Ubuntu #1: Not another tachypnoeic pregnant patient!
Guest Author: Dr Neville Vlok | Editor: Dr Katya Evans
- Mrs V is a 35 year old G3P2 female at 32 weeks pregnant by dates. She was referred to Ubuntu hospital for IVI antibiotics after being seen at the local clinic with a diagnosis of “severe pneumonia”.
- Complaints: dyspnoea & cough x 10 days – already receiving her second course of oral antibiotics.
- Background: she admits that she is sharing not only cigarettes, but also illicit smoked drugs (methamphetamines) with someone that has active pulmonary tuberculosis. Previous encounters with healthcare services included 2 previous uncomplicated vaginal deliveries & a stab wound to the left chest which required an intercostal-drain.
“Not another substance-abusing woman in labour” you think whilst the melody of moans, groans & monitor-alarm overtones fill the hospital.
- Obstetric & abdominal exam: non-significant with the uterus size corresponding with the 32 weeks given as history.
- Resp exam: decreased air entry in the lower left zone
- CVS: low-output status is suspected – pulse is noted to be of low volume, rapid with cool peripheries & soft cardiac tones. Jugular veins are distended
- Calves: soft, which is reassuring
Note: Globular heart with increased cardio-thoracic ratio. (Also note: X-ray being held up against window in true Ubuntu Hospital style due to lack of functional X-ray viewing box / electronic X-rays.. gives clue as to developing world location of patient..)
12 Lead ECG
Point of care ultrasound
- Working at Ubuntu Hospital your number 1 differential is TB pericarditis as you acknowledge the major difference in the aetiology of pericardial effusion in developed vs developing countries.
- TB accounts for 69% in developing countries compared to only 4% in developed!
- After pericardiocentesis – admitted to the obstetric highcare unit for cardiovascular & fetal monitoring.
- Diagnosis of HIV infection was made with a CD4 count of +/-500 & high viral load.
- Whilst awaiting culture & biochemistry of pericardial fluid she was started on standard 4-drug TB regimen as well as 10mg Prednisone on advice of the cardiologists.
- Day 4: Her stay was uncomplicated & she spontaneously went into labour, she delivered a healthy female infant via C-section with no complications.
- Day 6: discharged from the highcare to the ward.
- She was kept for another 14/7 of observation in the medical-obstetric ward, discharged with no recurrence of the tamponade, only a small residual uncomplicated effusion.
- 3 sets of sputum were negative for TB (?poor technique/non productive cough), as well as TB culture from the pericardial fluid. Cytology revealed scanty atypical cells of uncertain origin. Thus the diagnosis of TB not microbiologically proven, but favourable response on anti-tuberculous treatment prompted a 9 month course of TB treatment.