Description
● Overview of the Case:
➣ Patient Profile: 47-year-old man with a history of hypertension-related chronic kidney disease (CKD).
➣ The main complaints were:
• Three months of fever.
• Numerous nodular skin lesions on the thighs, back, and belly.
• Inadvertently losing six kilogrammes of weight over three months.
➣ Previous History:
• Self-medicated with oral corticosteroids and analgesics for pain management after being diagnosed with undifferentiated arthritis.
• No history of contact with TB or pulmonary tuberculosis is known.
● Clinical Assessment:
➣ General Examination:
• Skin thinning, skinny limbs, and a puffy face are signs of long-term steroid use.
• Vital signs are stable, and there are no respiratory, lymphadenopathic, or organomegaly symptoms.
➣ Dermatological Findings:
• Tonnes of nodules on the thighs, back, and belly.
• Some lesions had ulcers, while others had thin crusts.
• The surrounding erythema was mild, and the lesions were not painful.
● Findings from Microbiology and Histopathology:
➣ Skin biopsy
• revealed the presence of non-caseating granulomas and chronic inflammatory cell infiltration in the perivascular area.
• No malignancy or fungal components.
➣ Molecular Testing:
• Mycobacterium tuberculosis infection was confirmed by MTB-PCR, which found MTB-DNA.
• Rifampicin sensitivity was maintained; no resistance was found.
★ Final Diagnosis: ➣ Numerous Cutaneous Tuberculous Abscess (Disseminated Cutaneous Tuberculosis) in an individual with Chronic Steroid Exposure and Chronic Kidney Disease.
Protocol
● Handling & Handling:
➣ Antitubercular Therapy (ATT):
• Started the usual four-drug course of ethambutol, isoniazid, rifampicin, and pyrazinamide.
• A dose modification for renal impairment was made.
• Six months is the whole projected duration.
➣ Supportive Management:
• Corticosteroid reduction and cessation gradually.
• Hygiene and wound care for ulcerated lesions.
• Monitoring for ATT toxicity and nutritional support.
• Consistent follow-up with the nephrology and dermatological teams.
● Nursing Management Strategies and Interventions:
→These problems are addressed by evidence-based nursing strategies that are customised to the patient's two diseases, chronic kidney disease worsened by immunosuppression brought on by steroids and tuberculosis:
➣ Customised Patient Instruction
• Offer tailored instruction on how to prevent the spread of tuberculosis, how to take medications as prescribed, and how crucial it is to finish ATT even after symptoms have subsided.
• Inform the patient about the renal diet, limiting fluid intake, and staying away from steroids and over-the-counter pain relievers.
To stop TB from spreading to family members, strengthen infection control procedures.
➣ Drug Administration
• Pay close attention to medication dosages, particularly antitubercular medications that are modified for renal function.
• To guarantee compliance and avoid missing doses, keep a record of your medication administration.
• Keep an eye out for negative pharmacological effects, such as hepatotoxicity (from isoniazid and rifampicin) and visual abnormalities (from ethambutol).
• Work with the nephrology team to arrange for routine monitoring of the renal profile.
➣ Prevention of Infection
•Use personal protection equipment (PPE), practise good hand hygiene, and take isolation measures until the patient is no longer contagious.
•Teach the patient and their family how to cough properly, how to dispose of dressings safely, and how to take care of wounds that have ulcers.
• To avoid subsequent infections, use aseptic approach when treating wounds.
➣ Management of Pain and Wounds
• Prior to and following interventions, measure pain using a standardised pain rating scale.
• In addition to prescribed analgesics, use non-pharmacological techniques (such as guided visualisation, relaxation, and distraction).
• Provide wound care every day, keep the wound healing environment moist, and keep an eye out for any indications of infection or slowed healing.
➣ Ongoing Nursing Assistance and Monitoring
• Arrange for routine follow-ups for dermatological evaluation, renal function monitoring, and ATT response evaluation.
• To improve treatment adherence, make use of reminder systems.
• Encourage lifestyle changes like eating a healthy diet and getting enough sleep.
➣ Psychological Support
• Provide counselling and emotional support to treat anxiety associated with long-term illness, deformities, and fear of infection.
In order to foster understanding and lessen stigma, encourage family involvement in care.
In the event that the patient displays indications of anxiety or depression, make mental health help accessible.
➣ Coordinated and Team-Based Care
•To provide comprehensive care, work with interdisciplinary teams that include nephrologists, dermatologists, and infectious disease specialists.
• Take part in case discussions to make sure that the management strategies for TB and CKD are in line.
•Report any early indications of drug toxicity or decline while keeping an eye on patient safety and therapeutic progress.
Notes
For more details visit https://doi.org/10.1016/j.clinpr.2024.100383