Health Protection Week of Action 24th-28th Feb 2014
Protecting Health: Nursing and Midwifery Successes and Challenges
Case Studies on Tuberculosis
Case Study One
Patient – a young girl had been to see her GP with her Aunt due to feeling unwell, with nocturnal cough history and night sweats. The GP requested a CXR which showed changes but not convinced of TB. She was referred back to the TB department. I discussed the changes with the paediatrician and a decision was made to do a T-Spot and not do a mantoux test.
The T-Spot test was positive and therefore she was referred to a Paediatrician. A repeat Chest X-Ray showed deterioration and the decision was made to treat as an active disease and not Latent TB Infection. At the same time I discovered that the mum of the patient had died in 2012 due to kidney problems? Possibility of TB could have been a factor. A decision was made to screen patient’s sister and aunt and her children.
Results:
· sister = LTBI and commenced on LTB treatment,
· 6 cousins negative, and aunt negative. Screening repeated x 2.
· Social services are now involved due to who is now the legal guardian for the child.
Social History – after mum died patient was taken to Somalia for the summer and sometime during that period of time, her grandmother became ill. Grandmother developed a cough expectorator sputum and blood in latter stages of her illness. A diagnosis of Pulmonary TB was made. A diagnosis of Pulmonary TB was made. Patient became unwell at this stage and was treated by a local healthcare practitioner. There was no improvement and therefore the Aunt bought her back to England.
Now visiting patient weekly and 2 weekly due to complex family structure.
Case Study Two
39 year old gentleman moved from Romania in June 2012, living in Coventry with no past medical history nor any regular medications and living in a night shelter.
Diagnosed with sputum smear positive tuberculosis (TB) on the November 2012, and was since found to be culture positive and fully sensitive. Commenced standard TB therapy on the November 2012. Routine bloods were normal, HIV tested and found to be negative.
Multi Drug Resistance risk assessment performed and identified as low risk, directly observed (DOT) risk assessment identified at high risk due to language barrier, no fixed abode therefore DOT arranged on discharge. Initially there was a language barrier and interpreters were frequently used.
Discharged form hospital after 2 weeks treatment and resolution of his cough. On discharge he returned to the night shelter that provided two meals per day, Nic had no income from work or benefits.
Nic’s was referred to our TB link at the citizens advice bureau and it was discussed about his right to work and benefits, it was identified that Romanians have a right to come to the UK and are able to work providing they are self-employed, a work visa is needed to work as an employee, as a result of this Nic was not entitled to any benefits or housing assistance.
Nic had an episode of haemoptysis 2 months into his treatment where sputum was obtained and sent for TB culture this was found to be smear and culture positive again, he was readmitted for 2 weeks until smear negative as a public health risk to the communal night shelter.
During his treatment an application was submitted to TB alert for £600 to assist with transport to and from hospital appointments, clothing and food/hot drinks. This was received on the 25th of January. Nic, used this money to attend his appointments but also used this to apply for his work visa which he has was eventually successful in obtaining.
Nic has since completed his TB treatment and has gained weight from 58kg to 61.3kg. Nicu is now asymptomatic and has returned to normal activities.
The TB service had persistent contact with this patient to ensure his compliance and had a total of 47 visits/appointments through the course of his TB treatment between November 2012 and May 2013.
The night shelter was assessed and a total of 31 people identified 8 were negative
10 people screened out of area, 12 people did not attend 1 gentleman was screened and identified as active TB and went on to quadruple therapy.
Nic has since found a job in construction and has his own accommodation in a shared house and plans to bring his wife and children over from Romania.
Case Study Three
A 67 year old gentleman, Indian born and moved to the UK in 1999, currently living at a night shelter, identified as a contact of case two through the night shelter. Screened with a chest x-ray the gentleman was found to have an active TB lesion, this was not proven through cultures but treatment was commenced.
HS had stayed at the night shelter for the last 18 month which exceeded the usual length of stay of a couple of weeks; this was relaxed due to his age and ill health.
HS had a history of alcoholism but denied drinking throughout his TB therapy, he was assessed as high risk of non-compliance and commenced DOT (directly observed therapy).
DOT was performed at a number of locations such as the temple local clinic and occasional in an alley way where he spent some of his days.
We requested approx £300 from TB alert to help him comply with his TB therapy, we purchased on his behalf, hot drinks, small amount of food, some warm clothing and a telephone so we can contact him.
HS successfully completed his 6 months treatment unfortunately his social circumstance are a little different and is seeking support from the local law centre and social services.
Case Study Four