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Vol 2 | Issue 3 | Jul – Sep 2023                                                                           Indian J Pharm Drug Studies | 124 

Case Report 

Unraveling the Enigma of Anti-Tubercular Drug-Induced Vitamin B6 

Deficiency and its Role in Provoking Convulsive Seizures - A Revelatory 

Case Report 

Utpal Bhui1, Subhajit Sarkar1, Joy Das1, Indra Kumar Ghoshal1, Abhik Saha2, Bimlesh Kumar3 

From, 1PG Student, School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, 
2Pharmacovigilance Associate, R. G. Kar Medical College, Kolkata, West Bengal, 3Professor, Department of Pharmacology, 

School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, India. 

ABSTRACT 

The 65-year-old female patient with active tuberculosis who was hospitalized to the primary hospital and was on Category 1 

Antitubercular Drugs (Cat 1 ATD) is the subject of this case report. The patient had complications, a reduced appetite, had 

stopped eating, was nauseous, and had vomited. Eight months prior, the patient has prescribed the first-line anti-tubercular 

medications rifampin, rifabutin, ethambutol, and isoniazid. Three months prior, the patient stopped taking the medicine. Now, 

as a result of an unfavorable drug reaction to anti-tubercular medications, the patient had acquired acute hepatitis and 

convulsive seizuresdue to vitamin B6 deficiency. 

Key words: Cat 1 ATD, Hepatotoxicity, Convulsion, Tuberculosis, Vitamin deficiency, Drug-drug interaction, Adverse drug 

reaction. 

ycobacterium tuberculosis, which induces 

tuberculosis (TB), is a potentially serious 

infectious bacterial disease that primarily 

affects the lungs. This illness spreads when a person 

inhales sputum splashes that enter through the mouth and 

nose, upper respiratory tract, and bronchi before reaching 

the lungs' alveoli and potentially attacking internal organs. 

The bacteria that cause tuberculosis can infect a lot of 

people without any symptoms. The most typical signs of 

this are fever, weight loss, night sweats, and coughing that 

occasionally has a bloody tint [1].As a result, even if 

effective chemotherapy is available, TB remains a serious 

health concern in the majority of countries. This is owing 

to low patient adherence, primary multidrug resistance, 

and interruptions partly brought on by adverse drug 

reactions (ADRs). As a result, more resistant strains 

evolve, necessitating second-line therapy with more 

expensive medications and significant ADRs. 

Access this article online 

Received – 20th May 2023 

Initial Review – 29th May 2023 

Accepted – 1st June 2023 Quick Response Code 

ADRs significantly increase patient morbidity and 

mortality, which drives up healthcare costs and is a major 

issue for the common people, the pharmaceutical industry, 

regulatory agencies, and the medical community 

[2].Depending on the severity of the condition, taking 

medicine for TB might last between 6 and 9 months. The 

United States Food and Drug Administration (USFDA) 

has currently approved 10 medications for the treatment of 

TB. Isoniazid (INH), Rifampin (RIF), Ethambutol (EMB), 

and Rifabutin are recognized medications (RB) [3]. WHO 

estimates that TB affects one-third of the population and 

dies one in every four adult males. Primary anti-TB 

medications have the potential to be hepatotoxic. Anti-TB 

medications INH, RIF, and RB produce hepatotoxicity like 

2 transaminases and severe hepatitis failure, which are 

mentioned in the first line. Depending on the 

hepatotoxicity diagnosis criteria, the Anti-TB medication 

can cause hepatotoxicity in 3 to 30% of cases [4]. Seizures at 

standard doses are incredibly rare to be documented. This 

case study describes a convulsive seizure that happened 

after receiving a short-term therapeutic dose of INH. 

_______________________________________ 

Correspondence to: Utpal Bhui, Jhanjhra Colony, B type 

30/178, Paschim Bardhaman, West Bengal- 713385 

Email: bhuiutpal875@gmail.com , Tel: +91 7001719578 

M 

mailto:bhuiutpal875@gmail.com


Bhui U et al.                                                                       Anti-Tubercular Drug-Induced Vitamin B6 Deficiency 

Vol 2 | Issue 3 | Jul – Sep 2023                                                                           Indian J Pharm Drug Studies | 125 

CASE REPORT 

Despite having a known case of pulmonary tuberculosis 

and being on Cat 1 ATD, a 65-year-old female patient 

recently presented with the cause of appetite, decreased 

food intake, nausea/vomiting, and extreme fatigability. She 

is a known case of TB from eight months ago in the 

patient's previous medical history. An old high resolution 

CT scan thorax showed irregular cavities in the right upper 

and lower lobes, centrilobular nodules in both lungs 

collapsing with bronchiectasis in the right middle lobe, and 

a tiny (R) para tracheal pulmonary Koch's infection found 

on the chest. The ECG report overloaded the left atrium 

excessively, and an ultrasound scan reveals a bladder 

outflow obstruction. 

Table 1 - Laboratory Investigation 

 

On admission, the patient was started on antibiotics, 

hepatoprotective medications, laxatives, and a single anti-

tubercular drug were used as part of this therapeutic 

regimen to treat the main symptoms of appetite loss, 

nausea, and exhaustion. Decreasing the levels of 

SGOT/AST, SGPT/ALT, direct and indirect bilirubin, and 

bilirubin. Antibiotics, Anti-tubercular agents, and 

Hepatoprotective agents for the treatment of severe 

tuberculosis in the patient and reducing the bilirubin range 

but the patient developed a disturbance of consciousness 

and Tonic-clonic convulsions (Figure 1).  

On examination, her blood pressure was 180/92 

mmHg, her temperature was 36.3ºC, her heart rate was 107 

beats/min, her respiratory rate was 26 breaths/min, and her 

oxygen saturation was 97% on room air. The findings of 

the systemic examination was normal. No abnormal 

findings were detected on head CT scans. The user 

laboratory finding for causes of convulsion was absent, 

except for the important finding of the patient's serum, 

vitamin B6 level was low (Table 1). This leads us to 

diagnose the patient with convulsive seizure due to 

vitamin B6 deficiency is associated with isoniazid which is 

involved in the Cat 1 ATD. The justification for thera-

pystops Cat 1 ATD, causing hepatotoxicity and convulsive 

seizure to the patient. During follow-up, no medication 

interactions are discovered after rational drug 

administration. 

 
Figure 1: Clinical course of the patient. Convulsive 

seizure occurred eleven days after the administration 

of antitubercular drugs. Seizure refractory to standard 

anticonvulsant therapy were controlled with the 

administration of pyridoxal phosphate hydrate 

(vitamin B-6). EMB: Ethambutol, RIF: Rifampin, 

INH: Isoniazid, PHT: Phenytoin. 

DISCUSSION 

In India, 8-36% of cases of drug-induced hepatotoxicity 

occur. Asian nations have a greater rate of drug-induced 

hepatotoxicity (DIH), which may be attributed to racial 

vulnerability, the peculiarities of drug metabolism, and the 

existence of numerous known risk factors such HIV 

infections, nutritional deficiencies, and alcoholism [5]. The 

causes of hepatotoxicity in patients range between 1 and 

10% across different nations, depending on elements like 

social and economic situations as well as geographic 

location. India (8–10%) has the highest rate of drug-

induced hepatotoxicity, which may be related to genetics, 

chronic viral hepatitis, malnutrition, and drunkenness [6]. 

In the intrinsic phase of treatment, which is determined by 

the etiology of the second-line injectable agent, the WHO 

has recommended at least five medications [7].  

It is classified as a conditional recommendation with 

extremely low assurance in the estimate of the effect that 

Name of the test Day 2 Day 5 Day 10 

Serum Bilirubin 

(0.2-1 mg/dL) 

4.6  7.4  2.7  

Direct Bilirubin 

(0-0.2 mg/dL) 

3.5  1.9  1.4  

Indirect Bilirubin 

(0.3-1.0 mg/dL) 

1.9  3.0  1.4  

SR. Total Protein 

(6-8 g/dL) 

5.6  7.2  7.9  

Albumin 

(3.4-5.4 g/dL) 

2.9  3.0  3.9  

Globulin 

(2-3.5 g/dL) 

3.0  4.0  2.4  

S.G.O.T 

(4-17 IU/L) 

671.8  165  19  

S.G.P.T 

(3-5 IU/L) 

132.9  50  18  

Alkaline Phosphatase 

(44-147 IU/L) 

136.4  104  90  



Bhui U et al.                                                                       Anti-Tubercular Drug-Induced Vitamin B6 Deficiency 

Vol 2 | Issue 3 | Jul – Sep 2023                                                                           Indian J Pharm Drug Studies | 126 

the recent WHO moves to prescribe at least 4 effective 

medications at the beginning of treatment is effective. 

Note that the 2019 WHO guidelines and our guideline 

committee both promote the use of newer, more effective 

oral medicines with better repurposing and downplay the 

use of injectable treatments [8]. 

The new WHO recommendation for the previous 

approach is multidrug-resistant TB (MDR-TB) and are 

rifampin resistance TB (RR-TB) in several regards; 

levofloxacin or moxifloxacin may be used. For 

fluoroquinolone, levofloxacin is advised because to its 

safety profile and lower risk of medication interactions [9]. 

Isoniazid can cause various adverse events. Central 

nervous system (CNS) effects, such as headache seizure, 

dysphoria, and irritability, have been reported. CNS effects 

occur due to vitamin B-6 deficiency; in the patient's case, a 

deficiency of vitamin B-6 of regarded to be a cause of 

patient convulsions and seizures because the serum 

vitamin B-6 level was administration was low [10]. 

CONCLUSION 

The case is unique because the patient developed 

hepatotoxicity and convulsion seizures due to an adverse 

drug reaction of Cat 1 ATD. The supplementation of 

vitamin B-6 is recommended in patients with other 

conditions indicative of subclinical vitamin B-6 deficiency 

to prevent the central nervous system effect. The patient 

was diagnosed with Pulmonary Koch’s Infection, where 

standard treatments are provided to a patient to reduce the 

level of ALT/AST. Clinical advancements and positive 

patient outcomes are future goals that we can accomplish. 

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How to cite this article: Utpal Bhui, Subhajit Sarkar, 

Joy Das, Indra Kumar Ghoshal, Abhik Saha, Bimlesh 

Kumar.  Unraveling the Enigma of Anti-Tubercular 

Drug-Induced Vitamin B6 Deficiency and its Role in 

Provoking Convulsive Seizures - A Revelatory Case 

Report. Indian J Pharm Drug Studies. 2023; 2(3) 124-

126. 

Funding: None            Conflict of Interest: None Stated 

 

https://www.mayoclinic.org/diseasesconditions/tuberculosis/symptoms-causes/syc-20351250
https://www.mayoclinic.org/diseasesconditions/tuberculosis/symptoms-causes/syc-20351250

