1. Overview Case Presentation Diagnosis Treatment – Induction phase Treatment – Continuation Phase Treatment Monitoring Assessment of Transmission Outcome References

2. Case Presentation 18 y.o Hispanic female presents with 2 day hx of postpartum normal vaginal delivery and abnormal CXR. No cough, mild fever, no unexpected weight loss PPD 25 mm by history.

3. Case Presentation - 2 PMH: Pt is G1P1, otherwise unremarkable FMH: Mother alive and well living in El Salvador; father unknown health status. 1 sib living in El Salvador A/W. Social: Lives alone in bedroom room apt in 3- family house. Rents apartment.Works as babysitter. Marital status is single though does have BF. Medical coverage is Medicaid. Immigration status undocumented

4. Case Presentation - 3 Meds: Tylenol 1gm PRN pain Substance Abuse: Denies smoking, ETOH, and IVDU Allergies: none known

5. Physical Exam Pt sitting in bed in precaution room. In NAD, breathing comfortably. VS: WT 108 lbs, T 99.5 (F) HR 98-Pulse Reg--Resp18 BP 104/60 Resp: Symmetric chest wall motion. Neg for retractions or use of accessory muscles. No dullness noted on percussion. No palpable tenderness on palpation. BS with normal air movement, neg for rales and wheezes

6. Labs Hematocrit 40.8 MCV 84 WBC 6.0 Platelets 453 AST 22 Alk Phos 180 Creat 0.6 Serum Ca 9.9 PCO 2 36.9 O 2 sat 100 Sputum smear – x3 pending

7. Chest Radiograph and CT CXR suggestive of cavity lesion in LUL and RUL otherwise heart normal size. Diaphragm slightly elevated secondary to heightend uteral placement. Film suggestive of active process of pulmonary tuberculosis. CT confirms cavity opacity in RUL

9. Differential Diagnosis Tuberculosis Bacterial Pneumonia Carcinoma

10. Diagnosis CXR abnormal but not necessarily diagnostic. Sputum smears may be – or + depending on the level of infectiousness May need bronchoscopy with bronchial washings or lavage Biopsy may be warranted to confirm

11. Diagnosis - 2 Culture is gold standard but takes 3-6 weeks to grow in solid media, 12-28 days with liquid media Smear is strongly suggestive but could be due to nontuberculous mycobacteria Nucleic acid amplification can rule TB in but not out TB skin test not sensitive or specific In-vitro interferon gamma-based tests similar to TB skin test

12. Case Presentation - 4 Smears: 2+/1+/neg HIV serology - negative

13. Treatment - Induction Phase Because of the relatively high proportion of adult patients with tuberculosis caused by organisms that are resistant to isoniazid, four drugs are used in the induction phase for the 6-month regimen to be maximally effective. –Isoniazid 5-10 mg/kg day –Ethambutol15-20 mg/kg day –Rifampin10 mg/kg day –Pyrazinamide20-25 mg/kg/day

15. Case Presentation - 5 Our patient: Daily therapy with –Isoniazid 300 mg p.o. (1 pill) –Ethambutol800 mg p.o. (2 pills) –Rifampin600 mg p.o. (2 pills) –Pyrazinamide1000 mg p.o. (2 pills) Other issues: intermittent regimens, combination pills

16. Management DOT- directly observed therapy Self- Administered therapy Case Management Mandatory Confinement?

17. Assessment of Transmission How long to isolate the patient? Source case? Transmission to household contacts? Transmission in the workplace?

18. Case Presentation - 6 Initial sputum culture results from our patient: M. tuberculosis Isoniazid Sensitive Ethambutol Sensitive Rifampin Sensitive Pyrazinamide Sensitive

19. Treatment – Continuation P hase Because of the relatively small number of organisms remaining after 2 months of intensive phase treatment, most patients with tuberculosis can be placed on continuation phase treatment after 8 weeks of induction. Induction Phase usually lasts 4 months (18 weeks) and can be give daily or twice weekly –Isoniazid 5-10 mg/kg day –Rifampin10 mg/kg day

20. Treatment Monitoring Visit Schedule: q 2wk during induction q month during continuation Adherence monitoring Efficacy monitoring Weight, temperature 2 month and 6 month films monthly smear and culture Toxicity monitoring Skin rash, LFTs, Nausea, Color vision

21. Case Presentation - 7 Sputum culture results from our patient after 2 months of induction phase therapy: No Growth

22. Outcome Patient received induction and continuation therapy (2+4=6 months) and was cured All household members received TST and chest radiograph if TST+. There we no active cases, but the 2 persons with TST+ received INH for treatment of LTBI Baby received INH until follow-up TST 3months later was negative

23. References 1. Horsburgh CR, Burman WJ. Tuberculosis Treatment: Theory and Practice. In: Therapy of Infectious Diseases, ed Baddour L, Gorbach SL. Philadelphia PA; Saunders, 2003: 529-46. 2. Centers for Disease Control and Prevention. Treatment of Tuberculosis, American Thoracic Society, CDC, and Infectious Diseases Society of America. MMWR 2003;52(no. RR-11):1-80. 3. Horsburgh CR, Feldman S, Ridzon R. Quality standards for the treatment of tuberculosis. Clin Infect Dis 2000;31:633-9.