Medical nutritional therapy in infected bronchiectasis with impending respiratory failure: A case report.

OBJECTIVE: Bronchiectasis is a chronic infective and inflammatory respiratory disease that causes significant morbidity and mortality. Repeated respiratory infections may lead to infected bronchiectasis (IB) and acute exacerbations which often require hospital admission, increase risk of malnutrition and impact quality of life and eventually leads to death. Nutritional therapy is needed to modulate inflammation and enhance immunity to reduce severity of exacerbation, overcome malnutrition, as well as to decrease morbidity and mortality. METHODS: A 59-year-old female patient, diagnosed with IB. The patient had low oral intake due to productive cough and anorexia since 2 weeks before admission. Moreover, she had gradual shortness of breath that caused an impending respiratory failure during hospitalization, supported by continuous positive airway pressure (CPAP). Nutritional assessment was made based on Subjective Global Assessment (SGA) score C. Abnormal laboratory findings seen were increased in neutrophil-to-lymphocyte ratio (NLR) 9.3, moderate depletion of immune system with total lymphocyte count (TLC) 808.4/µl, hypoalbuminemia (3.2g/dl) and increased in liver enzymes: aspartate aminotransferase (AST) 206U/l, Alanine aminotransferase (ALT) 224U/l. Nutritional therapy was given gradually with target calorie 1400-1900kcal, protein 0.8-1.5g/kg IBW/day, carbohydrates 45-50%, and fat 33.3-43% through oral and parenteral nutrition. The patient was given supplementations such as vitamins (A, B complex, C, D), zinc, curcumin and snakehead fish extract high albumin content. RESULT: After 14 days of treatment, significant clinical and metabolic improvement in NLR, TLC, plasma albumin, liver enzymes (AST/ALT), blood gas analysis, and functional capacity (handgrip strength) were found. CONCLUSION: An adequate nutritional therapy with macro and micro-nutrients in IB patient can improve clinical outcome, nutritional status and quality of life.

Energy regulation in newly diagnosed TB with chronic energy deficiency: free fatty acids and RBP4.

BACKGROUND AND OBJECTIVES: Energy metabolism may be dysfunctionally integral between host and infective agent in active tuberculosis, mediated by adipocytokines and free fatty acids (FFA) as the products of triglyceride lipolysis in fat, blood or other tissues. Retinol Binding Protein 4 (RBP4) and asymmetric dimethylarginine (ADMA) are candidate adipocytokines. The possibility of a deleterious metabolic nexus in chronic energy deficiency (CED) (BMI <18.5 kg/m2) is explored. METHODS AND DESIGN: Newly diagnosed patients with tuberculosis (n=63) were selected using consecutive random sampling at a Centre for the Care and Treatment of Lung Diseases in Makassar, Indonesia. Diagnosis of pulmonary TB required microscopy with Ziehl-Neelsen stain. Anthropometric measurements were taken. Venesection allowed glomerular filtration rate, FFA, serum glutamic oxaloacetic transaminase and glutamate-pyruvate transaminase to be assessed. RESULTS: CED was evident in 60.3%. For the well and lesser nourished, medians were, respectively, FFA 0.30 and 0.37 mmol/mL (p=0.960); RBP4 199730 ng/mL and 11721 ng/mL (p=0.009); GFR 106 ml/min and 113 ml/min (p=0.673); and ADMA 0.52 ng/mL and 0.51 ng/mL (p=0.172). BMI and serum RBP4 were correlated (ρ=0.52, p<0.001), with odds ratios (OR) 5.8 (CI 1.68-20.3). RBP4 in CED was lower than in better nourished patients. Serum FFA is not evidently associated with BMI in patients with active TB. CONCLUSIONS: RBP4 is some 6-fold lower when active TB patients have CED than when BMI >25 kg/m2. However, FFA was not associated with CED in these active TB patients which may be a type 2 error or represent an energy impasse where infection and the host's metabolic needs are in competition.