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Latent intestinal TB

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I've suffered from abdominal pain/bloating to unexplained weight loss for about seven years. Extensive testings were done at institutions like the Mayo Clinic. All results were inconclusive. Four weeks ago I woke up one morning with pain on left shoulder that was diagnosed as pleural effusion. The fluid was removed. Skin test was positive for tuberculosis. My doctor concluded that the pleural effusion was due to TB infection. He prescribed me latent TB drugs Priftin and Isoniazid, based on 12 weeks CDC regiment (Priftin 900mg and Isoniazid 300mg)- taken once weekly. I'm in my second week with this treatment. The first time I took the drug I noticed my stomach symptoms and severe rashes around my nose are improving. I came to the conclusion that my undiagnosed symptoms could be also TB related. As such, I'm wondering whether current latent TB treatment is sufficient to tackle possible Intestinal TB also. If not, what would be the suggested course of treatment that could include current latent TB longer than 12 weeks, or the need to include additional drug to this regiment? I'm looking for best practiced approach to mitigate possible drug resistant. Feel free to follow-up if you need more information, including medical records.

Category: Pulmonologist

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Category: Allergy and Immunologist
 25 Doctors Online

Hello,

Thank you for choosing DoctorSpring

I understand that these symptoms and a diagnosis of TB can be quiet frustrating. I will try my best to help you out here.

First I would like to get some additional information from you (if it is available with you)

1. Was Protein, Sugar and LDH content, ADA and pH level of the pleural fluid done ?
2. What about TB PCR and Gamma Interferon ?
3. I assume that a lot other blood tests were done. Among them do you happen to know the values of ESR and CRP ?

You can reply as a followup
(With inputs from Dr.DS Sebastian )

Thank you


Patient replied :

Hello Doctor,

Thank you for the follow-up. My doctor had ordered some fluid test after the Thoracentesis that were not carried out. I'm have attached some test results that might be helpful.

As mentioned, My symptoms could not be diagnosed despite a bone marrow biopsy and stomach biopsy. Stomach biopsy was done for weight loss and before I experienced stomach inflammation. My stomach problems started after the stomach endoscopy procedure which led me to believe that the instrument was not properly sanitized. Let me know if you need more information.

Guy


Hello,

I understand that your Doctors have considered a wide range of possibilities and done a lot of tests. The pleural effusion is kind of god sent here. It is like a lead which we can follow to make a confirmed diagnosis.

Pleural effusion just don't occur like that. What ever tests you have been undergoing would have been bit direction less until you developed the pleural effusion.

I am of the opinion that the Thoracocentesis and pleural effusion should be well studied as it can lead on to a definitive diagnosis. TB is possible, but it is bit tricky here. There are no solid signs to say this is TB. (from the reports your have provided). This is because some critical tests are missing. But if asked TB will be the first possible diagnosis I would put.

The trick here is that while you have a response to treatment - which is a good sign, you should remember that anti TB medications are also antibiotics so it can be effective in some other infections also.

The current TB regimen seems just fine. It is always better to follow the recommend regimen in your country.

If possible I would recommend a re evaluation under the care of a Pulmonologist.

Hope this helps
Feel free to ask followups
Thank you

Dr.JG
Dr.DSS


Patient replied :


Doctor,

The TB diagnosis was made by a Pulmonologist. However, I do not believe he is skilled expert in this field, despite the fact that some of his recommended tests were not performed.

My medical issues spanned from ENT, Gastro to Infectious disease specialists. I've spent lot of money jumping from specialist to specialist without any collaboration in trying to diagnose my symptoms.

As you can imagine, it has been very frustrating that allows me to look for care beyond she shores of North America.

I've moderated the current regiment, from a weekly dose to every 6 days in order to allow the drugs to heal my stomach problems.

Over the years, I've tried gluten-free diet and removed most allergens from my diet to no avail.

Muscle loss persists. I went from 189 lbs to 165 lbs today.

I have good appetite. I do have sinus congestion at times along with seborrhea dermatitis. I struggle to gain weight.

I exercise daily that include some weight training along with walking.

Doctors here have given up me. So when skin test was positive for TB exposure, I figured it could the crux of my undiagnosed symptoms.

The question here is whether current treatment is sufficient, considering its weekly dosage, in order to deal other active TB like viruses that may be in tissues in my stomach or in my sinus?

Any suggestions, recommendations or other approaches would be appreciated. I can also be reached via email at [email protected]

Thank you,
Guy


Hello,

1. You may be having a latent TB.

2.The effusion MAY be because of another cause, and the duration of illness for 6 years cant be attributed to TB alone

3. I would recommend you to continue the treatment for latent TB, keep a follow up chest x ray every 3-6 months.

4. Would recommend anti allergic medicines such as monteleukast 10 mg in night daily, an anti- acid medicine - like 20 mg rabeprazole in empty stomach daily and to continue exercise.

5.Complete the anti TB medicine as per schedule for 6 months.

6.I recommend further evaluation under the care of a expert Pulmonologist to identify the definitive cause for pleural effusion. This should include the TB tests mentioned above.

Hope this helps
Thank you.


Patient replied :

Dr. George,

Thank you for response. Is monteleukast and rabeprazole recommendation designed to treat or to contain my symptoms? I'm looking to possible cause so proper treatment can be applied. what role does fungus have in my symptoms?

Borderline neutropenia was the only diagnose I've received from medical specialists when they could not diagnosed my symptoms.

I had taken other antibiotics (cipro, levofloxacin, xifaxan, amox/k clav) that failed to respond to my stomach problems. Only latent TB medications seem to help.

My current latent TB treatment is for 3 months. Do you suggest me to continue on this treatment for an additional 3 months for a total of 6 months?

Additional is it not possible that dormant TB could have caused my persistent weight loss and seborrheic dermatitis over the 6 year period?

Thanks
Guy


Hello,

1. Monte and Rebeprzole (or Omeprazole) are for symptomatic treatment only. Monte will help in addressing a possible allergic aetiology

2. Fungal cause unlikely - No evidence so far.

3. I would say 6 months is better. However it is better to followup country specific guidelines. Rather than just a blanket duration - followup, reassessment and then decide on duration of treatment.

4. Dormant TB is called "Dormant" for a reason. It won't have such a prolonged manifestation for these many years. It would be tempting to assume that all these are caused by TB (and it could be). But it is prudent to be careful and NOT overlook any other possible causes.

Honestly the evaluation for Pleural Effusion in incomplete. I would strongly recommend you to get in touch with a experienced MD and get in evaluated. As I said earlier this is very significant finding. Like the most important clue. Thorough evaluation is must. I cannot stress this enough.

Hope this helps


Dr. Jacob George Pulinilkunnathil
Category: Allergy and Immunologist
Experience: 
Residency, Post Graduation: MD, Respiratory Medicine, J L N Medical College, Ajmer, Rajasthan (2012).
Medical School, Internship: MBBS, Government Medical College, Kottayam, 2001-07 
Indian Diploma in Critical Care Medicine (IDCCM) - Medical Trust Hospital, 2013-2014.
Dr. Jacob George Pulinilkunnathil and 4 other Medical Specialists are ready to help you

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