1. Management of Tuberculosis: A Surgical Perspective
Alfred Lardizabal, MD
Assistant 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
Sensitive: SM / CM / AK; EMB; CS; PAS; CIP/OFL; CLA; CLO

6. 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

7. Sputum Smear & Culture - 1
AFB 2+ M.tb
* AFB TNC M.tb
AFB <1+ M.tb
neg neg
neg neg
neg neg
neg neg

8. September 21, 1999

9. January 10, 2000

10. Sputum Smear & Culture - 2
AFB neg M.tb
* neg neg
neg M.tb
neg M.tb
neg M.tb
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
neg MTBC
MTBC
MTBC
MTBC
MTBC
MTBC

15. May 2001

16. 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

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 (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

29. 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

30. 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

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

32. September 2007

33. 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+

34. 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