tb clinical case conference: challenging cases from the ... 1_21_09.pdfyaware of cavitary lung...
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TB Clinical Case Conference:Challenging Cases from the
Southeast Region: Case 1Margaret Tipple, MDVirginia Department of Health, Division of TB Control
With clinical and laboratory perspectives from . . .Robert Dana Bradshaw, MD, MPHMax Salfinger, MD
Case PresentationChief Complaint and symptoms:
– 48 year old pastor on tourist visa from Congo [Africa]
– Developed cough with bloody sputum in early October 2008, two to three weeks after arrival in Virginia
– Symptoms worsened over a three day period prompting visit to local county emergency department
Case PresentationInitial evaluation:
– Temperature in emergency department: 99.5° F
– Based on his pulmonary exam and complaint of hemoptysis and cough, a chest X-ray was done
AdmissionChest X-ray
Chest CT
Chest CT
Case PresentationHospital Course:
– Patient admitted and placed in respiratory isolation
– Initial coverage with levofloxacin, later changed to other non-quinolone broad spectrum coverage
– TST placed and read positive at 20 mm
– HIV and AFB smears X 3 negative
– Bronchoscopy done; sputum and lung cultures sent but results not to be available for weeks
Case PresentationHospital Course, continued:
– ID consultant elicited additional history:
Patient took multiple antibiotics including ciprofloxacin for cough shortly before departure to US
Aware of cavitary lung disease since 1990’s but (due to language barrier) unsure of diagnosis, cause or previous Rx
– Patient placed on INH, rifampin, PZA, ethambutol at D/C for presumptive tuberculosis
– Local health department notified to follow up with directly observed therapy (DOT)
Case PresentationPost-hospital course and additional history:
– Patient began DOT with public health nurse supervision
– Partial health records obtained (in French language)
Initially treated for tuberculosis between 1993 and 1997
Presented with hemoptysis in 1998, and documented to have received six months of four drug therapy
AFB smears x3 and a culture were reported as negative at end of treatment
Report of a chest X-ray in 1999 noted RUL cavitary lesions
At least one other three drug course of treatment, including rifamate and ethambutol, was given in 2003
Case PresentationPost-hospital course, continued:
– Patient reported some problems taking TB medications previously, but initial DOT went well
– On December 5, about four weeks after admission and a little more than three weeks into four drug therapy, the laboratory reported growth of AFB in liquid media
– Specimens were forwarded to the Virginia state lab– Complicating matters, the patient was no longer
welcome at the original home where he was a guest and went to live in another home in an adjoining county
– His return flight to the Congo was scheduled for December 15, and he was anxious to return to family
Question 1
What do you think the chances are that this patient currently has tuberculosis?
1. 0-24%
2. 25-49%
3. 50-74%
4. 75-100%
Question 2
What do you think the chances are that this patient has multidrug resistant tuberculosis?
1. 0-24%
2. 25-49%
3. 50-74%
4. 75-100%
Question 3
What do you think would be the most appropriate next step?
1. Allow the patient to return home.
2. Contact the State TB Program to review options
3. Contact the CDC to review options
4. Initiate legal actions to stop the patient from leaving the country
Margaret Tipple, MD
Virginia Department of Health, Division of TB Control
Question 4
Which tests do you have available to assess a patient like this?
1. Smears and cultures with traditional susceptibility testing
2. Above tests and nucleic acid amplification testing for TB detection
3. Items in 1 & 2 and molecular susceptibility testing
Question 5
How long, on average, does it take you to receive sufficient information to confirm or rule out that a patient like this has tuberculosis?
1. 0-3 days
2. 3-7 days
3. 1-2 weeks
4. 2-4 weeks
5. More than 4 weeks
6. “Too long”
Question 6
What do you feel is an acceptable length of time to receive sufficient information to confirm or rule out that a patient like this has tuberculosis?
1. 0-3 days
2. 3-7 days
3. 1-2 weeks
4. 2-4 weeks
5. More than 4 weeks
6. “Too long”
Max Salfinger, MD
Chief of Bureau of Laboratories, Florida Department of Health
Question 7
Would you allow him to fly at this time?
1. Yes
2. No
Sundari Mase
Medical Team Lead
CDC/DTBE/FSE
Case PresentationSubsequent management:
– VDH consulted with CDC and SNTC regarding whether the patient was safe to travel
– In particular, could we quickly determine if he:
Actually has m. tuberculosisIf so, is this either MDR or XDR-TB?
– If we could not expeditiously answer these questions, what would we need to do to at this point?
Case PresentationOutcome:
– Arranged for PCR/NAAT testing at Virginia DCLS and Florida State laboratory
– PCR and NAAT testing indicated that the AFB source was NOT m. tuberculosis
– Hain test also negative
– After discussion with CDC and other experts, decision was made to allow patient to travel home to Congo
Final culture: Mycobacterium Avium Complex (MAC)
HAIN TESTING
TB Clinical Case Conference:Challenging Cases from the
Southeast Region : Case 2Derietra Neal-Ferguson RN, BSN, MPHPBCHD, Senior Community Health Nursing Supervisor, TB Nurse Case Managers
DW
The Client is a 55 year old white male who presented to a local hospital ED after a MVA in June of 08.
Patient was found to have an abnormal Chest X-ray
6/11/08
Initial TB Signs & Symptoms
TB Symptoms:
– 40 lb wt loss over 3 months (weight 129 lbs; Ht 5’9”)
– Night sweats
– Productive Cough
– Fever
– Denied hemoptysis
DW
PMH:
– History of IV drug use and chronic ETOH abuse.
– 2005 Acute Renal Failure 2nd to rhabdomyolysis and myoglobinurea
– S/P right leg fasciectomy – 2005 MRSA– Traumatic right eye injury resulting in
visual acuity of 20/200
DW
Patient left AMA but returned the following day with C/O SOB and coughing.
Given prior CXR findings, a CT of the Chest was performed
6-12-08
6-12-08
DW
Micro bacteriology– AFB sputa smears 3+ 6/12/08– Culture confirmed M. TB 06/08– Pan-sensitive to all first line TB medication reported 7/08
Out Patient Lab Results
Baseline TB profile
– BUN 13
– Creatinine .93
– Uric Acid 11.1* (Reference Range 2.5-9.0)
– Total Bilirubin 0.7
– SGOT/AST 17
Baseline urine drug screen
– Positive for Opiates
Additional Lab Results
HIV – Declined
Hepatitis Screen
– HBsAg Non reactive
– Anti HBS Non reactive
– Anti HBC Reactive
– Ant HCV Reactive
Medication Regimen
Initial TB Med Regimen
6/13/08
INH 300 mg
EMB 800 mg
PZA 1500 mg
Rifampin 600 mg
Med Regimen Adjusted
7/08 (Post Hosp DC)
INH 300 mg
EMB 1000 mg
PZA 1500 mg
Rifampin 600 mg
Vitamin B6 50 mg
Out Patient Course of Therapy
Continued on 4 drug therapy for approximate 5 weeksEMB discontinued upon confirmation of Pan-sensitivity to 1st line TB drugsPatient continued on daily regimen with self-administered week-end medications in pillboxesBy 8/11/08 negative for TB symptoms except SOB on exertion
Out Patient Course of Therapy
9/08 Client again reporting TB symptoms– Cough
– Night sweat
– SOB
– Fatigue
Sputa collect 8/19/08 are AFB smear positive 2+ 1+
Isolation precaution are reinitiated
NAA is requested, however TNP by lab
Cultures reported as M. TB positive on 10/08
9-15-08
6-11-08 9-15-08
Out Patient Course of Therapy
Pan-sensitive to 1st line TB meds reported on 10/21/08 from positive culture collected 8/08Drug levels Obtained (from National Jewish Hospital HPLC)
– Rifampin 3.82 at 2hrs (Range 8-24)– INH 2.05 at 2 hrs (Range 3-6)– PZA 30.82 (confirm with Jerry)
Medication Regimen Adjusted– Rifampin changed from 600 – 900 mg q day– INH changed from 300 – 450 mg q day
Evaluation of Subsequent AFB Positive Culture
Sputa Culture positive for AFB reported 11/08
Collection Date mid September, 08– 2 Sputa specimens collected on dates preceding were both negative
– Culture grown in liquid media
– PRA x 3 no bands
– Gene Probe was negative for MTB
Decision – Contaminated Culture, no evidence of TB
Repeat Drug Levels
2 hr 6 hrINH 4.2 2.1 (Peak 1.0-4.5 mcg/ml) RIF 9.9 TNP (Peak 4-32 mcg/ml)PZA TNP 37.2 (Peak 30-50 mcg/ml)
Collected 10/23/08 TNP for RIF due to exposed to lightTNP for PZA due to insufficient volumeDone by Quest/Nichols Institute by HPLCMedication Regimen Continued
Treatment Plan
Expected Treatment Completion Date March 09
– 1st Negative Culture Mid September 08
– Medication started 6/08
Continue to encourage Drug and ETOH counseling
– Risk for Drug Overdose
Continue to monitor for evidence of treatment failure
Current Patient Profile
Continues on daily DOT
– INH 450 mg
– Rifampin 900 mg
– PZA 1500 mg
Currently asymptomatic
Weight is 143 lbs (14 lb weight gain)
9-15-0812-22-08
6-11-08 12-22-08
Lessons Learned
Expanded role for molecular testing
– NAA
– HINES test for early identification of drug susceptibility
Legal consultation for Court Ordered Admission to A.G. Holley Hospital
Drug & ETOH Counseling efforts continue
Questions