Management of Tuberculosis: A Surgical Perspective

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Management of Tuberculosis A Surgical
Perspective

• Alfred Lardizabal, MD
• Associate Professor
• Division of Pulmonary and Critical Care Medicine
• UMDNJ-NJ Medical School and Global Tuberculosis
  Institute

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Case 1- History

• WW, 38 year old male
• April 1999, AFB()
• Treatment with IRZE (self-administered)
• July 1999 AFB 2
• Referred by the private MD in July 1999 for the
  management of pulmonary tuberculosis

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July 15, 1999
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Case 1 Culture Results

• By August 1999, culture was identified as M.
  tuberculosis resistant to I,R,Z,E
• Specimen sent for 2nd line drug susceptibility
  testing
• I,R,Z,E continued during interim period

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Case 1 Susceptibility Results

• CDC
• Resistant RIF/RBT INH PZA
• Sensitive SM / CM / AK EMB CIP CS ETA
• NJMRC
• Resistant RIF/RBT INH PZA
• Sensitive SM / CM / AK EMB CS PAS CIP/OFL
  CLA CLO

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Case 1 Subsequent Regimen

• Treatment regimen changed by 8-24-99
• Capreomycin 1 gm IM 5 X/week
• Levofloxacin 500 mg OD
• Cycloserine 750 mg OD
• Clofazimine 300 mg OD
• Clarithromycin 500 mg BID

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Sputum Smear Culture - 1

• 7-13-99 AFB 2 M.tb
• 8-24-99 AFB TNC M.tb
• 9-21-99 AFB lt1 M.tb
• 10-19-99 neg neg
• 11-16-99 neg neg
• 12-14-99 neg neg
• 1-18-00 neg neg

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September 21, 1999
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January 10, 2000
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Sputum Smear Culture - 2

• 3-7-00 AFB neg M.tb
• 4-17-00 neg neg
• 4-28-00 neg M.tb
• 4-29-00 neg M.tb
• 5-1-00 neg M.tb
• 6-1-01 neg M. tb

capreomycin was discontinued after 8 mos.
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Pre-Op

• By June 2000, pt. continued to have positive
  sputum cultures (AFB-)
• CT Chest was requested
• Preparation and evaluation for adjunctive surgery
  was started
• FOB/Bronchial biopsy Sept 2000
• RUL bronchus clean

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June 2000
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Post-Op Medical Management - 1

• NJMRC Sept 2000
• Resistant RIF/RBT INH PZA
• Intermediate CLO CIP CLA
• Sensitive SM / CM / AK CS PAS EMB ETA
• Treatment Oct 2000 EMB SM PAS CS
• Discontinued CLA, CLO, LFX

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Sputum Smear Culture - 3

• 8-8-00 neg MTBC
• 9-1-00 1 MTBC
• 10-3-00 1 MTBC
• 12-7-00 1 MTBC
• 1-5-01 1 MTBC
• 6-3-01 1 MTBC

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May 2001
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Post-Op Medical Management - 2

• Patient was admitted for a right upper lobectomy
  6-10-01
• Discharged home on EMB, PAS, SM, CS
• Persistent GI complaints prompted D/C of PAS and
  changed to gatifloxacin by 7-1-01
• Post-surgery patient remained smear and culture
  negative

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June 17, 2001
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August 20, 2001
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October 1, 2002
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Post-Op Medical Management - 3

• CM continued until Feb 2002 (15 months)
• EMB, CS, GFX continued until Dec 2002 (18
  months post-surgery) remaining smear and culture
  negative

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Follow-Up - 1

• On the January 2004 follow-up patient had no
  complaints. He gained 20 lbs. since the last
  visit 6 months prior
• Chest x-ray and sputum cultures have been
  negative up to this point

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January 2004
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January 2004
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Follow-Up - 2

• Jan 2004 Sputum AFB1 MTBC
• Started EMB, CS, PAS, CM, linezolid (Zyvox)
• NJMRC
• Resistant INH, RIF, PZA, LFX
• Sensitive PZA, EMB, SM/CM/ ETA, CS, PAS
• CM stopped after 8 months
• Sputum conversion by March 2004
• Remained sputum negative

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July 2004
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August 2004
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Follow-Up Regimen

• Current regimen started 2/04 discontinued 24
  months after sputum culture conversion
• CM 7 mos.
• Remains smear and culture negative gt2 years after
  treatment completion

EMB CS LIN
24 mos
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Case 2 - History

• 53 year old Hispanic female with a history of
  breast carcinoma
• Has had chemotherapy and radiation therapy after
  total mastectomy of her right breast the last
  cycle of chemotherapy was given in May 2007
• On follow-up, PET/CT revealed positive uptake in
  the lung and colon

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Case 2 Chest X-ray
September 2007
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September 2007
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Case 2 Surgical Intervention

• Wedge resection of the right lung nodule as well
  as a colonoscopy was planned
• Lung tissue from the wedge resection was AFB
• Biopsy of the colon was also AFB

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Case 2 Post-Op Treatment

• Treatment with RIPE started
• Culture of lung tissue and sputum positive for M.
  tuberculosis
• DST sensitive to RIPE,SM
• Is currently on therapy and responding very well