Question: For request attention of Tropical TB specialists Panel/Dr. Chabufo Ditah please

MGR – 69 years XXXXXXX male

PRESENT HISTORY

Was finally detected with Renal M Tuberculosis on 11 Dec 2015 based on Urine culture after 7 weeks of incubation. Urine for M TB Genotype Detection Test – Haine’s Test also showed Mulyi Drug Resistant TB. Reports attached.
Started on following medicines each once a day since 12 Dec 15.
1.     Etambutol/Combutol 1200 – morning empty stomach.
2.     Rifabutin 300 – morning on empty stomach
3.     Linezoid/Lizolid 600 – after lunch
4.     Moxifloaxin 400 at night
5.     Kanamycin injection – twice a week as my audiometry was weak on the higher frequencies. Three months gets over by 10 Mar 16. After it finishes, start Clarithromycin twice aday.
6.     Omeprezole D once day in the morning
7.     Multivitamins + BP medications, Shell Cal for Osteoporosis.
8.     Very Recent repeat of Urine for M TB Genotype Detection Test – Haine’s
Test showed no Growth. Liver and Kidny tests OK except Total Beluribn was 1.37 which has been fluctuating marginally from different laboratories over past couple of years 0.9 to 1.4

Present symptoms after 2 and ½ month treatment –
     Low grade fever upto 99.5 F continues.
     Weight not stabilised.
     Energy levels poor.
     Appetite now OK since past two weeks.
     Small nodule left side centre of neck/occipital region. No lymph nodes in neck or arm pits etc.
     Both soles of feet front 1/4th seems numbish/neuropathy??
     Periodic headaches though less.
      Both fore fingers pain at joints and at times don’t bend fully. Rheumatoid test negative ie XXXXXXX etc. HIV negative last test 2 months ago.
Gas/flatulance and lightheadedness daily
Started getting black stains inbetween my teeth. Which medicine side effect?

Now what. Is diagnosis correct or something else still there causing the low grade fever. Any remote possibility of Low grade Infective Endocarditis due to Pace Maker/Lead. Trans Eosophagl Echo of heart was clear in end Sep 15.

Is TB medication correct or would you suggest any changes. I am tolerating just about OK. Lot of nausea and at times vomiting. Now less after started taking Moxicip at night. Kanamycin being stopped in 2 weeks since my left ear high frequencies have reduced further. Starting Clarithromycin twice a day in lieu.

Main bother presently is 98 to 99.5 fever every day still though appetite and energy levels are better.

General advise on diet and how much physical rest I need everyday. Can I do my normal routine/activities and a little walk daily.

PAST ONE YEAR HISTORY

1)     Fever – PUO since Apr 15.Mostly afternoons and evenings.
2)     Used to get itchy Rashes – small blobs which at times spread a cm or two.
3)     Loss of weight. 13 kgs in 11 months till todate.
4)     Headaches since past over 3 years. CT scan of brain in 2016 clear.
5)     Hypertensive past 20 years. On Telma 40 and Cilnidipine 10 OD.
6)     Pace maker fitted in Dec 1999 for ??? AV block. Box replaced in Apr14 by Dr. XXXXXXX Lokhandwala. Old lead retained. Have been 99% on my own sinus rhythm. Pain around the pace maker box since end Apr 15. No external lesion or redness or anything from wound area or around the PM box.
7)     Angiography done three times 1987, 1999 and 2002. All arteries clear and normal.
8)     Hep B + ve since past 10 years post angiography at Manipal Hospital XXXXXXX LFT, USGs, viral load normal all along.
9)     BPH for last three years. No medication. PV retention in XXXXXXX 15. Treated with Monocef IV 5 days and Oflox 15 days. Advised TURP. Surgery done in mid Aug 15 after cystoscopy showed severe infected prostate/prostatitis. Biopsy reported BPH with severe prostatitis. IV Morepenem BD from before surgery to post surgery for 7 days.
10)     Blood test CBC, ESR, CRP, PCT, LFT, Renal profiles, Thyroid repeatedly normal. Hb has been low. Was 11 but last report 8.5. Blood sugar mild since past 6 months. Random sugar last couple of times 120.
11)     USGs, Contrast CT scans, PET CT, Bone Marrow, X ray chest, spine, hip etc done. Nothing significant. General Osteoporosis noted. L1 mild compression. Cause not known/injury recollected.
12)     Urine culture showed Ecoli in aug 15.
13)     Blood culture showed Sphingomonas Pausimobilis bacteria in mid Sep 15 in all 3 blood samples.
14)      IV Morepenem TDS started 14th Sep 15 till 02 Oct 15 followed by IV Ertipenem OD till 12 Oct 15 for severe Prostatitis. IV Levoflox from 01 Oct to 05 Oct followed by oral 750 OD till 25 Oct 15.
15)     Trans Thoracic Echo and Trans Eesophageal Echo TEE done at Sahyadri Hospital, XXXXXXX in view of Sphingomonas. No signs of Endocarditis or vegetation on lead tips or heart valves. Earlier whole body PET CT with contrast showed no significant uptake in the PM pocket area or the heart chambers/valves etc. Small red spots on both palms past 9-12 months.
16)     Have pet dog past 8 years. She had ticks, fungal infections etc. Cared by me to a large extent. Have been getting itchy rashes/blobs and itchiness in the scalp, face, etc with no external signs past couple of months. Started Doxy 100 mg BD since 18 Oct 15 and continuing till date. ELISA test for Lymes showed IgG negative 0.1 as against 0.9 and positive IgM at 1.5 as against 0.9. Indicating acute recently acquired infection which is not possible since I have not been in contact with my pet dog past 4-5 months.
17)     Recently done Serum and Urine Electrophoresis test to rule out Multiple Myloma. Nothing abnormal shown in any bands including “M” band.
18)     Had viral bad cold cough. Taken Augmentin duo 625 BD for 5 days - 14 Nov. Also took a course for Anti Malaria just to rule out.

Dear Doctor,
Thank you very much for the encouraging words. There are some queries in my mind please -

1. Top most is that I have fever upto 99.5 F everyday, even after 2 and 1/2 months of medication. Earlier the fever used to be upto 99F. What could be the reason? Does the effect of medication take time more so because its Drug Resistant variety? How long do you expect before this fever to normalise? I am mentally fatigued with this fever for past 10 months!!
2. My eyes are burning throughout the day. Must be due to this marginal fever.
Would putting some lubricating drops help relieve the burning? If so can you please suggest some name.
3.I have been and still feel very cold all over. I am continuously wearing sweaters. Just cannot be under the fan. In the past I have had chills and once or twice rigors about 3 months ago. Why is this? Is it because of loss of weight/fat/even muscle wear or due to fever or low Hb of 8.5? What can I do?
4. Hb was 8.5 about a month ago. Its v low down from 11 about 6 months ago. Why has Hb come down? Any medication I need to take ? Will they cause addnl side effects too ?
5. What is the nodule at the centre of the neck? I noticed a smaller nodule on on the right side lower portion. Does this need any investigation? Are they enlarged due to fever or vice versa!!
6. Pray nothing to do with any malignancy.
7. After stopping Karamycin after 2 weeks, additionally is Clarithromycin necessary in lieu?
8. At what periodicity should I do LFT/KFT/Haemogram ?
9. Any chance of gaining some weight? After how long after starting ATT?
10. Any reason like side effect of any medication causing this numbness/tingling of front portions of both feet soles? Would B12 capsules help? Pl prescribe, if so.
11. How to reduce this light headedness please?
12. The black stains on the teeth so also some yellowish map type stains - I showed my son who is a PG Priodontice Dental from Manipal KG college today when he came. He said black possibly because of some tonic. I don't take any. The yellow is plaque. So we will leave that. Just for your info pl. I am not on any Iron capsules as of now.

Well I seem to be a hypocondriac !! Please bear with me.

With warm regards

MGR

Hello Doctor,

Thank you for the prompt reply. Final clarifications please -

1. These 5 ATT medicines to continue for how long? Can the number of drugs be reduced progressively?

2. What tests need to be done to verify that the medicines are taking effect? Is Haines test on urine a good indicator, as results come in a weeks time?

3. The nodules in the neck are two now. These have come up in the last 4-5 weeks. ATT was started 10 weeks ago. Why nodules come even after 5-6 weeks starting ATT?

4. FNAC (will probably do it too) may show TB. The treatment is the same which I am undergoing presently. How does FNAC help? Unless there is some other infection.

5. For Iron deficiency, can you please prescribe some oral supplements, what dosage etc. Can I take it with the ATT ?

6. Can I take any Vit supplements for the tingling and numbness of front portion of both feet.

Thank you very much for being very patient with a difficult patient ! Very much appreciate your replies and value your opinions.

With regards

MGR