Case of MDR-TB from Haiti Christopher Kovacs MD Infectious Disease Fellow Cleveland Clinic

History of Present Illness 29 year old male from Hinche, Haiti Previous calendar year – exchange student studying agriculture Diagnosed with TOF -- referred for surgical correction at the Cleveland Clinic Preoperative assessment completed – Surgery August 2013 Haiti from May until August 2013 Returned August 2013 for surgery Fever, cough, and weight loss over the last 2 months

Previous History Past Medical History – Tetralogy of Fallot, Typhoid fever, Pleural effusion, HIV negative Past Surgical History – Thoracentesis 2009, LHC June 2013

Presentation to Cleveland Clinic Returned to US for planned surgery Preoperative testing undertaken CT chest obtained for surgical planning Sent to ED for concern of tuberculosis after interviewed, examined, and imaging reviewed

Imaging

Initial Culture Results

Drug Resistance From CDC Drug Percent ResistanceInterpretation INH100R Rifampin100R Ethambutol100R Streptomycin100R Rifabutin3.33R Ciprofloxacin0S Kanamycin0S Ethionamide66.67R Capreomycin0S PAS0S Ofloxacin0S Amikacin0S

Hospital Course Patient started on cycloserine, linezolid, amikacin, moxifloxacin, PZA and pyridoxine 9/26/2013- smear and culture negative 10/6/2013- found down with aphasia, facial droop and right sided weakness abrupt cutoff M1 segment of LMCA tPA administered; transferred to ICU PICC related paradoxical embolus

Hospital Course 12/17/13- Meeting with ID, Social work, Physical Medicine and Rehabilitation, Pediatric Cardiothoracic Surgery Re-aspiration of left pleural space negative for AFB Repeat CT scan with decreased cavity size, less infiltrate, and healed bronchopleural fistula Infection prevention plan for operative plan developed Aggressive stroke rehab

Hospital Course Successful repair of TOF – using Gore-Tex VSD patch – Right ventricular outflow tract resection – 24-mm pulmonary homograft – Suture closure of atrial septal defect All cultures remain negative to date Discharged to host family on 3/20/14

Points for Discussion Role of thoracic surgery for this patient – Considerations: – Poor blood flow to the hypoplastic left lung? – Poor drug delivery? – Sequestered area for further resistance development? – Surgical morbidity in the setting of negative cultures and resolution of the BPF? – Access to thoracic surgery resources in Haiti should intervention be required in the future? – How should this be followed going forward?

Points for Discussion Transition of care from US to Haiti – Considerations: – Patient wishes and autonomy – Resource poor vs. Resource rich environments Ensuring DOT provided; logistics of care near Hinche Duration of aminoglycoside Adjustment of regimen to consider cost/access to meds Additional susceptibilities confirmed for cycloserine, clofazimine, clarithromycin, linezolid Transition of care to GHESKO or PIH