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Case of MDR-TB from Haiti

Case of MDR-TB from Haiti. Christopher Kovacs MD Infectious Disease Fellow Cleveland Clinic. History of Present Illness. 29 year old male from Hinche , Haiti Previous calendar year – exchange student studying agriculture

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Case of MDR-TB from Haiti

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  1. Case of MDR-TB from Haiti Christopher Kovacs MD Infectious Disease Fellow Cleveland Clinic

  2. History of Present Illness • 29 year old male from Hinche, Haiti • Previous calendar year – exchange student studying agriculture • Diagnosed with TOF -- referred for surgical correction at the Cleveland Clinic • Preoperative assessment completed – Surgery August 2013 • Haiti from May until August 2013 • Returned August 2013 for surgery • Fever, cough, and weight loss over the last 2 months

  3. Previous History • Past Medical History • Tetralogy of Fallot, Typhoid fever, Pleural effusion, HIV negative • Past Surgical History • Thoracentesis 2009, LHC June 2013

  4. Presentation to Cleveland Clinic • Returned to US for planned surgery • Preoperative testing undertaken • CT chest obtained for surgical planning • Sent to ED for concern of tuberculosis after interviewed, examined, and imaging reviewed

  5. Imaging

  6. Imaging

  7. Initial Culture Results

  8. Drug Resistance From CDC

  9. Hospital Course • Patient started on cycloserine, linezolid, amikacin, moxifloxacin, PZA and pyridoxine • 9/26/2013- smear and culture negative • 10/6/2013- found down with aphasia, facial droop and right sided weakness • abrupt cutoff M1 segment of LMCA • tPA administered; transferred to ICU • PICC related paradoxical embolus

  10. Hospital Course • 12/17/13- Meeting with ID, Social work, Physical Medicine and Rehabilitation, Pediatric Cardiothoracic Surgery • Re-aspiration of left pleural space negative for AFB • Repeat CT scan with decreased cavity size, less infiltrate , and healed bronchopleural fistula • Infection prevention plan for operative plan developed • Aggressive stroke rehab

  11. Hospital Course • Successful repair of TOF • using Gore-Tex VSD patch • Right ventricular outflow tract resection • 24-mm pulmonary homograft • Suture closure of atrial septal defect • All cultures remain negative to date • Discharged to host family on 3/20/14

  12. Points for Discussion • Role of thoracic surgery for this patient • Considerations: • Poor blood flow to the hypoplastic left lung? • Poor drug delivery? • Sequestered area for further resistance development? • Surgical morbidity in the setting of negative cultures and resolution of the BPF? • Access to thoracic surgery resources in Haiti should intervention be required in the future? • How should this be followed going forward?

  13. Points for Discussion • Transition of care from US to Haiti • Considerations: • Patient wishes and autonomy • Resource poor vs. Resource rich environments • Ensuring DOT provided; logistics of care near Hinche • Duration of aminoglycoside • Adjustment of regimen to consider cost/access to meds • Additional susceptibilities confirmed for cycloserine, clofazimine, clarithromycin, linezolid • Transition of care to GHESKO or PIH

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