1. TB Case Study Pulmonary TB in US-born Client

2. Overview  60-year old white male  Lifelong Madison resident, lives with wife and dog  Comorbidities: hypertension, seasonal allergies  HIV -  Daily tobacco & alcohol use  Unemployed with private health insurance through wife  2005 work exposure → appropriate screening completed  Summer 2012 → symptoms

3. DIAGNOSIS: 2012  Summer 2012: cough, dyspnea on exertion  August 2012 → laid off from work  September 2012 → bronchitis → augmentin  CXR shows bilateral airspace patchy process; no cavitation noted  November 2012 → pneumonia → omnicef  chest CT shows extensive upper left cavitation, scattered cavitary nodules bilaterally, infiltrates, & ground glass opacification  December 2012 → pulmonology consult → likely vasculitis + acute sinusitis → augmentin

4. DIAGNOSIS: 2013  January 2013 → worsening cough, DOE, 13# weight loss x 1 month, elevated cANCA; dx differential: vasculitis (Wegener’s granulomatosis or other) vs. super-infection  Prednisone 100mg daily prescribed  February 7 th → Pulm consult and bronch w/lung biopsy  February 11 th : BAL specimen is afb +, PCR + = Pulm TB  client isolated, and treatment started 2/12  Culture +  Genotype matched  Pansensitive  Sense of relief!

5. Diagnosis & treatment continued…  Initial sputums x 2, then weekly through 6/25/13  Resume RIPE & check therapeutic drug levels 2 ͦ smears 4+ and cx + (results in 7-8 days) after 2 months treatment  Slightly ↑ INH and ↓ EMB  Dr. Make recommends: ↑ EMB and continue RIPE until cx –  Re-check EMB level It is a long, cold, snowy winter…

6. Diagnosis & treatment continued… …and a long spring, too.

7. Diagnosis & treatment continued…  Released from isolation June 26th after 5/7 and 5/14 sputums culture negative  Culture conversion believed to be 5/7/13 (3 months)

8. Diagnosis & treatment continued…  SLOH pilot project extends duration of culture to 10 weeks in limited circumstances  On August 8th, culture positive specimens from 6/11/13 (8.5 weeks) and 6/18/13 (7.5 weeks)  Question effectiveness of treatment…Let’s review  What would you do?

9. Determinants of Health  What makes some people healthy and others unhealthy?  How can we create a society in which everyone has a chance to live long healthy lives?  “The social determinants of health are the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness.” World Health organization: http://www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/index.html

10. So much for the arc of my story...  October 13 th : 10/1 sputum specimen is culture positive.

11. Thank you! Questions?