Clinical CaseClinical Case

Female, 27 years of ageFemale, 27 years of age 33rdrd year Internal Medicine resident at year Internal Medicine resident at

the Mexicali General Hospitalthe Mexicali General Hospital Never smoked; does not ingest alcoholic Never smoked; does not ingest alcoholic

beverages or use illicit drugsbeverages or use illicit drugs Used to run 5 km daily before being illUsed to run 5 km daily before being ill Single, no children; lives with parents Single, no children; lives with parents

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

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

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

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

Chest x-ray at that time normalChest x-ray at that time normal December 2005:December 2005:

HeadacheHeadache MalaiseMalaise HyporexiaHyporexia Dry coughDry cough FeverFever DyaphoresisDyaphoresis

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

By the end of January 06 her By the end of January 06 her symptoms persistedsymptoms persisted

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

She was started on the five available She was started on the five available first-line drugs (RIPES), self-first-line drugs (RIPES), self-administeredadministered

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

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

HIV test: non reactive (ELISA)HIV test: non reactive (ELISA)

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

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

susceptible to ethambutol at 5susceptible to ethambutol at 5 Susceptible to capreomycin, ethionamide and Susceptible to capreomycin, ethionamide and

levofloxacinlevofloxacin A CT scan (03/29/06) shows persistence of A CT scan (03/29/06) shows persistence of

the lung cavitationsthe lung cavitations

March 06

March 06

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

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

Bronchoscopy performed on April Bronchoscopy performed on April 11, 2006 to perform BAL11, 2006 to perform BAL

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

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

She is started again on RIPS while She is started again on RIPS while waiting for the binational conference waiting for the binational conference