Request for help.

[Guest guest]

Dear MGIMS group members,

I am sending the details of a case and shall be highly thankful if someone could

go through it and advise regarding further line of management.

Thanks and regards.

A 25yr/F ,  developed low grade fever, dry cough, dyspnea at rest, orthpnea &

PND 1 year back

Echo showed moderate pericardial effusion .There was spontaneous resolution of

s/s in 10 days and resolution of the effusion in 2 weeks.

No pericadiocentesis was done as serial echos showed resolving effusion.

 

But within 2-3 days following resolution of  above she again developed

fever,chest pain & dyspnea. X-Ray chest PA view showed  bilateral pleural

effusion (R>L).Diagnostic pleural tapping was done and reports showed Exudative,

mainly Lymphocytic fluid with LDH=382, AFB –ve, ADA –ve,  Montoux  –ve &

HIV -ve.

Empirically started on ATT(Isoniazid 300, Rifampicin=600, Pyrizinamaide=1500,

Ethanbutol= 1200 – daily regime + steroids(40 mgx2 weeks and then tapered off)

). She showed dramatic improvement with resolution of s/s and completely clear

CXR after six weeks of treatment. After 2 months she was put on Isoniazid 300 +

Rifampicin=600 daily (continuation phase).

 But after 2 months of Intensive phase (HR),  i.e. after total 4 months of

 regular, daily ATT, she  developed painful right Thyroid lobe swelling

(progressively increased for 15 days).

 FNAC done- pus aspirated (AFB +ve tubercular abscess).

But BACTEC AFB c/s was -ve, PCR +ve.

At this stage (and even later till date) there was no  fever, loss of appetite,

loss of weight.

 Treatment regime was now modified and she was put on 6 drugs ( HRZE +

Streptomycin 1g I/M OD + Levoflox 750mg 1od  - daily regime).

After being on the modified 6 drug regime for 3 months she had a Generalised

Tonic Clonic Seizure. MRI showed bilateral Tuberculomas  (Lt.-single

conglomerate lesion, Rt.- multiple conglomerate lesions ,1.2x1.5cm in fronto

parietal region with significant perilesional edema))..Tab .Eptoin 100 mg TDS,

Tab. Clobazam 5mg HS started along with T. Wysolone 40mgx2 weeks and then

tapered off.

Her serial USG Thyroid reports showed slow decrease in size of Thyroid swelling

but to rule out resistant bacillus infection, repeat FNAC was done after 4

months of the modified 6 drug regimen. Straw colored fluid was aspirated & it

was MGIT c/s –ve & Gene Xpert- report showed NOT RESISTANT to Rifampicin. MTB

was however detected but very low.

Same ATT (6 drugs) was continued. After 5 months of modified regime,Inj.

Streptomycin was  stopped and  rest 5 drugs continued

In the sixth month, she had an episode of left partial seizure with left upper

limb weakness. Tab.Leviteracitam 250mg BD started, T. Wysolone 40mgx2weeks and

then tapered off (upper limb weakness improved). MRI- no significant change in

size of lesion/edema.

Although serial USG of thyroid showed decrease in size of swelling (last size

reported 1.2cmx1.1cm, FNAC tried again but now pus could not be aspirated.

However, pathological analysis showed 3-4 AFB/slide(?dead?alive could not be

commented).

Patient continuing on 5 drugs but periodic seizures continuing :-

Had multiple recurrent episodes of left partial seizures (once in 15 days) +

multiple jerky movements of left upper limb (5-6 epiodes/day while on t/t).

Tab.Leviteracitam increased to 500 BD.

Subsequently on t/t left partial seizure frequency increased to once per week

with multiple jerky movements of left upper limb (10-12 episodes/day).

Tab.Leviteracitam increased to 750 BD.

Subsequently episode of left partial focal seizure occurred lasting 4 hours. T.

Clobazam added HS 20 days back. 3 to 4 similar episodes lasting 1/2/2.5 hours on

t/t about 2/week. Tab. Oxcarbazine 300mg BD added.

Latest MRI Scan shows a slight increase in size of the tuberculoma.

During t/t TFTs/SERFTs/LFTs within normal limit. Presently on

HRZEQ(600/300/1500/1200/750mg). taken daily regime throughout the course of t/t.

No fever, loss of wt. appetite, thyroid swelling markedly decreased.

Now what should be the further course of action ? Can it be MDR TB ? Is the

brain edema simply a paradoxical response ? Any suggestion about changing the

treatment ?

Anything else that can be tried ?