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(+) 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 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 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 Regimen Treatment regimen changed by : –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 AFB 2+M.tb *AFB TNCM.tb AFB <1+M.tb negneg negneg negneg negneg

September 21, 1999

January 10, 2000

Sputum Smear & Culture AFB negM.tb *negneg negM.tb negM.tb negM.tb negM. tb *capreomycin was discontinued after 8 mos.

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 - 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 negMTBC MTBC MTBC MTBC MTBC MTBC

May 2001

Post-Op Medical Management - 2 Patient was admitted for a right upper lobectomy Discharged home on EMB, PAS, SM, CS Persistent GI complaints prompted D/C of PAS and changed to gatifloxacin by Post-surgery patient remained smear and culture negative

June 17, 2001

August 20, 2001

October 1, 2002

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

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

January 2004

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

July 2004

August 2004

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

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

Case #2 – Chest X-ray September 2007

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+

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