1. A Homeless Alcoholic Patient with TB
Marcos Burgos M.D.
Medical Director Tuberculosis Program, NM DOH
Department of Medicine, Veteran Affairs Medical Center, The University of New Mexico School of Medicine, Albuquerque, NM.
October 23, 2012
Durango, Colorado

2. TB case
November 2008 paramedics brought to the ER a 52 year old Navajo man that was found on the streets acutely intoxicated with ETOH.
In the ER the patient had an alcohol level of 325
On evaluation, the patient was found to have a chest X-ray with a large left apical cavity.
The patient gave a history of homelessness, history of tuberculosis treatment in the past and a current cough and weight loss of a couple of months duration

3. CXR/CT

4. TB case
Multiple sputum samples were found to be 4+ for AFB and MTB complex probe positive.
He was admitted to the Medical Intensive Care Unit for management of alcohol withdrawal, and he was started on 5 drugs: isoniazid, rifampin, ethambutol, pyrazinamide and moxifloxacin for presumed tuberculosis disease and superimposed pneumonia.
The tuberculosis programs was notified and the patient was interviewed and records reviewed

5. What other information will you want to know?
What treatment did the patient get in the past?

6. TB case - PMH
The patient is homeless and an alcoholic for most of his adult life
February 1992 the patient was diagnosed with pulmonary tuberculosis in Utah and was started on IRP
November 1992 readmitted to McKay-Dee Hospital in Ogden, Utah
Patient left against medical advice and lost again to follow up

7. TB case - PMH
April 1993 readmitted in with a febrile illness, hypoxia and shortness of breath and a chest X-ray with a miliary pattern
The patient again lost to follow up and because of poor compliance the patient is court ordered to receive treatment under DOT in Oct
The patient’s tuberculosis isolate from May 5, 1993 was susceptible to all drugs

8. TB case - PMH
In addition to Ogden, Utah, the patient received treatment in Boise, Idaho, and in Eugene, Oregon where he completed treatment for pulmonary TB in January 1994
There are no records of the type of treatment he received.
After this episode of tuberculosis, he was evaluated in California and Colorado for active tuberculosis in 2001 and 2003.

9. TB case
A sputum sample was sent to the California State Laboratory for rapid susceptibility testing (molecular beacons).
Rapid susceptibility results became available on November 22 and the M. tuberculosis isolate was found to have resistant mutations for isoniazid and rifampin (MDR-TB)

10. MDR-TB case
MDR-TB treatment: ethambutol 1200 po QD, pyrazinamide 1250 po QD, cycloserine 250 mg po BID, ethionamide 500 mg po BID, moxifloxacin 600 mg po QD and amikacin 1000 mg IV TIW.
In addition to MDR-TB disease, the patient was found by psychiatry to be ETOH dependent with a depressive disorder.
The patient refused referral to an alcohol treatment center.
Susceptibility results by standard methods were still pending.

11. Can we treat this case as an outpatient?

12. MDR-TB case
The patient was deemed a poor candidate for outpatient treatment
Potential risk to public health
History of non-adherence to treatment for TB disease
History of homelessness and an alcohol abuse, both commonly associated with non-adherence.
The patient remained in the hospital after he was determined to be non-infectious as the program struggled to prepare for the next phase of his treatment

13. MDR-TB case
TB program has limited resources to retain high risk patients and provide a regimen for MDR TB
DOH worked together with HIS to come up with the funds to pay for an inpatient facility
In the past New Mexico had a similar case for which IHS and DOH split up the cost for an inpatient treatment of a MDR-TB case at the Center for Infectious Diseases (TCID) in San Antonio, Texas.

14. TB case
The results of drug susceptibility testing by standard methods took more than 8 weeks to become available
The drug susceptibility results showed that the isolate was susceptible to all primary and secondary drugs
Due to the discrepancies in results from standard methods and the rapid method, the initial culture was sent to the California State Laboratory for molecular beacons
The isolate did not have any resistant mutations

15. TB case The patient was no longer infectious
He was started on isoniazid, rifampin, and pyrazinamide and the patient was discharged from the hospital to a motel room arranged and paid by the TB control program.
The patient started receiving his treatment under DOT with close follow up by the TB program
The patient completed additional 6 months of treatment

16. TB case
The diagnosis of TB opened the door for the development of a trusting relationship with the TB program that eventually allowed him to stay sober and obtain an apartment
The cost of his hospitalization: $160,000

17. Tuberculosis in an Urban Setting
M. Frances Vasquez, M.S.
Tuberculosis Case Manger
Stanford Public Health Office
Albuquerque, NM

18. Initial Situation Phone call, we have a new client
at Lovelace Hospital
Help him apply for
General Assistance
Apply for Institutional level care
He may qualify for D&E Waiver
New case manager
Started off with a really big challenge
Complex case

19. General History First DOT on 11-03-2008. Age: 51
History of Alcoholism and Homelessness
BAC was .325 when admitted.
Client was malnourished and gave a history of previous injuries and hospitalizations.
Client appeared to be ‘slow’ or mentally challenged
Had arthritis, hearing loss and hx of previous injuries from being hit with a car, fights, etc.

20. First Visit
Met client on wearing my endearing ensemble of N-95 mask, gown and gloves
I am one of 3 or 4 people in the room talking to him.
He receives lots of information but speaks very little.
Dr. Burgos and Martha Tanuz in the room.
From notes: Client was guarded when asked questions, at time refusing to respond and other times appeared annoyed, stating we had already asked these question. .

21. Homework GA is $266 per month Needs photo ID for Food Stamps
Needs Birth Certificate – no record in NM system
Ageing and Long Term Services stated wait list is over 2 years; do not think my client would qualify
If found incompetent, check out guardianship.
Homeless shelters may be best option for persons w/o an income.
I didn’t even have numbers for Navajo Nation or contacts. Carla Gordon was a big help.

22. Surprise!
On visit to client on , he told Dr. Burgos that he finished his TB medicine in in Eugene, OR.
Stated he started treatment in Ogden, UT., then moved to Boise Idaho and then completed treatment in Oregon.
Arrived in ABQ two weeks ago from Kingman AZ and before that he lived in Phoenix.
BAC was .325 when admitted.
Obviously he lived the life of a transient. His family is the 4 corners area

23. 04-23-09 Phone call received from sister.
Reported that mother had active TB in 1950’s and was treated in a sanatorium in Albuquerque.

24. a
Around this time client given neuropsychological evaluation. Found incompetent. Makes our job easier.
Sister calls and complains that the neuropsych eval needs to be in Navajo, his native language.
Navajo interpreter difficult to find. Finally I recruit our WIC clerk from Cuba to come and interpret. Client refuses to use her!
Client is more cooperative and responsive during second evaluation and is found to be competent.
Cooperated during second interview because a nurse he now trusted was in the room.
Client refused to use interpreter because he did not want the whole reservation knowing his business.

25. Building Rapport and Trust
Inquired about ID. Client stated that he has no documents on his person or in his wallet.
Began to stop in when time permitted to spend time with client and make small talk. I asked him if there was anything he was craving.
Began to bring burritos from home or snacks.
One day he told me he had an AZ ID
and a Social Security card!

26. I felt like . . .

27. Isolation Client was in isolation about 4 months.
Had lots of time to think about his situation and his life.
Decided to quit drinking while in hospital.
Requested, and was given,
double portions of food.

28. Spent his time watching TV and he seemed to enjoy the newspaper.
Revealed he could only read some of the words in the newspaper.
Once client was coming to office for DOT, I began to tutor him in reading.
Client always asked good questions about words and their meaning. He felt that he didn’t understand English as well as Navajo.
Told me he was kept home while other siblings went to school

29. Meeting with Key Stakeholders
Question as to how to proceed once found competent.
Meeting with hospital staff, DOH attorneys, Indian Health Service, TB Staff, MD’s regarding payment for services if client was sent to Heartland in TX.
Everyone had their iron in the
All the planning became somewhat of a mute point when it was determined he was not a drug resistant case.

30. Upon Release Was set up in hotel to complete DOT.
Set up with a few utensils for cooking.
When no long infectious used local services for homeless for food, bus passes, clothes, etc.
Eventually received GA
Eventually received Social Security
Found low-income housing for client.
Has been clean and sober since he was hospitalized at the end of 2008.
Our medical director bought him some new clothes, I brought extra utensils and kitchen items, towels, etc from home.

31. Post Treatment I became his representative payee for Social Security.
He did continue to receive reading tutoring for several months.
He lives independently and is still clean and sober.
He lives a fairly isolated life but manages his life well.
He likes to watch wrestling on TV – goes to the library and checks out book and music
Continues to keep his follow up appts.

32. Good Outcome!

33. A homeless alcoholic patient with TB
Marcos Burgos M.D.
Department of Internal Medicine, Division of Infectious Diseases, UNM SOM
Medical Director TB Program, DOH NM
Durango, Colorado