the Worsening of Tuberculosis During Treatment: Key Insights

Worsening during the treatment process of pulmonary tuberculosis?

Hello Doctor: In early December last year, I suddenly experienced full-body chills and shivering at night.
The next day, I had severe chest pain.
I had previously experienced night sweats while sleeping.
I initially thought it was a cold and visited a clinic, where I was prescribed antibiotics for a week, but my condition did not improve; instead, I developed a persistent cough and a fever that wouldn't subside.
After some time, I went to a large hospital to see a pulmonologist.
An X-ray showed that my bronchi and lungs were almost completely white, and the doctors could not determine the diagnosis.
A CT scan was ordered, and while waiting for the report, I was given two different antibiotics for two weeks, but I continued to cough without improvement.
When the CT report came back, it revealed a deep cavity in my right lung, suspected to be tuberculosis.
I started taking tuberculosis medication in early January, consisting of RFT (5 tablets) and EMB (2.5 tablets), and I followed the treatment plan.
My condition gradually improved, and I felt increasingly better.
Each X-ray showed a reduction in the white areas.
By early March, I thought I might be close to recovery, as sputum tests from December to March were all negative.
In mid-March, the doctor said I could switch medications to RFN (300 mg, two capsules).
However, on the first day of taking the new medication, I felt worse than before, and some symptoms returned that were similar to those I had in January.
I became concerned that the medication might not be effective against the tuberculosis bacteria.
Nevertheless, I did not experience any significant issues.
In April, I continued the new medication, but the doctor did not perform any further X-rays after switching the medication, so I was unaware of the condition of my chest after taking RFN for a month.
A few days ago, I woke up in the morning and coughed up blood with my first sputum.
I was alarmed.
The next morning, I coughed up blood again, and that afternoon, I felt feverish and had tightness in my chest.
Two days later, I rushed to see a doctor, who performed an X-ray and found that the lung infiltrates had increased significantly compared to the X-ray taken in early March.
As a result, I was prescribed PZA (3 tablets) and had another sputum test.
I am feeling very frustrated and do not understand why this is happening.
The doctor and the pharmacist were also surprised, as this is not typical.

Doctor, I have a few questions:
1.
Why did my condition become uncontrollable after switching medications? Am I going to have to take medication for life? If my condition worsens even while on medication, what will happen if I stop taking it? Is it related to my living environment? I have read that tuberculosis recurrence is often due to insufficient immunity.
Would taking vitamins help? If so, which ones should I take? Are there ways to eliminate tuberculosis bacteria in the air or on surfaces?
2.
My condition was only determined through the CT scan.
Is it particularly serious for it to be this way? I have only had one CT scan in December of last year and have not had any since.
Is it necessary to have regular CT scans? Thank you!

Danxin, 40~49 year old female. Ask Date: 2018/04/22

Dr. Jian Shuntian reply Pulmonology

1.
It is important to know whether the sputum culture was positive at the time of diagnosis and if there are results from drug susceptibility testing.

2.
The current condition requires another sputum test to check for the presence of bacteria, and a rapid diagnostic test for antibiotic resistance genes can be performed to identify any new resistance.

3.
It is necessary to clarify whether the worsening of the chest X-ray is due to other causes.

4.
A second opinion can be sought from a specialized hospital in the area.

5.
Vitamins do not have a significant correlation with tuberculosis treatment.

6.
Whether a CT scan is needed again should be determined by the attending physician based on clinical changes.
Thank you.

Reply Date: 2018/04/22

More Info

Understanding the worsening of tuberculosis (TB) during treatment is a complex issue that involves various factors, including the nature of the disease, the effectiveness of the medications, and the patient's overall health. In your case, it seems that after an initial positive response to the treatment, you experienced a deterioration in your condition following a change in medication. This situation raises several important points to consider.

1. Medication Efficacy and Resistance: Tuberculosis treatment typically involves a combination of antibiotics to effectively kill the bacteria and prevent resistance. The initial regimen you were on (RFT and EMB) appeared to be effective, as evidenced by the improvement in your symptoms and the reduction in the size of the lesions on your X-rays. However, switching to RFN300 may have resulted in inadequate bacterial suppression, especially if the strain of TB you are dealing with has developed resistance to one or more of the drugs. Drug resistance is a significant concern in TB treatment, and it can lead to treatment failure and worsening of the disease. It is crucial to conduct susceptibility testing to determine if the bacteria are resistant to the new medication.

2. Monitoring and Follow-Up: Regular monitoring through clinical evaluations and imaging studies (like X-rays or CT scans) is essential during TB treatment. It helps assess the response to therapy and detect any potential complications early. In your case, the lack of follow-up imaging after the medication change may have contributed to the delayed recognition of the worsening condition. It is advisable to have regular follow-ups with your healthcare provider to monitor your progress and make necessary adjustments to your treatment plan.

3. Impact of Immune System: The immune system plays a critical role in controlling TB infection. Factors such as stress, poor nutrition, and underlying health conditions can weaken your immune response, making it harder for your body to fight off the infection. While vitamins and a balanced diet can support overall health, they should not replace standard TB treatment. If you are concerned about your immune status, discussing this with your healthcare provider may lead to additional supportive measures.

4. Environmental Factors: TB is primarily transmitted through airborne particles, so living in crowded or poorly ventilated spaces can increase the risk of exposure to the bacteria. Ensuring good ventilation and minimizing exposure to potential sources of infection are important preventive measures. However, once you are diagnosed with TB, the focus should be on effective treatment rather than solely on environmental factors.

5. Long-Term Treatment Considerations: TB treatment typically lasts for at least six months, and in cases of drug-resistant TB, it may extend to 18-24 months or longer. It is crucial to adhere to the prescribed treatment regimen to prevent relapse and further complications. If you have concerns about the duration of treatment or potential side effects, these should be discussed with your healthcare provider, who can provide guidance tailored to your specific situation.

6. Need for Imaging: Regarding the necessity of regular imaging, it is generally recommended to have follow-up X-rays or CT scans at intervals determined by your healthcare provider. This helps in assessing the treatment response and making timely decisions regarding any changes in therapy.

In conclusion, the worsening of your condition after a medication change could be due to several factors, including potential drug resistance, inadequate monitoring, and the overall health of your immune system. It is essential to maintain open communication with your healthcare provider, adhere to the treatment plan, and seek regular follow-up evaluations to ensure the best possible outcome in your TB treatment journey.

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