Acquired Drug Resistance
64 year old female of Hmong ethnicity with long
standing, poorly controlled diabetes. No hx TB
dx/tx.
11/6/08 CXR “active processes in both upper
lobes that are most likely inflammatory in nature”
Sputa AFB smear negative
Plan was to begin empiric treatment after
pulmonary consult
Referred to pulmonologist, but failed
appointments, no treatment
Culture negative, no treatment
Acquired Drug Resistance
Aug 2009 she collapsed in her home
Arrived at hospital via ambulance, unconscious
Transferred to Doctor’s Hospital in Modesto
Reportedly had cough since the November 2008
exam
Pt reports that she is now “skinny”, implying
weight loss, but none documented
Acquired Drug Resistance
8/29/09 - Heavily smear (+) with bilateral
infiltrates on CXR
8/31/09 - Began RIPE
Initial isolate pan-sensitive
10/2/09 - EMB discontinued
11/6/09 - PZA discontinued
10/8/09 - Smears become negative
Cultures remain positive
Acquired Drug Resistance
1/12/10 - CXR “Progressive bilateral upper
lobe infiltrates”
1/27/10 - Smears become 2+ AFB positive
Subsequently, it was learned that she had
begun vomiting (start date unclear) shortly
after DOT worker left each day
She did not report this for several months
Acquired Drug Resistance
Repeat DST results show:
Resistance to INH, Rif
Sensitive to EMB, PZA, ETA, CM, AK & LFX
Acquired Drug Resistance
Hospitalized & expanded regimen started:
Amikacin, 750 mg 5x wk via PICC (later lowered)
Moxifloxacin, 400 mg po qd
Ethambutol, 1200 mg po qd
PZA, 1250 mg po qd
Linezolid, 600 mg po qd
B6, 100 mg po qd
Zofran for vomiting
Baseline color vision and hearing OK. Glucose levels,
LFTs, and renal functions were excellent throughout
hospital stay
Therapeutic Drug Levels
(MFX collected 4/19/10, all others 4/23/10)
Drug Dose 2 hr 6 hr Ref Range
level level
1200 mg 2 hr 2-6 mcg/ml
EMB 0.90 1.86
po qd
1250 mg 2 hr 20-60 mcg/ml
PZA 18.18 29.53
po qd
400 mg 2 hr 3-5 mcg/ml
MFX 3.36 2.06
po qd No 6 hr range
600 mg 2 hr 12-24 mcg/ml
LNZ 3.53 7.02
po qd
AK 550 mg 20.8 7.3 Cmax 35-45 mcg/ml
IV 5d/wk
Cmax 35.1