Post on 01-Jan-2016
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Management of Tuberculosis: A Surgical Perspective
Management of Tuberculosis: A Surgical Perspective
Alfred Lardizabal, MDAssociate Professor
Division of Pulmonary and Critical Care MedicineUMDNJ-NJ Medical School and Global Tuberculosis
Institute
Case #1- HistoryCase #1- History
• WW, 38 year old male
• April 1999, AFB(+)
• Treatment with IRZE (self-administered)
• July 1999: AFB 2+
• Referred by the private MD in July 1999 for the management of pulmonary tuberculosis
July 15, 1999
Case #1 – Culture ResultsCase #1 – Culture Results
• By August 1999, culture was identified as M. tuberculosis; resistant to I,R,Z,E
• Specimen sent for 2nd line drug susceptibility testing
• I,R,Z,E continued during interim period
Case #1 – Susceptibility ResultsCase #1 – Susceptibility Results
• CDC– Resistant: RIF/RBT; INH; PZA– Sensitive: SM / CM / AK; EMB; CIP; CS; ETA
• NJMRC– Resistant: RIF/RBT; INH; PZA– Sensitive: SM / CM / AK; EMB; CS; PAS; CIP/OFL;
CLA; CLO
Case #1 – Subsequent RegimenCase #1 – Subsequent Regimen
• Treatment regimen changed by 8-24-99: – Capreomycin 1 gm IM 5 X/week– Levofloxacin 500 mg OD– Cycloserine 750 mg OD– Clofazimine 300 mg OD– Clarithromycin 500 mg BID
Sputum Smear & Culture - 1Sputum Smear & Culture - 1
• 7-13-99 AFB 2+ M.tb
• 8-24-99* AFB TNC M.tb
• 9-21-99 AFB <1+ M.tb
• 10-19-99 neg neg
• 11-16-99 neg neg
• 12-14-99 neg neg
• 1-18-00 neg neg
September 21, 1999
January 10, 2000
Sputum Smear & Culture - 2Sputum Smear & Culture - 2
• 3-7-00 AFB neg M.tb
• 4-17-00* neg neg
• 4-28-00 neg M.tb
• 4-29-00 neg M.tb
• 5-1-00 neg M.tb
• 6-1-01 neg M. tb*capreomycin was discontinued after 8 mos.
Pre-Op Pre-Op
• By June 2000, pt. continued to have positive sputum cultures (AFB-)
• CT Chest was requested
• Preparation and evaluation for adjunctive surgery was started
• FOB/Bronchial biopsy Sept 2000 – RUL bronchus clean
June 2000
Post-Op Medical Management - 1Post-Op Medical Management - 1
• NJMRC Sept 2000– Resistant: RIF/RBT; INH; PZA– Intermediate: CLO; CIP; CLA– Sensitive: SM / CM / AK; CS; PAS; EMB; ETA
• Treatment Oct 2000: EMB; SM; PAS; CS
• Discontinued CLA, CLO, LFX
Sputum Smear & Culture - 3Sputum Smear & Culture - 3
• 8-8-00 neg MTBC
• 9-1-00 +1 MTBC
• 10-3-00 +1 MTBC
• 12-7-00 +1 MTBC
• 1-5-01 +1 MTBC
• 6-3-01 +1 MTBC
May 2001
Post-Op Medical Management - 2Post-Op Medical Management - 2
• Patient was admitted for a right upper lobectomy 6-10-01
• Discharged home on EMB, PAS, SM, CS
• Persistent GI complaints prompted D/C of PAS and changed to gatifloxacin by 7-1-01
• Post-surgery patient remained smear and culture negative
June 17, 2001
August 20, 2001
October 1, 2002
Post-Op Medical Management - 3Post-Op Medical Management - 3
• CM continued until Feb 2002 (15 months)
• EMB, CS, GFX continued until Dec 2002 (18 months post-surgery) remaining smear and culture negative
Follow-Up - 1Follow-Up - 1
• On the January 2004 follow-up patient had no complaints. He gained 20 lbs. since the last visit 6 months prior
• Chest x-ray and sputum cultures have been negative up to this point
January 2004
January 2004
Follow-Up - 2Follow-Up - 2
• Jan 2004 Sputum: AFB1+: MTBC
• Started EMB, CS, PAS, CM, linezolid (Zyvox)
• NJMRC:
• Resistant: INH, RIF, PZA, LFX
• Sensitive: PZA, EMB, SM/CM/ ETA, CS, PAS
• CM stopped after 8 months
• Sputum conversion by March 2004
• Remained sputum negative
July 2004
August 2004
Follow-Up RegimenFollow-Up Regimen
• Current regimen started 2/04; discontinued 24 months after sputum culture conversion
– CM – 7 mos.
• Remains smear and culture negative >2 years after treatment completion
EMBCSLIN
24 mos
Case #2 - HistoryCase #2 - History
• 53 year old Hispanic female with a history of breast carcinoma
• Has had chemotherapy and radiation therapy after total mastectomy of her right breast the last cycle of chemotherapy was given in May 2007
• On follow-up, PET/CT revealed positive uptake in the lung and colon
Case #2 – Chest X-rayCase #2 – Chest X-ray
September 2007
September 2007September 2007
Case #2 – Surgical InterventionCase #2 – Surgical Intervention
• Wedge resection of the right lung nodule as well as a colonoscopy was planned
• Lung tissue from the wedge resection was AFB+
• Biopsy of the colon was also AFB+
Case #2 – Post-Op TreatmentCase #2 – Post-Op Treatment
• Treatment with RIPE started
• Culture of lung tissue and sputum positive for M. tuberculosis
• DST: sensitive to RIPE,SM
• Is currently on therapy and responding very well