Face of the Case
In a 400-600 word answer, properly cited with an APA-formatted reference list and in-text citations, please answer the following questions. In addition to the researched facts you present as your answer, you may provide opinions and real-world experiences where appropriate.
Scenario: You are a medical assistant at a local hospital. You have been asked to give a presentation on the diagnosis and treatment of latent tuberculosis infection. The presentation will be open to the public so instead of presenting a real patient case, you decide to create a fictional sample case.
- Create a single case and list the characteristics of the person you will be testing and treating. Describe basic information about the patient including age, sex, lifestyle, and pertinent medical history.
- Take the audience through the typical diagnosis and treatment of TB. (See page 4 of the Latent Tuberculosis Infection guide below for two sample scenarios leading to latent TB.) Describe the person and their experience including their feelings and concerns at this time. Hospital personnel should leave the presentation understanding the physical and psychological consequences for the patient.
- Considering the research data available, answer these questions about your fictional patient with latent TB:
- Without treatment, what is your patient’s lifetime risk for TB reactivation?
- Your case patient has reported or has been diagnosed with another risk factor of developing active TB infection (e.g. – diabetes, HIV, organ transplant). How much does this factor increase their risk? Does it change the recommended treatment for this patient?
Resources to get you started
Advances in Diagnosis and Treatment of Latent Tuberculosis Infection
http://www.jabfm.org/content/27/5/704.full.pdf
Latent Tuberculosis Infection: A Quick Guide to Case Management
http://www.doh.wa.gov/Portals/1/Documents/Pubs/343-122-LTBIGuide.pdf
Core Curriculum on Tuberculosis: What the Clinician Should Know, Chapter 2, Transmission and Pathogenesis of Tuberculosis, Pages 21-42
http://www.cdc.gov/tb/education/corecurr/pdf/chapter2.pdf
Treatment Guidelines for Latent Tuberculosis Infection
http://www.kekkaku.gr.jp/pub/vol89(2014)/vol89no1p21-37.pdf
TB Elimination: Treatment Options for Latent Tuberculosis Infection
http://dpbh.nv.gov/uploadedFiles/dpbh.nv.gov/content/Programs/TB/dta/Providers/LTBI%20Treatment.pdf
Abstruct
Mycobacterium tuberculosis is dispersed in the air when a patient with tuberculosis symptoms coughs or sneezes, and people around them become infected when they inhale these. Mycobacterium tuberculosis usually affects the lungs but can also affect other organs such as the kidneys, spine, and brain. Latent tuberculosis infection (LTBI) refers to a state in which patients are 'infected' with Mycobacterium tuberculosis but have not yet 'developed the disease'. In other words, LTBI patients have no symptoms of tuberculosis and do not infect others.
Fictional sample case
Name: Private
Age: 51
Gender: Female
Physical information: Weight 68 kg, Body temperature 36.9°C. No symptoms.
Occupation: Part-time work at a supermarket three days a week
Her family history: Her father had pulmonary tuberculosis (living separately).
Past medical history: She was diagnosed with rheumatoid arthritis nine years ago and is undergoing treatment at an orthopedic clinic. Dyslipidemia. High blood pressure.
Lifestyle: She has rheumatoid arthritis symptoms but is relatively active. Has a history of smoking (currently no smoking). No drinking.
The typical diagnosis for TB
・The tuberculin skin test (TST)
TST is performed by intradermally injecting 0.1 mL of a purified protein derivative of Mycobacterium tuberculosis-secreted protein into the volar surface of the forearm and assessing delayed hypersensitivity reactions between 48 and 72 hours (Chapman & Lauzardo, 2014). Although the TST is an easy, fast, and inexpensive diagnostic method, it must be used in combination with other tests for an accurate diagnosis, as it causes a variety of false positives and false negatives.
・IGRA test
Interferon-y release assays (IGRAs) "assess the immunologic reaction of cytokines (interferon-y) to specific antigens to mycobacterium tuberculosis" in the blood (Chapman & Lauzardo, 2014, p.2).
・Chest radiograph or chest CT scan
If there is inflammation in the patient's lungs, it will appear white on an X-ray or chest CT scan.
・Sputum test
It is a test that collects a patient's sputum and observes whether it contains mycobacterium tuberculosis.
The typical treatment
LTBI is treatable by medications of "isoniazid (INH) and rifampin (RIF), which have opposing mechanisms of action on cytochrome P450 enzymes" (Chapman & Lauzardo, 2014, p.4). In the case of treatment via INH, patients should take INH daily or every other week for a total of 6 to 9 months (Chapman & Lauzardo, 2014).
Application to the case
The patient was diagnosed with rheumatoid arthritis nine years ago and was under treatment at an orthopedic clinic. In screening tests conducted before the administration of new therapeutic agents, the tuberculin skin test (TST) was positive, QFT positive in a blood test (IGRA). So her doctor ordered a chest radiograph, and the radiograph showed inflammatory changes in the lungs. However, since she had no respiratory symptoms and no findings suggestive of tuberculosis, her doctor diagnosed her with Latent tuberculosis infection (LTBI). The doctor instructed the patient to take INH 300mg/daily, and she followed the instructions. As a result, LTBI treatment was completed for her after six months.
Tuberculosis is a very rare disease in modern Japanese society, and patients were agitated when diagnosed. However, when her doctor politely explained that it is possible to treat with medication alone, and that there is no risk of infecting other people if there are no symptoms, she calmed down and showed attitude toward treatment. Her doctor explained and emphasized that her adherence to her medication regimen was essential for effective treatment. As a result, the treatment was successful and completed after six months.
In about 5-10% of infected people, Mycobacterium tuberculosis eventually begins to multiply and cause active tuberculosis if the patient refuses or does not follow the medication regimen (Tierney & Nardell, 2022). It also weakens the patient's immune system and might lead to life-threatening conditions and death if patients refuse the treatment.
Also, patients with compromised immune systems, such as HIV, are more likely to develop active tuberculosis infection, worsening symptoms, and increased mortality. HIV-positive patients are also treated for TB longer than HIV-negative patients (Chapman & Lauzardo, 2014).
References
Chapman, H. J., & Lauzardo, M. (2014). Advances in diagnosis and treatment of latent tuberculosis infection. American Board of Family Medicine. Retrieved from https://www.jabfm.org/content/27/5/704
Tierney, D., & Nardell, E. A. (2022). Tuberculosis (TB). MSD Manual Consumer Version. Retrieved from https://www.msdmanuals.com/en-jp/home/infections/tuberculosis-and-related-infections/tuberculosis-tb
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