[The following is an example of Nyaya’s teamwork approach to providing the best care to patients. These case studies were discussed via our international listserv, to provide a spectrum of professional input.]
Case 1: A 38 year old female with four days of fever, cough, and epigastric discomfort. Hemoglobin on admission 6.7. Chest x-ray showing diffuse patchy infiltration. Clinical picture concerning for tuberculosis (TB), malignancy, or severe pneumonia (PNA). Condition improved following administration of Levofloxacin and Clotrimazole.
Case 2-65 yr female presenting with dyspnea on exertion, facial swelling, and bilateral pitting edema. Lung exam shows bilateral lower lobe crepitations. Past history of Hypertension, Chronic Obstructive Pulmonary Disorder, and APD (Acid Peptic Disease). Chest X-Ray (CXR) shows diffuse enlargement of heart concerning for severe Chronic Heart Failure(CHF) and bilateral pleural effusions. Improved on Lasix, Ceftriaxone, and nebulization treatments.
Case 3: 50 year old female presenting with several month history of cough, hemoptysis, weight-loss, and anxiety. Upon examination, patient is tachycardic to the 180s with an irregular heartbeat. Past history of pulmonary tuberculosis and COPD. CXR taken 3 days Prior To Admission showing hyperexpansion of lung fields and tubular heart, typical in a COPD patient. Pulmonary nodules consistent with past TB infection are also visible. Clinical picture is concerning for relapse of TB as well as superimposed supraventricular tachycardia vs. atrial fibrillation with rapid ventricular rate (RVR). Unfortunately there is currently no ECG available at Bayalpata Hospital, so the best course of action is to continue close heart rate monitoring, IV fluid resuscitation, and administration of broad spectrum antibiotics (Levofloxacin or Ceftriaxone/Azithromycin) to treat lung disease. She is currently stable but if the heart symptoms worsen we will start her on Diltiazem for rate control. We are awaiting AFB results (to test for TB) from 3 days prior. This patient is severely ill and still managed to walk an entire day to seek medical care at Bayalpata Hospital.
These cases are heartbreaking. In America we pride ourselves on practicing evidence-based medicine, but we also rely heavily on the ease of ordering any diagnostic test whenever we please. We never question the availability of something as basic as an ECG! The patients I have met in Achham are resilient and brave beyond my wildest imagination, and what this experience has taught me is that sometimes all you can do is the best you can. Sometimes you have to make choices within your constraints and hope that your patients can hold on for one more day.
Above are also some pictures from x-ray rounds, which Dr. Thapa has been conducting each morning. The Health Assistants systematically go through x-rays from the previous night. They describe the presentation of the patient and read each x-ray in English. The x-ray machine is a valuable piece of equipment and a fantastic diagnostic tool which we try hard to utilize to the best of its ability. X-ray rounds are just one example of this.
[The following illustrates some of the feedback provided by our medical consultant listserv.]
Jason Andrews, MD: Thank you for sharing these interesting cases and your very thoughtful management. One suggestion I would make is not to use Levofloxacin in patients suspected of tuberculosis. The reason is twofold: one, you risk developing further resistance to quinolones (already 30% of multi-drug resistant TB cases in Nepal have quinolone resistance, likely due to their indiscriminate use); two, you may delay the diagnosis, as quinolones have potent antituberculous activity and can lead to temporary improvement in the patient’s condition. There is quite a bit of literature on this issue.
I would suggest that Levofloxacin not be the initial antibiotic of choice in cases in which TB is being considered, and would consider not using it for initial therapy for pneumonia at all for this reason. Doxycycline or Azithromycin can be used for atypical bacterial coverage if needed, and used with Ceftriaxone for severe/hospitalized cases.
In the first case, for example, the 38 year old woman with a Hemoglobin count of 6.7, I doubt very much that pneumonia was the only diagnosis leading to that degree of anemia, and would evaluate other medical comorbidities (and nutrition).
Michael Polifka, MD: Case 1: For a 38 year old female with these x-ray findings, TB is certainly highest on the differential list. Her Hemoglobin of 6.7 goes along with a chronic process. She very well may have a superimposed secondary bacterial infection, which would respond to standard antibiotic Rx, though with underlying TB I would have try to avoid a quinolone to minimize resistance if she turns out to have MDR-TB. Has her HIV status been checked? Are there any other findings on physical exam to suggest a primary source of malignancy (much less likely inherent age group)?
Case 2: Has an ultrasound been done for pericardial effusion?
Case 3: The chest x-ray does have diffuse calcifications, suggesting old TB, but there is also a right apical infiltrate that with her hemoptysis very likely indicates recurrent TB. Again, I probably wouldn’t use Levofloxacin, as in Case 1. With her irregular tachycardia and COPD she very likely has either rapid atrial fibrillation or multifocal atrial tachycardia; with rates of 180, she would absolutely benefit from a slower rate. A calcium channel blocker is a good choice if her blood pressure can stand it. If not, Digoxin would work, though slower, as long as her potassium levels are okay.
Aarti Bhatt is currently a 4th year medical student at the Medical College of Wisconsin, and will soon start her residency in Internal Medicine/Pediatrics. She is also a Community Health Volunteer at Bayalpata Hospital.