TB CONSIDERED: DERAILING THE HIGHLY VIRULENT XDR-TB

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Worldwide, there are 25,000 cases of extensively drug resistant tuberculosis (XDR-TB) diagnosed yearly. Between 1993-2017, 65 cases of XDR-TB were reported in the US. When XDR TB first came to public attention in 2006 it was portrayed as an incurable disease. However, with novel diagnostic tests and medication, XDR-TB can be cured. We present a case of XDR-TB in a native Chinese lady. CASE PRESENTATION: A 37-year-old Chinese woman presented with worsening shortness of breath, weight loss, subjective fevers, and hemoptysis for six months. She was treated for TB 10 years ago in China with a 2-drug regimen for 10 months. Physical exam revealed a resting tachycardia and crackles in both lungs. CBC showed a WBC of 10,300 with a normal differential. CT scan of chest revealed consolidations and multiple cavitary regions in the bilateral upper lobes with prominent hilar lymph nodes. HIV testing was negative and cultures were positive for Mycobacterium TB and drug sensitivities revealed XDR-TB. Sputum smear revealed 4+ acid fast bacilli (AFB)(>30 bacilli/HPF). She was placed in isolation on a cocktail of 8 antibiotics and observed for drug tolerance and side effects. Baseline electrolytes, liver enzymes and ECG were normal. Due to rarity of the disease and public health concern, she was transferred to an NIH facility and is currently responding well to bedaquiline, clofazimine, linezolid, amikacin, meropenem and cycloserine. Two months into therapy, she no longer has hemoptysis and sputum smears remain negative for AFB. DISCUSSION: XDR-TB is resistant to first line drugs: isoniazid and rifampin, second line fluoroquinolones, and at least 1 injectable drug. Current XDR-TB treatment is long, toxic, complicated, expensive and essentially ineffective. Research is thriving in the field of TB treatment. A 2018 WHO update designated bedaquiline, a drug proven to reduce mortality, treatment duration and increase treatment success, as the core component in XDR-TB management. The Nix-TB, ZeNix and SimpliciTB are clinical trials testing bedaquiline, pretomanid and linezolid; a regimen removing injectables, expected to treat XDR-TB in 6-9 months. However, a 6-month course of bedaquiline costs $30,000 in US and $513,000 is required to treat XDR-TB. Petty politics, lack of organization and responsibility among state legislature denied our patient appropriate treatment for more than two months. CONCLUSIONS: Due to extensive travel and immigration from TB-endemic areas, 70.1% of TB cases in the US occur among non-U.S.-born persons. The mortality rate of XDR-TB is 50% and although rare, suitable treatment must be provided, because TB somewhere, is TB everywhere. Unfortunately, our patient’s son succumbed to XDR-TB. Our country and world must come together to eliminate this global threat that we are currently inadequately equipped to tackle. Reference #1: Brigden, Grania et al. “New developments in the treatment of drug-resistant tuberculosis: clinical utility of bedaquiline and delamanid” Infection and drug resistance vol. 8 367-78. 30 Oct. 2015 Reference #2: “Fact Sheets | Drug-Resistant TB | Extensively Drug-Resistant Tuberculosis (XDR TB) | TB | CDC.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, www.cdc.gov/tb/publications/factsheets/drtb/xdrtb.htm. Reference #3: Companion Handbook to the WHO Guidelines for the Programmatic Management of Drug-Resistant Tuberculosis. Geneva: World Health Organization; 2014. 5, Treatment strategies for MDR-TB and XDR-TB.Available from: tps://www.ncbi.nlm.nih.gov/books/NBK247431/ DISCLOSURES: No relevant relationships by Leonard Berkowitz, source=Web Response no disclosure on file for Ozana Lipka; No relevant relationships by Meghana Parsi, source=Web Response