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Comprehensive Case Analysis of a Strong TB Suspect: Challenges in Diagnosis and Treatment

This case study explores the diagnostic journey of a 31-year-old female from Kenosha County, Wisconsin, suspected of having tuberculosis (TB). With a significant medical history, including a positive QuantiFERON (QFT) test and abnormal chest X-ray (CXR), the patient presented a unique diagnostic challenge. Despite varied results from smear tests and TB PCR, the identification of Mycobacterium tuberculosis (M. tbc) was eventually confirmed. The study highlights the complexities of TB testing, treatment regimens, and the impacts of personal circumstances on patient management.

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Comprehensive Case Analysis of a Strong TB Suspect: Challenges in Diagnosis and Treatment

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  1. Case Study Youngmi Kim, MS, ASCP(M) Senior Microbiologist, Wisconsin State Laboratory of Hygiene

  2. 31 year old female from Kenosha County • Strong TB suspect: foreign born, abnormal CXR, positive QFT • Received sputa for smear and culture collected 2/20, 2/21, and 2/22/13

  3. Two of the three specimens were smear positive (1+ and 3+), but TB PCR was negative for both • Specimen sent to CA PHL for parallel testing (WI & CA Shared Services Project) • NAAT • MDDR (CA only) • Conventional TB DST

  4. CA lab had a weak positive NAAT result and contacted WI SLH for more information on the patient. • California was hesitant to send out a positive result, given WSLH’s TB PCR results (both negative). • CA report 3/1/13: “identification of MTB is inconclusive”.

  5. MGIT became positive (GU=2278) 3/4/13

  6. HPLC :Prelim reported as MAIS 3/6/13 • Positive MGIT growth subcultured to • 7H10, LJ, & 7H9

  7. 3/12/13: Small colonies with cording in 1st quadrant noticed amongst the confluent MAC growth

  8. 3rd Quadrant of 7H10 plate

  9. 3/12/13: TB PCR performed from MGIT broth was positive for M. tbc (Ct=22) • Tried very hard to isolate M. tbc for susceptibility testing • Growth in broth containing clarithromycin • Growth on plate with clarithromycin disk

  10. 4/15/13 at WSLH: M. tbc isolated & 1st line DST set up (49 days after receipt) • CA PHL report 3/18/13: • MDDR testing: no mutations that confer resistance to INH, rifampin, quinolones or injectables

  11. 4/25/13 • 1st line DST result out as pan susceptible to all 4 drugs

  12. Questions for County PHN • Any signs and symptoms?

  13. Questions for County PHN • Any signs and symptoms? • No

  14. Questions for County PHN • Why was sputum collected?

  15. Questions for County PHN • Why was sputum collected? • Pre-employment screening at a nursing home • Patient refused skin test due to BCG vacc. • CXR Abnormal • QTF + • 3 Sputa collected • 2 of 3 Smear Positive

  16. TB Risk Factors -came from Cameroon 2 yrs ago -Husband with 2 sons (also pregnant) Husband: CXR Neg, QFT Neg 5 yr old: CXR a little abnormal QFT Pos 1.5 yr old: CXR Neg, QFT Neg

  17. Patient Status • Positive culture for M. tbc on 3/13/13 • Patient pulled out of employment and placed in respiratory isolation • Contact investigation: 80 residents and 100 staff members skin tested; all negative • Patient on 3 drug regimen (no PZA) • Till end of Dec. 2013 / DOT • Refused 5 year old son to be treated • Had a daughter and breast feeding

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