Management of Tuberculosis: A Surgical Perspective

Management of Tuberculosis: A Surgical Perspective

Alfred Lardizabal, MDAssociate Professor

Division of Pulmonary and Critical Care MedicineUMDNJ-NJ Medical School and Global Tuberculosis

Institute

Case #1- HistoryCase #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

July 15, 1999

Case #1 – Culture ResultsCase #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

Case #1 – Susceptibility ResultsCase #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

Case #1 – Subsequent RegimenCase #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

Sputum Smear & Culture - 1Sputum 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

September 21, 1999

January 10, 2000

Sputum Smear & Culture - 2Sputum 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.

Pre-Op 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

June 2000

Post-Op Medical Management - 1Post-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

Sputum Smear & Culture - 3Sputum 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

May 2001

Post-Op Medical Management - 2Post-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

June 17, 2001

August 20, 2001

October 1, 2002

Post-Op Medical Management - 3Post-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

Follow-Up - 1Follow-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

January 2004

January 2004

Follow-Up - 2Follow-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

July 2004

August 2004

Follow-Up RegimenFollow-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

EMBCSLIN

24 mos

Case #2 - HistoryCase #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

Case #2 – Chest X-rayCase #2 – Chest X-ray

September 2007

September 2007September 2007

Case #2 – Surgical InterventionCase #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+

Case #2 – Post-Op TreatmentCase #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