Clinical Case

• Female, 27 years of age

• 3rd year Internal Medicine resident at the Mexicali General Hospital

• Never smoked; does not ingest alcoholic beverages or use illicit drugs

• Used to run 5 km daily before being ill

• Single, no children; lives with parents

• Previous medical history: non-relevant; no known allergies

• Contact with tuberculosis patients: extremely frequent at her hospital; assisted in bronchoscopy procedures several times during her 1st year of residency

• Has never been diagnosed with TB or received TB treatment before

• Started her symptoms – July 2005; right pleuritic chest pain; self-limited. Chest

x-ray at that time normal– December 2005:

• Headache• Malaise• Hyporexia• Dry cough• Fever• Dyaphoresis

– She received 10 days of gatifloxacin (400 mg OD)

• By the end of January 06 her symptoms persisted

• chest- x-ray Jan 29, 2006 showed two small cavities in the right lower lobe

• She was started on the five available first-line drugs (IRZES), self-administered

• Five days later she underwent bronchoscopy (she could not produce any sputum for AFB exam)

• AFB from bronchoscopy: reported as positive with 354 AFB in 100 fields

• HIV test: non reactive (ELISA)

• She feels better; fever and cough disappeared, gained weight (3 kg)

• Culture results are reported from Imperial Valley Laboratory– Resistant to ISRZ and ethambutol at 2.5; susceptible

to ethambutol at 5– Susceptible to capreomycin, ethionamide and

levofloxacin

• A CT scan (03/29/06) shows persistence of the lung cavitations

March 06

March 06

• On Dr. Laniado’s advise she stops all treatment on April 01, 2006

• Examined by Dr. Laniado on April 10, 2006; she is asymptomatic and her physical examination is negative; does not expectorate

• Bronchoscopy performed on April 11, 2006 to perform BAL

• AFB from BAL in the State Laboratory in Tijuana and the General Hospital in Mexicali are reported as negative. Culture pending

• PCR analysis of the BAL is reported as positive for Mycobacterium tuberculosis and the mutation for rifampin resistance is detected

• She is started again on IRSZ while waiting for the binational conference