Is a 5-day trial of prednisolone (corticosteroid) 20 mg appropriate for a 46 kg patient with tuberculosis (TB) pleurisy, experiencing continuous chest pain that worsens with breathing, and unable to take deep breaths, currently in the continuation phase of treatment with 4 months completed?

Use of Prednisolone in TB Pleurisy with Persistent Chest Pain

Prednisolone 20 mg daily for 5 days is appropriate and beneficial for a 46 kg patient with TB pleurisy experiencing continuous chest pain that worsens with breathing, as corticosteroids have been shown to provide more rapid symptomatic relief in tuberculous pleural effusions. 1

Evidence for Corticosteroid Use in TB Pleurisy

The American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America guidelines specifically address the use of corticosteroids in tuberculous pleural effusions. Two prospective, double-blind, randomized studies have demonstrated that:

• Patients with pleural tuberculosis who received prednisone had significantly more rapid resolution of symptoms including fever, chest pain, and dyspnea compared to those given placebo 1
• Patients who received prednisone experienced more rapid radiographic resolution of pleural effusions 1

Dosing Considerations

For this 46 kg patient in the continuation phase of TB treatment:

• The proposed 20 mg dose (approximately 0.43 mg/kg) is within a reasonable range for symptomatic relief
• The short 5-day course minimizes potential adverse effects while providing symptom relief
• This dose is lower than the doses used for tuberculous pericarditis (60 mg/day), which reduces risk of side effects 1

Safety Considerations

When using prednisolone in TB patients, important safety considerations include:

1. Infection risk: Prednisolone must only be used in conjunction with appropriate anti-tuberculous therapy, as the patient is already receiving 2

2. Monitoring: During the 5-day course, monitor for:

   • Improvement in respiratory symptoms
   • Any signs of worsening infection
   • Blood glucose levels, especially if the patient has diabetes

3. TB treatment status: The patient is in the continuation phase with 4 months of treatment completed, making the risk of corticosteroid-induced TB exacerbation lower than in early treatment 3

Potential Benefits

The short course of prednisolone may provide:

• Faster relief of pleuritic chest pain
• Improved ability to take deep breaths
• Better quality of life during the continuation phase of TB treatment
• Potentially more rapid resolution of pleural inflammation 1, 3

Potential Pitfalls

1. Masking of symptoms: Corticosteroids may mask signs of treatment failure or drug-resistant TB
2. Immune suppression: Even short courses can suppress immune function
3. Metabolic effects: Monitor for hyperglycemia, especially in patients with diabetes

Conclusion

Based on the evidence from randomized controlled trials, a 5-day course of prednisolone 20 mg is appropriate for this 46 kg patient with TB pleurisy experiencing persistent chest pain. The benefits of symptom relief outweigh the potential risks of this short-term therapy, particularly since the patient is already in the continuation phase of TB treatment.