Patient History 1 The Role of Surgery in the Management of TB Reynard McDonald, MD & Paul Bolanowski, MD September 16, 2010 42 y/o AA male was initially diagnosed with pansensitive pulmonary TB in 1986 and subsequently developed MDR- TB because of non-adherence in taking anti-tb medications Patient was followed by a Southern NJ chest clinic until he was lost to follow up in May 1996 At the time of disappearance, his physician concluded that his MDR TB is a serious threat to his contacts and potentially to the (community). Commitment proceedings should proceed immediately. Recommendation was not carried out at that time Patient History 2 On April 9, 1999, 13 years after initial TB diagnosis and 3 years after last follow up, patient presented to Southern NJ hospital with c/o hemoptysis, night sweats, and left chest pain was smear and culture positive for CXRs and CT scan of the chest revealed: Left pneumothorax with pleural thickening, an effusion, and LUL and LLL consolidation with cavitation No obvious disease was noted in the right lung A left chest tube was placed with re-expansion of the left lung and the patient remained intermittently febrile but otherwise well HIV serology was negative The chest tube was removed and the patient was transferred to Northern NJ hospital on May 4, 1999 Social History Patient denied recent use of IV drugs but had previous history of heroin use Patient was single and lived alone prior to hospital admission He planned to live with his mother upon discharge He has 3 children, 1 had a positive TST 25 pack/yr history of smoking and drinks socially 1
Hospital Course 1 Upon transfer, the patient was placed in respiratory isolation because sputum smears were positive for AFB (4) results revealed resistance to RIPE, ethionamide, and cycloserine CXR and chest CT revealed a left empyema with cavitary infiltrates in the left lung, pleural thickening and partial collapse of the left lung Hospital Course 2 On 5/12/99, the patient was started on the following regimen: Capreomycin (1 gm IM) 5x/wk PAS (8 gm AM; 4 gm PM) PO daily Clarithromycin (500 mg) PO BID On 5/19/99, EMB (2,400 mg PO daily) was added to the regimen and on 7/22/99 it was reduced to 2 gm PO daily On 6/28/99, Clarithromycin was d/c Baseline vision & hearing test results were normal at the start of therapy Surgical Intervention - 1 Bacteriology 1 On 5/13/99, the patient had a thoracotomy with placement of a chest tube in the left pleural space to drain the loculated left empyema (700cc) Fiberoptic bronchoscopy with bronchial biopsy and insertion of a mediport into the right subclavian vein were also done The empyema fluid cultured coagulase neg Staph epidermidis and 7-10-87 2-10-88 8-17-88 10-25-89 7-10-91 12-6-91 1-3-92 3-6-92 4-27-92 12-6-92 3-11-94 5-20-94 7-27-94 8-18-94 10-5-94 11-11-94 12-14-94 S: INH, RIF, EMB, SM R: INH, RIF R: INH, RIF S: EMB, SM R: INH, RIF S: EMB, SM R: INH, RIF S: EMB, SM, PZA R: INH, RIF S: EMB, SM, PZA, CS, KM, CM, ETA, PAS 2
Bacteriology 2 Bacteriology 3 1-25-95 2-24-95 2-7-96 4-3-96 5-16-96 7-3-96 8-23-96 11-18-96 Prison 3-13-97 3-19-97 4-10-99 5-6-99 5-10-99 4 3 R: RIP, ETA S: EMB, SM, CS, KM, CM, PAS, AK, Cipro, OFX R: RIPE, ETA, CS S: SM, CS, KM, CM, PAS, AK, Cipro, OFX R: RIP, RBT, Clarithromycin S: EMB, SM, CS, KM, CM, ETA, PAS, AK, Clofazimine, OFX, LFX R: RIPE 6-1-99 6-7-99 6-19-99 6-24-99 7-2-99 7-10-99 7-13-99 7-14-99 7-28-99 8-2-99 T-Tube LN Tracheal Sec Pleura Pl. Eff. Lung Skin Abscess 3 3 2 2 1 2 M.tb 5-14-99 5-24-99 Empyema 4 4 R: INH, RIF S: SM, EMB, PZA remained persistently positive on smear and culture for M. tuberculosis for approx. 12 years Treatment Course Results (Nat l Jewish) 6-29-99 On 6-29-99, results became available from a specimen collected 4-10-99 The regimen was modified as follows: Capreomycin (1 gm) IM 5x/wk PAS (8gm AM; 4 gm PM) PO daily Ethambutol (2400 mg) PO daily In July 1999, the patient s symptoms improved (cough & night sweats resolved), sputum smears were negative for AFB, and respiratory isolation was d/c Resistant INH 0.2 mcg/ml INH 1.0 mcg/ml RIF 1.0 mcg/ml PZA >300.0 mcg/ml Resistant (Tentative) RBT >0.5 mcg/ml Clarithromycin 32.0 mcg/ml Susceptible EMB 7.5 mcg/ml SM 2.0 mcg/ml SM 10.0 mcg/ml CM 10.0 mcg/ml KM 6.0 mcg/ml AK 4.0 mcg/ml CS 60.0 mcg/ml PAS 8.0 mcg/ml ETA 10.0 mcg/ml Susceptible (Tentative) Clofazimine 0.06 mcg/ml Cipro 1.0 mcg/ml Ofloxacin 2.0 mcg/ml LFX 2.0 mcg/ml 3
Surgical Intervention - 2 The patient s left lung failed to re-expand and he had a chronically draining left TB empyema A perfusion lung scan revealed that approximately 97% of the perfusion went to the right lung and 3% to the left lung and bedside spirometry revealed a vital capacity of >2L On 7/7/99, the patient had a left pneumonectomy Massive adhesions, thickened pleura and pus pockets were removed Patient continued to improve on the current regimen and remained sputum smear negative for AFB Complications 1 Patient became febrile with c/o of general malaise and had an elevated WBC MRSA was cultured from multiple specimens: LN and pleural fluid from left hemithorax obtained during thoracotomy on 7/7/99 Skin abscess along upper suture line in the left chest on 7/14/99 Needle aspiration of pleural fluid on 7/19/99 He completed 2 wk treatment course with Vancomycin and had marked improvement in signs and symptoms Complications 2 Following initiation of therapy with CM, the patient had significant reduction in serum Mg, K, Ca levels Electrolyte deficits were corrected with Mg replacement therapy and he is being maintained on Magnesium Oxide 400mg BID PO 140 113 16 4.0 19 0.7 Ca 8.3 Mg 1.8 Phos 4.1 94 10.9 9.1 28 ESR 130 526 Discharge Plan 1 Patient was discharged from Northern NJ hospital and was again followed up by Southern NJ chest clinic Court order was recommended to mandate patient compliance with treatment and confinement if patient reverts to previous non-adherent behavior Treatment was continued with daily DOT Capreomycin (1 gm) IM 5x/wk PAS (8gm AM; 4 gm PM) PO daily Ethambutol (2000 mg) PO daily 4
Discharge Plan 2 Monthly evaluation of visual acuity, color vision and hearing Periodic monitoring of ESR and electrolytes Monthly flush of Mediport to insure adequate function Monthly monitoring of sputum for AFB Treatment Standards Injectable agent should be given for total of 6 mos If CM is stopped for muscle pain or sterile abscess, may substitute SM, AK, or KM and give IV through Mediport until treatment completion Treatment for 18-24 months with anti-tb medications using DOT The patient completed 24 months of treatment following sputum conversion to negative on culture Final Outcomes The patient completed 24 months of treatment following sputum conversion to negative on culture 5