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