Medical Grand Rounds Clinical Vignette September 5, 2007 by historyman


									Medical Grand Rounds
  Clinical Vignette
   September 5, 2007

      Shugi Zheng, M.D.
          Chief Complaint
• 18 year-old man who complains of 3
  months of productive cough.
      History of Present Illness
• The patient was living in Tibet in his usual state
  of excellent health until approximately 1 year
  prior to admission when a classmate was
  diagnosed with tuberculosis and the patient was
  started on isoniazid prophylaxis.

• Three months later, the patient developed
  productive cough and was started on a three-
  drug regimen.
     History of Present Illness
• Two months later, the patient emigrated to the
  United States and was evaluated at the Corona
  Chest Center for continued treatment. Chest x-
  ray at that time showed bilateral upper lobe
  infiltrates, and the patient was started on
  isoniazid, rifampin, ethambutol, and

• Resistance testing then revealed M. tuberculosis
  resistant to isoniazid, rifampin, ethambutol,
  pyrazinamide, and streptomycin.
     History of Present Illness
• He was then admitted to Bellevue Hospital, and
  treated with PAS, cycloserine, ethionamide, and
  levofloxacin and when sputum smears became
  negative, was discharged to home isolation for 3
  months with weekly sputum surveillance.

• Three months later, his sputum returned smear
             Sputum Culture
• Culture of that smear grew M. tuberculosis with
  extensive resistance.

• Remaining susceptibility included:
  Capreomycin 10 ug/ml:     10% Resistant
  Cycloserine 30 ug/ml:     Susceptible
  Kanamycin 5.0 ug/ml:      10% Resistant
  PAS 2.0 ug/ml:            20% Resistant
  Amikacin 2.0 ug/ml:       20% Resistant
  Amikacin 4.0 ug/ml:       20% Resistant
  Ofloxacin 1.0 ug/ml:      Susceptible
  Ofloxacin 2.0 ug/mL:      Susceptible
     History of Present Illness
• He was started on a regimen of
  cycloserine 750mg po daily, ethionamide
  500mg po BID, PAS 4,000mg po BID, and
  levofloxacin 750mg po daily.

• 4 months later, patient was noted to have
  new drug resistance on surveillance
  sputum culture, susceptible only to
  capreomycin and cycloserine.
     History of Present Illness
The patient was referred by the Department
 of Health to return to Bellevue for further
           Other History
• Medications: Cycloserine 750mg daily,
  Ethionamide 500mg bid, PAS 4000mg bid,
  Levofloxacin 750mg daily, Synthroid 75
  mcg daily
• Allergies:   No known drug allergies
• Social Hx: No smoking history
• Family Hx: Non-contributory
              Physical Exam
• GENERAL: young cachectic man in no acute

• VS: Afebrile, BP 113/54 mmHg, HR 67 bpm, RR
  20/min, O2 saturation 100% on room air

• Lung: diffuse crackles bilaterally.

• The remainder of the physical exam was normal.
       Laboratory Findings
• WBC 11.9 mm3, 76% neutrophils, 16.4%
• Hgb 14.1 g/dL
• Platelet count 334 mm3
• Basic metabolic panel normal
• Hepatic panel normal
            Additional Data
• CXR: Extensive fibronodular changes in
  both lung apices. Right apical pleural
  thickening. Peribronchial thickening and
  nodularity within the majority of the left
  lung. Segmental right middle lobe
  collapse. No pleural effusion or
• EKG: sinus rhythm, otherwise normal
              Hospital Course
• The patient underwent a right upper lobe lobectomy and
  right lower lobe wedge resection.

• The patient’s remains well on this regimen:

  Linezolid 600mg twice a day
  Cycloserine 500mg twice a day
  Ethionamide 500mg twice a day
  Clofazimine 100mg daily
  Capreomycin 750mg daily
  Azithromycin 500mg daily
  Moxifloxacin 400mg daily
  Gamma Interferon 200ug three times per week

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