Transcript TB TODAY Case Presentation November 10, 2005 Marie Turner

Case Presentation
“and the band played on”
to the tune of MDR-TB
November 24 2006
Marie Turner, M.D.
Jo-Ann Keegan, R.N., M.S.N.
Case Details
♫ 16 y.o. U.S.A. born student in a suburban high
school
♫ Played a wind instrument in one of the largest
high school bands in the state
♫ Presented with cough, fever, chest pain for
more than 1 month duration
♫ CXR: RUL pneumonia TX with Quinolone x
10 days with improvement. CXR 2 weeks later:
resolving pneumonia
Case Details
♫ Several weeks later symptoms returned,
hospitalized – pneumonia treated with
Azithromycin, transferred to a medical center
for IV anti-biotics.
♫ DX at Medical CTR.: SM (+), cavitary TB
♫ D/C on 5 drugs INH, RIF, PZA, EMB and
Levo. INH resistance suspected
History
♫ Student visited endemic country from age 2 –
11 months
♫ TST positive, CXR negative at age 2
♫ Treated with INH for 1 year
♫ Sensitivities after 8 weeks treatment:
Resistant to INH RIF EMB STREP
History
♫ Treatment guidelines what would you do here?
♫ Treatment
 INH changed to 900 mg briefly, then discontinued
 EMB and RIF discontinued, PZA continued
 LEVO changed to CIPRO then GATI due to joint
symptoms
 CYCLO and CAPREO added
Table 1: Treatment Summary for Case
Medication
Duration
Reason to Discontinue
Isoniazid (INH)
8 weeks
Organism resistant to INH
2 weeks of 900 MG dosages
Rifampin (RIF)
6 weeks
Organism resistant to RIF
Pyrazinamide (PZA)
9 months
Elevated liver function tests
Asymptomatic with severe hepatitis
Ethambutol (EMB)
6 weeks
Organism resistant to EMB
Levofloxacin (Levo)
1 month
Joint symptoms
Ciprofloxacin (Cipro)
3 weeks
Physician preference – changed to
Tequin
Gatifloxacin (Tequin)
12 months
Treatment completed – (Drug well
tolerated)
Cycloserine
12 months
Treatment completed – (Drug well
tolerated)
Capreomycin IM
2 months
Intensive induction phase
completed – Maximum dose
PASER
10 months
Treatment completed – Drug well
tolerated
Identifying and Treating Contacts
♫ Period of infectiousness prior to diagnosis and
treatment determined from symptom history
♫ School staff, parents and health care providers
interviewed to determine possible school, home,
social and work contacts
♫ Contacts classified into risk groups for recent
exposure and previous infection
♫ Contacts interviewed to determine previous skin
test status
Identifying and Treating Contacts
♫ Band members stratified by instrument type
and room position.
♫ Contacts likely infected with MDR TB started
on at least 2 drugs based on known
susceptibility of the source case isolate.
♫ Medical consultation was from a physician
with expertise in MDR TB.
♫ Contacts’ treatment and complication history
tracked.
Identifying and Treating Contacts
♫ Patient remained in school while symptomatic for 2
months prior to diagnosis.
♫ Household: 2 of 3 household contacts had positive
TST’s, with time of infection undetermined.
Dad previous positive TST current CXR
WNL, not treated.
Mom current TST 25MM baseline 0MM TX
with INH 900 mg twice weekly.
TX options
Boosting ?
Conversion ?
Sibling 13 y.o. (-) TST, (-) CXR (no window
prophylaxis)
♫ School: 264 students and teacher contacts identified
250 (95%) completed TST’s and CXR’s.
Identifying and Treating Contacts
♫ School: 7 of 250 (3%) were TST positive.





All 7 were in close physical proximity to the case
5/7 played a wind instrument in the band
2/7 were in close proximity in the classroom
4/7 had documented TST conversions
All 7 had no known risk factors for previous
exposure and were presumed to be newly infected
with MDR TB.
Drug treatment for school contacts:
• Treatment with 2 drugs to which organism sensitive
(PZA, LEVO)
• Joint symptoms in 1 adult and 3 students were
resolved after TEQUIN substituted for LEVO
Identify and Treating Contacts
♫ Drug treatment for school contacts:
(continued)
 One student developed drug induced hepatitis
toxicity
 Directly observed therapy was refused by parents
but parents agreed to supervise meds
 Adolescents under reported adverse reactions to
avoid serologic testing
♫ Table 2 summarizes drugs and treatment of
MDR Latent Infection.
Table 2: School Converters –
Treatment Summary for MDR Latent Infection
Patient
Exposur
e Type
PPD
Size
Drugs
Complications
Drug
Change
Disposition
#1
Teacher
25
mm
PZA,
Levo
Uric acid elevated
(11.1)
PZA, Tequin
Completed
Rx
#2
Band
10
mm
PZA,
Levo
Uric acid elevated
PZA, Tequin
Completed
Rx
#3
Band
15
mm
PZA,
Levo
Uric acid elevated (8.2)
PZA, Tequin
Completed
Rx
#4
Band
10
mm
PZA,
Levo
None
None
Completed
Rx
#5
Classroo
m
15
mm
PZA,
Levo
None
None
Completed
Rx
#6
Band
12
mm
PZA,
Levo
Foot and joint pain
with no elevation of
Uric acid
PZA, Tequin
Completed
Rx
#7
Band
18
mm
PZA,
Levo
Admitted with acute
liver failure and listed
for a liver transplant
until liver functions
improved
All TB drugs
discontinued
Unable to
complete Rx
OTHER ISSUES
♫ Student did not return to school until nearly 2
months after diagnosis
♫ Culture conversion occurred over nine weeks
after initial treatment started
♫ Student was not allowed to return to the same
high school she was attending (with 6 weeks left
to the school year)
♫ Fear and stigma of the disease extended to the
school administration
♫ School nurse was threatened, to induce her to
reveal the students identity, she refused caller
Conclusions - Discussion
Contacts treated with second line drugs for
MDR latent TB infection had clinically
significant variations in adverse reactions to
quinolones
Source case transmission of MDR TB was
extended by missed diagnosis and subsequent
treatment with a quinolone for suspected
community acquired pneumonia
Conclusions - Discussion
Patient and family education regarding the
importance of stopping medications, if adverse
reactions suspected, is vital to health and
treatment outcome
Contacts treated with second line drugs for
MDR TB require close monitoring, including
serologic testing and DOT.
Conclusions - Discussion
Directly Observed Therapy of MDR TB
contacts would likely enhance clinical followup. Although parents refused this option, more
education and a comprehensive effort on the
part of all providers would most likely be
needed to reverse this decision. Another
benefit of DOT is the possible prevention of
further drug resistance.
Further research is necessary to address the
complexities and duration of treatment for
MDR latent TB infection.