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Management of Tuberculosis: A Surgical Perspective

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. Case #1- History. WW, 38 year old male April 1999, AFB(+)

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Management of Tuberculosis: A Surgical Perspective

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  1. 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

  2. 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

  3. July 15, 1999

  4. 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

  5. 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

  6. 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

  7. Sputum Smear & Culture - 1 • 7-13-99 AFB 2+ M.tb • 8-24-99* AFB TNC M.tb • 9-21-99 AFB <1+ M.tb • 10-19-99 neg neg • 11-16-99 neg neg • 12-14-99 neg neg • 1-18-00 neg neg

  8. September 21, 1999

  9. January 10, 2000

  10. 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.

  11. 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

  12. June 2000

  13. 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

  14. 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

  15. May 2001

  16. 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

  17. June 17, 2001

  18. August 20, 2001

  19. October 1, 2002

  20. 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

  21. 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

  22. January 2004

  23. January 2004

  24. 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

  25. July 2004

  26. August 2004

  27. Follow-Up Regimen • Current regimen started 2/04; discontinued 24 months after sputum culture conversion • CM – 7 mos. • Remains smear and culture negative >2 years after treatment completion EMB CS LIN 24 mos

  28. 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

  29. Case #2 – Chest X-ray September 2007

  30. September 2007

  31. 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+

  32. 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

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