1. 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

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 –Resistant: RIF/RBT; INH; PZA –Sensitive: SM / CM / AK; EMB; CS; PAS; CIP/OFL; CLA; CLO

6. Case #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

7. Sputum Smear & Culture - 1 7-13-99 AFB 2+M.tb 8-24-99*AFB TNCM.tb 9-21-99 AFB <1+M.tb 10-19-99negneg 11-16-99negneg 12-14-99negneg 1-18-00negneg

8. September 21, 1999

9. January 10, 2000

10. Sputum Smear & Culture - 2 3-7-00AFB negM.tb 4-17-00*negneg 4-28-00negM.tb 4-29-00negM.tb 5-1-00negM.tb 6-1-01negM. 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 8-8-00negMTBC 9-1-00+1MTBC 10-3-00+1MTBC 12-7-00+1MTBC 1-5-01+1MTBC 6-3-01+1MTBC

15. May 2001

16. Post-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

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 2002 (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

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

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