1. Wisconsin State Laboratory of Hygiene

2. WISCONSIN STATE LABORATORY OF HYGIENE Case Study Youngmi Kim, MS, ASCP(M) Senior Microbiologist, Wisconsin State Laboratory of Hygiene 2

3. WISCONSIN STATE LABORATORY OF HYGIENE 3 31 year old female from Kenosha County Strong TB suspect: foreign born, abnormal CXR, positive QFT Received sputa for smear and culture collected 2/20, 2/21, and 2/22/13

4. WISCONSIN STATE LABORATORY OF HYGIENE Two of the three specimens were smear positive (1+ and 3+), but TB PCR was negative for both Specimen sent to CA PHL for parallel testing (WI & CA Shared Services Project) –NAAT –MDDR (CA only) –Conventional TB DST 4

5. WISCONSIN STATE LABORATORY OF HYGIENE CA lab had a weak positive NAAT result and contacted WI SLH for more information on the patient. California was hesitant to send out a positive result, given WSLH’s TB PCR results (both negative). CA report 3/1/13: “identification of MTB is inconclusive”. 5

6. WISCONSIN STATE LABORATORY OF HYGIENE MGIT became positive (GU=2278) 3/4/13 6

7. WISCONSIN STATE LABORATORY OF HYGIENE 7

8. HPLC:Prelim reported as MAIS 3/6/13 Positive MGIT growth subcultured to »7H10, LJ, & 7H9 8

9. WISCONSIN STATE LABORATORY OF HYGIENE 3/12/13: Small colonies with cording in 1 st quadrant noticed amongst the confluent MAC growth 9

10. WISCONSIN STATE LABORATORY OF HYGIENE 3 rd Quadrant of 7H10 plate 10

11. WISCONSIN STATE LABORATORY OF HYGIENE 3/12/13: TB PCR performed from MGIT broth was positive for M. tbc (Ct=22) Tried very hard to isolate M. tbc for susceptibility testing –Growth in broth containing clarithromycin –Growth on plate with clarithromycin disk 11

12. WISCONSIN STATE LABORATORY OF HYGIENE 4/15/13 at WSLH: M. tbc isolated & 1 st line DST set up (49 days after receipt) CA PHL report 3/18/13: –MDDR testing: no mutations that confer resistance to INH, rifampin, quinolones or injectables 12

13. WISCONSIN STATE LABORATORY OF HYGIENE 4/25/13 –1 st line DST result out as pan susceptible to all 4 drugs 13

14. WISCONSIN STATE LABORATORY OF HYGIENE Specime n # (All Sputum) DOCSmearCulture 13MM18112/20/13NegMAC & M. tbc 13MM18352/21/131-9/ fMAC & M. tbc 13MM18642/22/131-9/100 fMAC 13MM21893/15/13NegMAC 13MM25804/9/131-9/100 fMAC 13MM25794/10/13QuestionableMAC 13MM26064/11/13NegMAC 13MM27124/17/13NegMAC 13MM28094/23/131-9/100 fMAC 13MM29404/30/13NegMAC 13MM30035/6/13NegMAC 13MM31525/10/13NegMAC 14

15. WISCONSIN STATE LABORATORY OF HYGIENE Questions for County PHN Any signs and symptoms? 15

16. WISCONSIN STATE LABORATORY OF HYGIENE Questions for County PHN Any signs and symptoms? –No 16

17. WISCONSIN STATE LABORATORY OF HYGIENE Questions for County PHN Why was sputum collected? 17

18. WISCONSIN STATE LABORATORY OF HYGIENE Questions for County PHN Why was sputum collected? –Pre-employment screening at a nursing home –Patient refused skin test due to BCG vacc. –CXRAbnormal –QTF + –3 Sputa collected –2 of 3 Smear Positive 18

19. WISCONSIN STATE LABORATORY OF HYGIENE TB Risk Factors -came from Cameroon 2 yrs ago -Husband with 2 sons (also pregnant) Husband: CXR Neg, QFT Neg 5 yr old:CXR a little abnormal QFT Pos 1.5 yr old: CXR Neg, QFT Neg 19

20. WISCONSIN STATE LABORATORY OF HYGIENE Patient Status Positive culture for M. tbc on 3/13/13 Patient pulled out of employment and placed in respiratory isolation Contact investigation: 80 residents and 100 staff members skin tested; all negative Patient on 3 drug regimen (no PZA) –Till end of Dec. 2013 / DOT –Refused 5 year old son to be treated –Had a daughter and breast feeding 20