A 30-year-old male homosexual patient with HIV confirmed by the ISP in March 1995 with a history of orophan-ringeal candidiasis and a CD4 lymphocyte count (CD4 count) of zidovudine administered prior to January 1999.
He was admitted to our hospital due to fever and dyspnea, with a 10-day evolution.
At that time, the patient had a L-CD4 count of 314 cells/mm3 and an undetectable viral load.
Physical examination revealed lesions in the right ear compatible with herpes zoster and a pericardial fleet.
The chest X-ray showed cardiomegaly, the electrocardiogram showed a ST-segment elevation with inversion of T and surface echocardiogram showed an important effusion with mild ventricular systolic dysfunction.
Percutaneous puncture of the pericardium yielded negative tuberculin skin test results with 2,900 cAD semmm3, 74% mononuclear A/B, 2 dL sputum smears (+++), 4.63 mg/dL glucose.
Empirical initiation of anti-tuberculosis treatment with HIN 300 mg/day, RFP 600 mg/day, PZ (PZ) and pyrazinamide 600 mg/day and pyrazinamide 1,200 mg/day was decided.
Sepsis was discontinued by RFP interaction.
On the ninth day of hospitalization, a pericranial biopsy showed mononuclear granulomatous inflammation without areas of necrosis and with presence of acid-resistant bacilli (BAAR).
The cytological study of the pericardial fluid did not detect the presence of leukocytes.
The PPD test was negative.
Febrile persisted after 12 days of therapy so the anti-mycobacterial coverage was extended with clarithromycin 1000 mg/day and amikacin 1000 mg/day, achieving a decrease in fever three days later.
The patient was hospitalized for a total of 20 days, and due to his stability, he became a center of lesser complexity to continue his anti-tuberculosis treatment.
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The result of polymerase chain reaction (PCR) for M. tuberculosis complex positive complex in pericardial fluid was received (Labor of Clarithromycine during 14 days + Catholic University), so it was decided to adjust the scheme to HIN + RFP
Then, for the second month RFP was suspended, remaining with HIN + PZ + E and ciprofloxacin (Cp) 1,000 mg/day, in daily doses, and the initial restart therapy was started.
The patient was admitted favorably, without fever, and after completing 51 daily anti-tuberculosis treatment doses, she was sent home with an HIN regimen: 800 mg/day and RFP: 600 mg/day biweek.
The pericardial fluid culture confirmed by ISP showed M. tuberculosis.
The patient remained seated and hospitalized again until 28 months of the biweekly phase, when she developed fever and chest pain.
The sensitivity report of the PSI for M tuberculosis isolated in the pericardial fluid showed resistance to HIN and RFP.
Treatment was initiated with kanamycin (K) 750 mg/day IM, ethionamide (Et) 750 mg/day, PZ 1,250 mg/day and E 1,000 mg/day, a scheme that received for eight weeks.
At the fourth week of treatment with this new therapy the patient developed an episode of generalized tonic-clonic seizure that was managed with phenytoin.
A brain CT scan and CSF study were normal and the event was attributed to an adverse reaction caused by Et.
He was treated with phenytoin and had no new seizures.
After eight weeks of treatment K was discontinued and maintained with PZ + E + Et for another 10 weeks.
During this period, isolated thermal loops persisted.
At week 12 of treatment with a second-line scheme, the patient presented low chest pain; a subxiphoid collection was evidenced, which was punctured and purulent material was removed with the presence of AFB.
The culture at 30 days showed intractable colonies of M. tuberculosis.
The treatment was maintained without variations and cures, despite which fever persisted.
At week 18, an echocardiogram was performed, which showed a collection of a retro-eastern collection with presence of a new surgical effusion plus moderate amount of AFB. The collection was drained daily with abundant purulent fluid regimen.
Culture for mycobacteria from the retroestemal collection was negative.
At week 26 she developed a right cervical lymph node abscess that was drained and showed AFB, with Koch culture also negative.
After completing 40 weeks of second-line treatment in the hospital, the patient was discharged without fever and with echocardiogragna which later ruled out a retrofit condition.
In an outpatient phase, she received a daily regimen with PZ + E + Et + Cp for 22 more weeks.
In short, the patient received 62 weeks of second-line anti-tuberculosis treatment.
At present, nine years later, the patient is living a normal life and suffering from arthritis.
