Miliary Tuberculosis Mr.

Arta, a 38 year old inpatient came into Ari Canti Hospital on the 9th March 2010 with chief complaint of cough producing blood and sputum without dyspnoea. Cough was presence since a month ago, while the patient confessed that blood was presence since a week ago. Swelling was found underneath the right ear, patient seemed weakened. On the 12th of March 2010, Patient suffered septic shock and was referred to Sanglah Hospital. Patient was taken into the infectious department. Patient mentioned about a saddleback fever since a month ago. He also felt nausea, presence of vomiting, and worsening symptoms since a week ago. Gastrointestinal problems were seen, patient suffered diarrhea since a month ago. His stool consistency was liquified, yellowish in color with presence of blood; however there were no abdominal pain. On vital signs examination, patient is in a shock condition patient blood pressure was 100/60 mmHg, Respiratory Rate: 25x/mnt irregular breathing, axillary temperature 37.8C with sweating, Pulse rate was 118x/mnt. Physical Examination found submandibulae lymph node was swelling at a size around 5 cm, solid consistency, clear surface, and pain when pressure was applied. Thorax was symmetrical with no complaints. Abdomen was normal, however peristaltic motion increased. Other body extremities were warm. Based on laboratory testing, patient suffered microcytic anemia, anisocytosis, thrombocytopenia and a low albumin count. Calcium and Calium levels were also decreased. X-ray was done on the same day. Results found cardiomegaly, infiltrate on the right apex and diagnosis of pulmonary tuberculosis. AFB test was planned. Patients submandibular lymph node was swollen and suspected with miliary tuberculosis (Tuberculosis that spreads into the lymph node). Patient was in a weak condition, with severe weight loss. Doctor suspected wasting (WS) syndrome. Bicitopenia (decreased trombocyte and haemoglobin) was significant as well as the hypoalbuminemia. The suspect of diagnosis leads to the symptoms of Stage IV B24 (Code HIV) and Bicitopenia on HIV related, however the patients main complaint was the breathlessness and chest pain. Further investigation was planned. TB drugs was given to patient, Cotrimoxazole 960mg, nystatin, cefoperazone sulbactam, dopamine drip 5mcg/KgBW/mnt, NaCl 0.9% 500cc at 20 drops/minute and vitamins. All were given to prevent further infection and spreading of disease. Thoracoabdominal nasal cannula was directed to support respiratory breathing. Review of family and social history were taken. Patient came from a village in Gianyar, they were farmers. Patients occupation other than a farmer was also a long distance driver and a builder. Home environment were kept clean by his family. Food and water are home-based. Based on his body, tattoos were found from the upper right arm until the shoulder. Patient claimed of weakness and cough since the start of TB more than a month ago but only seek medical care when he was in Ari Canti Hospital.

13th of March 2010. Patient was still in a shock condition (low blood pressure, irregular breathing, and coldness). KOH swab for fungi examination was taken and the result was positive. VCT was conducted for HIV-AIDS testing. Fever start to show again until the 15th, and paracetamol was given. 16th of March 2010. Abdominal pain arises. Pain was mentioned when pressure was applied on the abdomen. Inspection showed swollen distended abdomen on all four quadrants. Rantin and Antacid was given for gastritic effect. Splenomegaly and hepatomegaly were taken as a consideration due to the systemic effect of anemia and low albumin. 18th of March 2010. No significant improvement was shown by the patient. Faces had resolve to normal consistency, with less abdominal pain. Further investigation was taken patient had the AFB (Acid-Fast Bacilli) test completed today. The result was positive of Mycobacterium Tuberculosis. This further helps to support the diagnosis. 19th of March 2010. Abdominal symptoms resolved. ECG was done to the patient. Result shows an increase effort of the heart to pump the blood; however the patient was still in a hypotension condition, and this result in a cardiomegaly shown in the previous thoracic photo. In related to the immune deficiency, lab results were low CD4+ count and a positive-reactive Toxoplasma IgG, which further support the immune deficiency syndrome. 22nd of March 2010. Respiratory distress was improved, cannula ventilation was removed, but patient was still in a weak condition. NaCL 0.9%, Ciprofloxacin IV, and 1st category TB drugs, and other antibacterial and antifungal drugs were given. PRC was given a few times previously to increase the haemoglobin and thrombocyte. Up to the end of our hospital visit on the 24 th of March 2010. Patient was in the same condition, medication were the same. Patient was concluded as a Tuberculosis patient with B24 (HIV+) Stadium IV with Toxoplasma Cerebri (+). Neither the patient nor doctor suspected HIV on the first place. Patient came with a main complaint of TB symptom. However, surprisingly further investigation showed TB of HIV related, in this case, Miliary Tuberculosis.

Sanglah Hospital Inpatient: 12th of March 2010 Medical Record: 01361195 Hospital Ward: Nusa Indah Doctor in Charge: dr. Yasa Asmara and dr. Weda Hospital visits: 18th, 19th, 22nd, 23rd, 24th of March 2010