scenario

• Haemoptysis


  Coughing up blood
• Sabino


  • 35-year-old primary school teacher
  • Cough for 3 months, getting worse
  • Coughing up blood for 2 weeks
• Presenting Complaint


  1. Sabino has had a cough for the past 3 months which is getting worse

  2. For the past 2 weeks, he has been coughing up blood
• History of the Presenting Complaint

  1. Sabino started coughing about 3 months ago

  2. Cough was dry at first, then became productive, with white sputum

  3. Sputum became blood-streaked about a month ago

  4. For the past 2 weeks, he has coughed up about a teaspoonful of blood, 2 or 3 times a day

  5. Yesterday he coughed up a large amount of blood
• Sabino has no chest pain, and no shortness of breath
• Sabino has fever sometimes (not measured), but no chills. He has had night sweats, for about a month
• Sabino's appetite is not as good as it used to be several months ago
• Sabino thinks he has lost weight -- his pants seem looser now, for the past month or so
• Sabino feels more fatigued these days. He has been missing about a day of school per week for the last month. Also, he does less work around the house than he used to, due to fatigue
• Past Medical History


  1. Sabino was admitted to hospital 1 year ago, for about a week, for the same complaint of coughing blood

  2. He was given medicine, which he took for several weeks

  3. 10 years ago, Sabino went overseas for a mitral valve replacement with a tissue valve, for rheumatic heart disease
• Sabino has no known allergies
• Sabino is not taking any medications
• As far as Sabino knows, no one in his family has tuberculosis or cancer
• Sabino's mother is still alive and well. His father died many years ago – he had a cough for a long time
• Sabino has two brothers and one sister, all are well. His wife and children are well
• Sabino


  • Married with two children, aged 6 and 3
  • School teacher, teaching Class 4, for 10 years
  • His family, his mother, and his wife's brother stay in a 2-bedroom flat in town
  • Water is from the town supply. Flush toilet
  • He does not smoke cigarettes. He occasionally drinks alcohol, six beers in a weekend
• Physical Examination


  • Sabino is a thin male, slightly pale
  • Temp – 38.2; Resp rate – 16/minute; Heart Rate - 72/minute; Blood pressure – 135/80; Height 178 cm; Weight 63 kg
  • His conjunctivae are slightly pale. No palpable anterior or posterior cervical lymph nodes
  • No clubbing, no cyanosis. His chest is symmetrical on inspiration, without indrawing
  • His trachea is midline. His chest expansion is symmetrical
  • Normal resonant percussion note throughout
  • Coarse crackles are heard in the upper chest on the right side, especially anteriorly
  • The JVP is normal. The 1st and 2nd heart sounds are normal. There are no murmurs
  • Symmetrical abdomen, soft, non-tender, no masses, no hepatosplenomegaly. Bowel sounds are normal
• Sputum


  • Gram stain: normal flora
  • Acid-Fast Bacilli stain (AFB stain): AFB seen, 10 per high power field
  • Bacterial culture: Negative
  • Mycobacterial culture: Sent
• Chest X-ray


  Infiltrate in the apex of right lung; evidence of cavitation in the right upper lobe
• Full blood count


  Hb 10.5 grams/dl; PCV 34%; WCC 13,500/mm3; Platelets 200,000/mm3
• Blood film: Normocytic, normochromic RBCs
• HIV test: Sent
• Information from previous admission

  1. Sabino's sputum was positive then for AFB

  2. He had been treated with 3 anti-tuberculosis medications (Isoniazid, Rifampicin, and Pyrazinamide) in hospital for 10 days

  3. He was discharged home with one month's supply of medications

  4. He was booked for a follow-up appointment one month later, but did not appear for follow-up appointment, and was lost to further follow-up
• Management


  1. Sabino was started on treatment for tuberculosis with four anti-tuberculosis medications daily in hospital: Isoniazid, Rifampin, Pyrazinamide, and Ethambutol

  2. Contact tracing was carried out. Five students in the classroom had positive Mantoux skin tests (induration > 10 mm), as did all of the children in Sabino's household. None had symptoms of active tuberculosis. The students in the classroom with positive Mantoux and his children were given prophylaxis with Isoniazid for 6 months. The adults in the household were followed closely for development of symptoms
• Outcome


  1. After one week in hospital, Sabino's fever and haemoptysis resolved, and he started feeling better. His appetite improved. After two weeks in hospital, he began to gain weight

  2. He was discharged from hospital after two months of daily medications, directly observed

  3. The result of the sputum culture sent for MTB culture was reported positive for Mycobacterium tuberculosis after 6 weeks. The organism was sensitive to Isoniazid and Rifampin

  4. His HIV test result was negative

  5. On discharge from hospital, Sabino was advised to come to the public health department at the hospital three times a week, to receive his medications. A nurse was responsible for administering his medicines, and making sure he swallowed them on each visit. If he missed any visit, she was to phone him to remind him of his visit

  6. After two months of treatment, the medications were changed to Isoniazid and Rifampin, three times weekly, also directly observed by the public health nurse under the same arrangements

  7. Sabino completed 6 months of directly observed therapy, and remained asymptomatic 1 year later

  8. He was also restarted on Benzathine penicillin injections for rheumatic fever prophylaxis
• Hospital staff responded to community concerns about children at risk of TB infection, by doubling their efforts to find and treat active cases of tuberculosis, as the most reliable way to control tuberculosis in the community
• Finding active cases could best be done by tracing contacts of already-known cases
• Curing those found to have active TB could best be done by supervising every dose of medication for six months of therapy: daily therapy for two months, thrice weekly therapy for four months