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Case Study

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

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Case Study

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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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