for the Diagnosis of TB in HIV Positive Sputum Smear Negative Patient.

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Anele is a 31-year-old female diagnosed with HIV infection 2 years ago. She presents today with a fever and cough of 2-3 weeks duration. She also tells you that she thinks she has lost some weight but is not sure. She has no previous history of TB. She takes an herbal drink given to her by her mother “to keep her healthy” and occasionally paracetamol when her feet hurt after standing at her work. She disclosed her HIV status to her mother, who she lives with along with her grandmother. She tells you that her grandmother has been coughing but refuses to go to the clinic.

Vital signs: Temperature: 37.6 C, HR: 63 and regular, RR: 18 B/P 118/76

Physical exam: Unremarkable except for a small (1cm) submandibular lymph node on the right side

1. What is the next step in the evaluation of this patient?
   • Collect spot sputum specimen and instruct patient to obtain second specimen in the morning and bring it to the laboratory immediately. If unable to come back to the clinic, have Anele wait for 2 hours and collect the second specimen.
   • Get a chest x-ray (if available).

Additional Information
The spot sputum specimen is positive.

2. Discuss the management of Anele now that she has a positive sputum specimen and is HIV positive.
   • Obtain sputum for culture and DST (if available).
   • Get chest x-ray (if available).
   • Treat for TB.
   • Begin CPT unless she is already taking this.
   • Do contact tracing.
   • Refer for comprehensive HIV care and treatment unless she is already being seen in that clinic.
   • Initiate ART when tolerating TB treatment but at least 2 weeks after the start of TB treatment (Zimbabwe ART Guidelines 2013).
   • Get a baseline CD4 count.
   • Discourage the herbal drink because some herbs interact with medications by either increasing/slowing metabolism. This interaction alters the plasma concentration, which has an effect on the optimal therapeutic drug levels.

Case Study 3

Tell your mentee that you will review a case study and ask some questions to help him/her improve skills in using the Algorithm for the Diagnosis of TB in HIV Negative Initially Sputum Smear Negative Patients.

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Bukhosi is a 42-year-old man complaining of a productive cough and fatigue for 2 months. He is complaining of weight loss. He tells you that his wife was treated for TB in the past but he does not know if she finished her medication. She went to live with her mother and took their 2 children.

Vital signs: Temperature: 38.0 C, HR: 100, RR: 18, B/P 118/70, Weight: 70 kg
Bukhosi is thin and breathing comfortably.

Physical exam: Chest exam reveals fine crackles in all lung fields.
HIV test is negative. Spot sputum smear is negative.

1. What would be the next steps in evaluating this patient?
   • Collect spot sample of sputum and send to the laboratory immediately.

Additional Information
Bukhosi’s spot sputum specimen is negative. You explain that a second specimen is needed to make sure that he does not have TB. The specimen should be taken tomorrow morning and brought to the laboratory. Bukhosi tells you that he lives too far from the clinic and cannot return tomorrow. He is also afraid that if he does not go to work, his boss will be very angry and he could lose his job.

2. Do you need a second specimen? If so, how will you obtain the second sputum specimen?
   • Yes. Have Bukhosi wait 2 hours and collect a second specimen today.

Additional Information
Bukhosi’s second specimen is also negative.

3. What is the next step in managing this patient?
   • He is HIV-negative and has no danger signs (unable to walk unaided, respiratory rate 30 or more, T>39.0, pulse>120).
   • He should be treated with antibiotics but not a Fluoroquinolone or streptomycin. Amoxicillin for 5 days is one option. Close follow-up is needed to evaluate for improvement.
   • If there is improvement, his would suggest that he may have bacterial pneumonia or another respiratory condition, although TB should remain one of your differential diagnoses. It is important that the patient is closely monitored and returns to the clinic to be re-evaluated after antibiotics.

Additional Information
Bukhosi takes the 5 day course of amoxicillin and returns to your clinic. He is still having a cough and fatigue. The vital signs and exam are not significantly changed from the last visit.

4. What is the next step in evaluating this patient?
   • Repeat sputum smear microscopy. If negative, check chest x-ray (if available).
   • Refer for further evaluation as patient is not responding to treatment.
5. If Bukhosi’s chest X-ray results indicate TB disease what is his diagnosis and what else will you do as part of follow-up for this patient’s family?
   • Diagnosis is Sputum smear negative pulmonary TB
   • Contact screening for all family, household, and community members in close contact with patient.
   • Treat any family members who show evidence of TB disease.