Week 8 Extended Case Study Tuberculosis Assignment
Week 8 Extended Case Study Tuberculosis Assignment
Tuberculosis (TB) is an infectious disease that primarily affects human beings caused by Mycobacterium tuberculosis. The disease principally affects the lungs making pulmonary manifestations the commonest presentation of this disease process. Globally, the disease is the most frequent infectious cause of morbidity and mortality. Consequently, efforts are being concerted worldwide to eradicate this menace. The incidence of TB in the United States has been gradually decreasing with an estimated incidence rate of 2.2 cases per 100 000 population in 2020 (Adigun & Singh, 2022). Meanwhile, the incidence of multidrug-resistant TB is steadily ascending. The mortality rate of TB in the US is 0.2/100 000. However, the burden of TB is still enormous in developing countries. According to Adigun and Singh (2022), India, Indonesia, Pakistan, Nigeria, China, the Philippines, Bangladesh, and South Africa are among the countries with the highest incidence rate of TB. This assignment will elaborate on the transmission, pathophysiology, and clinical manifestations of TB. Similarly, medical concerns, psychosocial concerns of a TB patient as well as the implications of TB for critical care and advanced practice nurses.
Transmission and Pathophysiology of TB
Transmission of TB is mainly the inhalation of infected aerosolized droplets. The size of these aerosol droplets ranges from 1to5 micrometers in diameter. According to Hunter (2018), a single cough can produce 3000 infective droplets but only a few bacilli (about 10) are necessary to initiate the infection.
Following transmission, inhaled droplet nuclei are lodged in the terminal alveoli of the lung. The organisms multiple for 2 to 12 weeks to reach a substantial amount (1000-10 000) to stimulate an immune response. The organisms are engulfed by alveolar macrophages since the mycobacterial cell wall contains pathogen-associated molecular patterns (PAMPs) including lipomannan and lipoarabinomannan. Alveolar macrophages recognize these PAMPs via toll-like receptors (TLRs) as well as scavenger, mannose, and complement receptors. Subsequently, proinflammatory cytokines such as IL-1, IL-12, and TNF alpha are released and the mycobacteria are phagocytosed.
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Ordinarily, phagosome maturation, fusion with the lysosome to form phagolysosome, and killing of bacteria by reactive oxygen and nitrogen species as well as lysosomal enzymes follow phagocytosis. However, mycobacteria evade this intracellular killing by inhibiting both maturation and phagolysosome fusion. Virulence factors involved in this process include sulfatides, cord factor, lipoarabinomannan, and catalase-peroxidase (Hunter, 2018). Consequently, continued replication inside the macrophages eventually leads to macrophage lysis and the release of bacteria. Recruitment of antigen processing cells such as dendritic cells migrate to the infection site and present mycobacterial antigens complexed with MHC 2 to naïve T cells. Dendritic cells further secrete IL-12which promotes differentiation of T cells. Activated CD4+ T cells migrate to the infection focus (type 4 hypersensitivity reaction) secreting interferon-gamma that stimulates macrophages and enables bacterial killing. Similarly, interferon-gamma-activated macrophages release TNF alpha that promotes the collection and aggregation of macrophages and T cells to form granulomas in the lungs and regional nodes.
Besides, the destruction of mycobacteria-infected macrophages causes central caseous necrosis and tissue damage. The granuloma limited the spread of infection and is referred to as a ghon focus if located in the middle/lower lung zones. A collection of ghon focus, regional lymph node, and linking lymphatic forms ghon complex (Hunter, 2018). At this point, the progression of the disease depends on the immune status. For instance, an infection may be cleared by the host, or persist as latent tuberculosis, or the granulomas may undergo fibrosis and calcification to form Ranke complex if sufficient immune status. Insufficient immune response results in progressive primary TB and can also facilitate reactivation of latent Tb leading to secondary tuberculosis.
Primary TB is usually asymptomatic. Nevertheless, clinical features include constitutional, pulmonary, and extrapulmonary manifestations owing to its multisystemic presentation (Carvalho et al., 2018). Constitutional symptoms include low-grade fever, anorexia, malaise, and weight loss while pulmonary symptoms include productive cough, shortness of breath, and pleuritic chest pain. TB meningitis presents with headache, mental status changes, and low grade/absent fever. Skeletal TB includes back pain, lower extremity paralysis, and tuberculous arthritis while gastrointestinal TB nonhealing ulcers, malabsorption, dysphagia, diarrhea, and hematochezia (Carvalho et al., 2018). Furthermore, genitourinary TB manifests as frequency, flank pain, and hematuria. Other manifestations include miliary TB, TB pericarditis, adrenal TB, and cutaneous TB. Finally, TB lymphadenitis presenting as lymphadenopathy is the commonest extrapulmonary presentation.
Medical and Psychosocial Concerns
Patients with diagnosed or suspected TB usually have multiple concerns including medical and psychosocial concerns. For instance, medical concerns expressed by this patient include the diagnosis, procedures, general drugs, duration of treatment, side effects of drugs, compliance to treatment, and resistance to treatment. These concerns result from being aware of the general approach to patients in a clinical set up mostly due to the previous encounter or thorough perusal. On the other hand, psychosocial concerns include fear of stigma, lack of social support, negative emotional states, depression, and anxiety. The patient is usually aware of this condition thus anxious and depressed due to fear of its side effects. Furthermore, the duration and cost of treatment necessitate social support. Finally, the condition is highly infectious which makes a TB patient afraid of isolation or rather a stigmatization.
Implications of Treatment Regimen
Treatment of TB involves two phases. A 2-month intensive phase with rifampin plus isoniazid, pyrazinamide, and ethambutol and a 4-month continuation phase with rifampin plus isoniazid (Adigun & Singh, 2022). However, the continuation phase can be extended by 3 months if, at the end of the intensive phase, the sputum is still positive. Drug-resistant TB is usually managed by second-line drugs such as aminoglycosides (amikacin, kanamycin, capreomycin, streptomycin), fluoroquinolones (levofloxacin, moxifloxacin), ethionamide, cycloserine, and para-aminosalicylic acid. On the other hand, latent TB can be treated by isoniazid plus rifapentine once weekly for 3 months or rifampin daily for 4 months or isoniazid daily for 6 months. Compliance is a critical element of TB treatment and therefore daily dosing or 3 times weekly dosing (no HIV/low risk of relapse is preferred). Likewise, the choice between self-administered and directly observed therapy has to be made (Hunter, 2018). Finally, monitoring and assessment of drug-specific side effects of medications are imperative including hepatotoxicity, optic neuritis, peripheral neuropathy, arthralgia.
Role of Community Clinic
Community clinics focus on availing primary health care services to TB patients that are hindered from seeking these services elsewhere. The community clinic notifies undocumented TB patients to the local health department and establishes connections to link them to TB support programs (Sinha et al., 2020). Moreover, these clinics provide equipped medical staff to assess, diagnose and initiate treatment for these patients. Similarly, the clinic provides patient education and provide infection control practices that limit the spread of the disease (Sinha et al., 2020). Several resources are in existence at the community health centers and include primary care physicians, nutritionists, laboratory services, pharmacy, nurses, infection prevention services, patient education materials, community health workers, community-based TB programs, resources for TB screening and testing, comprehensive care clinics, genotyping and TB surveillance data (Sinha et al., 2020). All these resources facilitate the comprehensive management of TB. Finally, the cost of treatment of TB is relatively cheaper for subsidized compared to unsubsidized since the subsidized are given small grants to address their travel, nutrition, electricity, and medications along with hospitalization that limits the development of drug resistance.
Implications of TB for critical Care and Advanced Practice Nurses
TB is a multisystemic disease with devastating effects if not treated promptly. Consequently, critical care and advanced practice nurses have essential roles as far as TB is concerned. Firstly, they ought to ensure that patients are given the right medication in addition to supporting the patients as well as relatives to enhance compliance and diminish relapses (Akande, 2020). Secondly, they should provide continuous education to patients as well as monitor the side effects of the treatment regimens. Nurses should further use their comprehensive knowledge of TB to identify TB cases, notify and make appropriate referrals for timely interventions (Akande, 2020). Finally, being a highly infectious disease, nurses advanced practice nurses should institute proper infection control measures and practices to prevent transmission.
TB is a highly infectious but preventable disease. It is imperative to evaluate both the medical and psychosocial concerns of a patient. The community health centers, as well as nurses, play a critical role in the management of TB. Treatment for TB usually faces hurdles including long duration of treatment, compliance issues, side effects of drugs, and the emergence of drug-resistant tuberculosis.
Adigun, R., & Singh, R. (2022). Tuberculosis. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441916/
Akande, P. A. (2020). Knowledge and practices regarding tuberculosis infection control among nurses in Ibadan, south-west Nigeria: a cross-sectional study. BMC Health Services Research, 20(1), 280. https://doi.org/10.1186/s12913-020-05156-y
Carvalho, A. C. C., Cardoso, C. A. A., Martire, T. M., Migliori, G. B., & Sant’Anna, C. C. (2018). Epidemiological aspects, clinical manifestations, and prevention of pediatric tuberculosis from the perspective of the End TB Strategy. Jornal Brasileiro de Pneumologia: Publicacao Oficial Da Sociedade Brasileira de Pneumologia e Tisilogia, 44(2), 134–144. https://doi.org/10.1590/s1806-37562017000000461
Hunter, R. L. (2018). The pathogenesis of tuberculosis: The early infiltrate of post-primary (adult pulmonary) tuberculosis: A distinct disease entity. Frontiers in Immunology, 9, 2108. https://doi.org/10.3389/fimmu.2018.02108
Sinha, P., Shenoi, S. V., & Friedland, G. H. (2020). Opportunities for community health workers to contribute to global efforts to end tuberculosis. Global Public Health, 15(3), 474–484. https://doi.org/10.1080/17441692.2019.1663361
Conduct an evidence-based literature search to identify the most recent standards of care/treatment modalities from peer-reviewed articles and professional association guidelines (www.guideline.gov (Links to an external site.)). These articles and guidelines can be referenced, but not directly copied into the clinical case presentation. Cite a minimum of three resources.
Answer the following questions:
1. What is the transmission and pathophysiology of TB?
2. What are the clinical manifestations?
3. After considering this scenario, what are the primary identified medical concerns for this patient?
4. What are the primary psychosocial concerns?
5. What are the implications of the treatment regimen, as far as likelihood of compliance and outcomes? Search the Internet to research rates of patient compliance in treatment of TB, as well as drug resistant TB.
6. Identify the role of the community clinic in assisting patients, particularly undocumented patients, in covering the cost of TB treatment. What resources exist for TB treatment in community health centers around the United States? Compare the cost for treatment between subsidized and unsubsidized.
7. What are the implications of TB for critical care and advanced practice nurses?
The use of medical terminology and appropriate graduate level writing is expected.
Your paper should be 4â€“5 pages, excluding cover page and references page.