ANSWER 49
The chest X-ray shows extensive changes in the right upper zone which seem as if they
are likely to be more extensive than those described at the first admission 2 months earl-
ier. It is likely that this is a worsening of his pulmonary tuberculosis. This might have
occurred because he had a resistant organism or, more likely, because he had not taken his
treatment as prescribed. Risk factors for development of tuberculosis are poor nutrition,
high alcohol intake and immunosuppression (HIV, immunosuppressive therapy). Higher rates
occur in those from the Indian subcontinent and parts of Africa.
The headache and confusion raise the possibility of tuberculous meningitis. Other possi-
bilities would be liver damage from the antituberculous drugs and the alcohol, although
clinical jaundice would be expected, or electrolyte imbalance. If these are not present a
lumbar puncture would be indicated, provided that there is no sign to suggest raised
intracranial pressure. It would be advisable to do a computed tomography (CT) scan of the
brain first since a fall related to his high alcohol consumption might have led to a sub-
dural haemorrhage to give him his headache and confusion.
It is now 2 months since the initial finding of acid-fast bacilli in the sputum and the cul-
tures and sensitivities of the organism should now be available. These should be checked
to be sure that the organism was Mycobacterium tuberculosisand that it was sensitive
to the four antituberculous drugs which he was given. As a check on compliance, blood
levels of antituberculous drugs can be measured. The urine will be coloured orangy-red by
metabolites of rifampicin taken in the last 8 h or so.
Comparison with his old chest X-rays showed extension of the right upper-lobe shadow-
ing. It is difficult to be sure about activity from a chest X-ray but extension of shadow-
ing is obviously suspicious. ‘Softer’ more fluffy shadowing is more likely to be associated
with active disease. A direct smear of the sputum showed that acid-fast bacilli were still
present on direct smear. He confirmed that he was not taking his medication regularly. His
headache and confusion resolved as he stopped his high alcohol intake. Subsequently the
antituberculous therapy should be given as directly observed therapy (DOT) in a thrice-
weekly regime supervised at each administration by a district nurse or health visitor.
- Poor adherence to treatment regimes is the commonest cause of failure of antitubercu-
lous and other treatment. - Directly observed therapy should be used when there is any doubt about adherence to
treatment. - Four drugs should be used (rifampicin, isoniazid, pyrazinamide and ethambutol) when
there is a higher risk of resistant organisms, e.g. immigrants from Africa, Asia, previously
treated patients, patients of no fixed abode.