藥物性肝炎而未完治但拒絕住院隔離治療之活動性肺結核居家個案報告

Active Pulmonary Tuberculosis with Incomplete Treatment owing to Drug-induced Hepatitis plus Refusal to Observe Compulsory Isolation: A Home Care Case Report

活動性肺結核若未隔離治療，在社區存在傳染風險，若難治居家病人拒絕住院，居家醫療醫師及護理師將面臨困境。本文報告一位87歲女性，主訴喘及胸痛至急診，大量血性心包積液接受手術引流後仍喘，3套痰液塗片耐酸性染色顯示陽性，診斷為肺結核即轉隔離病房接受抗結核藥物治療。給藥第10天因藥物性肝炎而停用抗結核藥物，停藥後連續塗片染色陰性而出院接受居家醫療。日後結核菌培養報告有結核菌，但家屬拒絕住院以重新用藥。此個案提醒居家醫師及護理師若遇到類似病況時，了解抗結核藥物肝毒性處置指引、強制隔離就醫治療相關法規、主責單位和流程，並依醫學倫理思考、從出院準備開始改善，方能做出較適當的決策及處置。

 

Active pulmonary tuberculosis without isolation may increase risk of community infection. Family physicians and nurses are often put into a difficult situation when complicated patients refuse hospitalization. The article presents an 87-year-old woman with dyspnea and chest pain visiting the emergency department. Massive bloody pericardial effusion was drained by pericardial-pleural window, but dyspnea with productive cough still persisted. Three sets of acid-fast stain showed positive; tuberculosis was accordingly diagnosed. She was transferred to isolation ward and received anti-tuberculosis drugs discontinued on the 10th day of treatment due to drug-induced hepatitis. She was then discharged with improved symptoms and continuous negative findings of acid-fast stain. However, the sputum culture indicated the presence of tuberculosis after her discharge. Her family, however, refused to have her hospitalized again to restart the treatment. In the face of such a difficulty, family physicians and nurses need to make proper decisions by understanding the guidelines for treating hepatotoxicity of anti-tuberculosis drugs, as well as the competent authorities, procedures, and relevant laws and regulations of compulsory isolation. Last but not least, it is also vital to consider medical ethics and to adjust discharge planning so as to facilitate optimal management.