1. Marie Turner, M.D. Jo-Ann Keegan, R.N., M.S.N.
Case Presentation “and the band played on” to the tune of MDR-TB November
Marie Turner, M.D.
Jo-Ann Keegan, R.N., M.S.N.

2. Case Details 16 y.o. U.S.A. born student in a suburban high school
Played a wind instrument in one of the largest high school bands in the state
Presented with cough, fever, chest pain for more than 1 month duration
CXR: RUL pneumonia TX with Quinolone x 10 days with improvement. CXR 2 weeks later: resolving pneumonia

3. Case Details
Several weeks later symptoms returned, hospitalized – pneumonia treated with Azithromycin, transferred to a medical center for IV anti-biotics.
DX at Medical CTR.: SM (+), cavitary TB
D/C on 5 drugs INH, RIF, PZA, EMB and Levo. INH resistance suspected

5. History Student visited endemic country from age 2 – 11 months
TST positive, CXR negative at age 2
Treated with INH for 1 year
Sensitivities after 8 weeks treatment: Resistant to INH RIF EMB STREP

6. History Treatment guidelines what would you do here? Treatment
INH changed to 900 mg briefly, then discontinued
EMB and RIF discontinued, PZA continued
LEVO changed to CIPRO then GATI due to joint symptoms
CYCLO and CAPREO added

7. Table 1: Treatment Summary for Case
Medication
Duration
Reason to Discontinue
Isoniazid (INH)
8 weeks
Organism resistant to INH
2 weeks of 900 MG dosages
Rifampin (RIF)
6 weeks
Organism resistant to RIF
Pyrazinamide (PZA)
9 months
Elevated liver function tests
Asymptomatic with severe hepatitis
Ethambutol (EMB)
Organism resistant to EMB
Levofloxacin (Levo)
1 month
Joint symptoms
Ciprofloxacin (Cipro)
3 weeks
Physician preference – changed to Tequin
Gatifloxacin (Tequin)
12 months
Treatment completed – (Drug well tolerated)
Cycloserine
Capreomycin IM
2 months
Intensive induction phase completed – Maximum dose
PASER
10 months
Treatment completed – Drug well tolerated

8. Identifying and Treating Contacts
Period of infectiousness prior to diagnosis and treatment determined from symptom history
School staff, parents and health care providers interviewed to determine possible school, home, social and work contacts
Contacts classified into risk groups for recent exposure and previous infection
Contacts interviewed to determine previous skin test status

10. Identifying and Treating Contacts
Band members stratified by instrument type and room position.
Contacts likely infected with MDR TB started on at least 2 drugs based on known susceptibility of the source case isolate.
Medical consultation was from a physician with expertise in MDR TB.
Contacts’ treatment and complication history tracked.

11. Identifying and Treating Contacts
Patient remained in school while symptomatic for 2 months prior to diagnosis.
Household: 2 of 3 household contacts had positive TST’s, with time of infection undetermined.
Dad previous positive TST current CXR WNL, not treated.
Mom current TST 25MM baseline 0MM TX with INH 900 mg twice weekly.
TX options
Boosting ?
Conversion ?
Sibling 13 y.o. (-) TST, (-) CXR (no window prophylaxis)
School: 264 students and teacher contacts identified
250 (95%) completed TST’s and CXR’s.

12. Identifying and Treating Contacts
School: 7 of 250 (3%) were TST positive.
All 7 were in close physical proximity to the case
5/7 played a wind instrument in the band
2/7 were in close proximity in the classroom
4/7 had documented TST conversions
All 7 had no known risk factors for previous exposure and were presumed to be newly infected with MDR TB.
Drug treatment for school contacts:
Treatment with 2 drugs to which organism sensitive (PZA, LEVO)
Joint symptoms in 1 adult and 3 students were resolved after TEQUIN substituted for LEVO

13. Identify and Treating Contacts
Drug treatment for school contacts: (continued)
One student developed drug induced hepatitis toxicity
Directly observed therapy was refused by parents but parents agreed to supervise meds
Adolescents under reported adverse reactions to avoid serologic testing
Table 2 summarizes drugs and treatment of MDR Latent Infection.

14. Table 2: School Converters –
Treatment Summary for MDR Latent Infection
Patient
Exposure Type
PPD Size
Drugs
Complications
Drug Change
Disposition
# 1
Teacher
25 mm
PZA, Levo
Uric acid elevated (11.1)
PZA, Tequin
Completed Rx
# 2
Band
10 mm
Uric acid elevated
# 3
15 mm
Uric acid elevated (8.2)
# 4
None
# 5
Classroom
# 6
12 mm
Foot and joint pain with no elevation of Uric acid
# 7
18 mm
Admitted with acute liver failure and listed for a liver transplant until liver functions improved
All TB drugs discontinued
Unable to complete Rx

15. OTHER ISSUES
Student did not return to school until nearly 2 months after diagnosis
Culture conversion occurred over nine weeks after initial treatment started
Student was not allowed to return to the same high school she was attending (with 6 weeks left to the school year)
Fear and stigma of the disease extended to the school administration
School nurse was threatened, to induce her to reveal the students identity, she refused caller

16. Conclusions - Discussion
Contacts treated with second line drugs for MDR latent TB infection had clinically significant variations in adverse reactions to quinolones
Source case transmission of MDR TB was extended by missed diagnosis and subsequent treatment with a quinolone for suspected community acquired pneumonia

17. Conclusions - Discussion
Patient and family education regarding the importance of stopping medications, if adverse reactions suspected, is vital to health and treatment outcome
Contacts treated with second line drugs for MDR TB require close monitoring, including serologic testing and DOT.

18. Conclusions - Discussion
Directly Observed Therapy of MDR TB contacts would likely enhance clinical follow-up. Although parents refused this option, more education and a comprehensive effort on the part of all providers would most likely be needed to reverse this decision. Another benefit of DOT is the possible prevention of further drug resistance.
Further research is necessary to address the complexities and duration of treatment for MDR latent TB infection.