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2016: The Year of Unusual TB Cases

2016: The Year of Unusual TB Cases. Erika Pitcher, MPH Director of Community Health & Case Mgmt. Fort Wayne-Allen County Dept. of Health. Case Study #1. 20yo immigrant from Philippines 8/3/16 – presented to a walk-in clinic with 6-8 month history of: Weight loss (14lb)

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2016: The Year of Unusual TB Cases

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  1. 2016: The Year of Unusual TB Cases Erika Pitcher, MPH Director of Community Health & Case Mgmt. Fort Wayne-Allen County Dept. of Health

  2. Case Study #1 • 20yo immigrant from Philippines • 8/3/16 – presented to a walk-in clinic with 6-8 month history of: • Weight loss (14lb) • Non-productive cough • Night sweats • Hoarseness • Shortness of breath (3 family members had just converted IGRA’s)

  3. Case Study #1 • 8/3/16 – Chest x-ray noted dense RUL consolidation with small right pleural effusion (note: extensive active TB) • Walk-in clinic nurse called FWACDOH to report suspect case and we informed them to send patient home in isolation • FWACDOH collected 3 sputum: • 8/4/16: AFB smear (-), PCR+, culture + • 8/4/16: leaking specimen, unable to test • 8/5/16: AFB smear (+) 1-10/field, PCR+, culture +

  4. Case Study #1 • Patient was in isolation from 8/3/16-9/29/16 • Infectious period determined to be 12/2015 - 9/29/2016 • Started on RIPE 8/10/16 and finished treatment on 2/6/2016 • Pan-sensitive strain of TB • Genotype: 0157-001

  5. Case Study #1 • 14 close contacts tested • 6 people with positive PPD or IGRA • Eventually….3 active TB cases!

  6. Case Study #1 Contact #1: • 13yo immigrant from Philippines • Close contact to active case • 1st TST placed 8/10/16 (0mm) • 9/7/16 – Mom called to report slight cough • 3 sputum samples collected: • 9/7/16: smear (-), PCR (-), culture (+) on 9/28 • 9/8/16: smear (-), PCR (-), culture (-) • 9/9/16: smear (equivocal), PCR (-), culture (-) • 3 repeat sputum samples collected due to equivocal smear: • 9/14/16: smear (-), culture (+) • 9/14/16: smear (-), culture (+) • 9/15/16: smear (-), culture (-)

  7. Case Study #1 • 9/28/16- Jessica Gentry called to report (+) culture results • 9/28/16- 2nd TST placed, read at 19mm • Symptom review: NO symptoms, cough resolved on its own • 9/29/16: Chest x-ray: No Active Disease • 3 new sputum samples collected: all 3 were smear, PCR and culture negative • Started on RIPE 9/30/16, will finish treatment on 3/31/17 • Genotype match to index case: 0157-001

  8. Case Study #1 Contact #2: • 11 year old American born patient • Contact to active, infectious TB case • Initial TST placed 8/15/16: negative • Dad called to report a cough on 9/9/16 • 3 sputum collected: • 9/9/16: smear (-), culture overgrown • 9/10/16: smear (-), culture + on 9/30 • 9/11/16: smear (-), culture (-) • 9/26/16: 2nd TST placed, read at 0mm

  9. Case Study #1 • 9/30/16 Jessica Gentry called to report positive PCR off culture for Mtb • 9/30/16: Symptom Review: NO symptoms, cough resolved on its own • 10/3/16: Chest x-ray showed minor scarring or atelectasis in suprahilar portion of R lung • 3 new sputum samples: • 10/4/16: smear (-), PCR (-), culture (-) • 10/5/16: smear (-), culture (-) • 10/6/16: smear (-), culture (-) • Started on RIPE 10/4/16 and will finish treatment 4/3/17 • Genotype match to index case: 0157-001

  10. Case Study #1 Contact #3: • 48yo immigrant from Philippines • (+) QFT-G on 7/21/16 at work place (previous IGRA was negative) • Household contact to active, infectious TB case • 8/3/17 –chest x-ray showed NO active disease • Symptom Review: NO symptoms

  11. Case Study #1 • With 2 active cases off index case, FWACDOH decided to collect sputum on entire family regardless of symptoms • 3 sputum samples: • 10/18/16: smear (equivocal), PCR (-), culture (-) • 10/19/16: smear (-), PCR (-), culture (-) • 10/19/16: smear (-), PCR (-), culture (+) on 11/10

  12. Case Study #1 • Once again…Jessica Gentry called on 11/10/16 to report a positive culture for Mtb • 3 new sputum samples collected: all 3 were smear and culture negative • Patient started on RIPE 11/14/16 and will finish treatment 5/2017 • Genotype match to index case: 0157-001

  13. Case Study #1: Timeline of Events 7/21/16: 3 family members converted IGRAs 9/30/16: Contact #2 confirmed via culture 8/10/16: Index case confirmed 11/10/16: 3rd contact confirmed via culture 9/9/16: Contact #2 developed a cough 8/3/16: Index case reported as suspect case 10/18/16: Decision made to collect sputum on entire family 9/7/16: Contact #1 developed a cough 9/28/16: Contact #1 confirmed via culture

  14. Case Study #2 • 27yo Burmese refugee (arrived 9/2016) • Initial refugee screening: • 9/29/16: TST read at 11mm • Symptom Review: No symptoms • 10/13/16: Chest x-ray: no active pulmonary disease…but… “rounded soft tissue prominence at midline lower chest, appearing to be in association with deformity of the T8 vertebral body”

  15. Case Study #2 • 10/25/16 – Patient saw Dr. McMahan for Initial Exam • Patient complained of epigastric pain and right upper quadrant pain • Tested (+) for H. Pylori • Tested (+) for B. Hominus

  16. Case Study #2 • 10/28/16 – patient went to ER with reported right upper quadrant pain and palpitations • 10/29 CTA – no pulmonary embolism, but findings of severe destruction & collapse of T7-T8 vertebral bodies with change of upper T9 level • 10/31 CT Guided Biopsy – aspirate collected from T7&T8 vertebra (eventually grew in culture and confirmed Mtb complex on 11/25/16) • 11/1 – very abnormal MRI, focusing on degeneration of T6-T9 vertebral bodies

  17. What you expect to see…. What we saw….

  18. Case Study #2 • 11/1/16 – ID physician called and reported as suspect case of TB, started patient on RIPE • 11/2/16 – patient discharged from hospital and FWACDOH took over care • 12/9/16 – referred to physiotherapy and reported no intervention is necessary at this time • 2/24/17 – isolate was confirmed as M. bovis • Will continue to treat patient a minimum of 9 months, will evaluate after MRI this summer

  19. Case Study #3 • 63yo American born female • 4/11/16: evaluated at a walk-in clinic for night sweats and cough, dx w/sinusitis • 4/18/16: ER Visit – complaint of fatigue, shortness of breath, loss of appetite • 4/18 - 4/28/16 – admitted to Hospital #1 for weakness, non-caseating bladder tumors, bilateral hydronephrosis, UTI, atypical pneumonia • 5/8 - 5/24/16 – admitted to Hospital #2 for stroke, pulmonary infiltrates, fevers, pneumonia, chronic kidney disease • 5/24 - 6/14/16 – admitted to Rehab Unit at Hospital #3

  20. Case Study #3 • 6/14/16: FWACDOH received notification from ID physician that patient had a (+) urine culture for Mtb (specimen collected 5/17/16) • ID was consulted during stay at Hospital #2 due to: • +QFT-G • History of non-caseating granulomas in bladder • Low grade fevers • RLL and left basilar infiltrates • Stage 3 chronic kidney disease

  21. Case Study #3 Was the patient infectious? • 5/8/16: Chest x-ray • Dense infiltrate RLL and possible left base • 5/14/16: Chest x-ray • No change, recommend CT • 5/16/16: Chest CT • Increase in density of consolidation of RUL and both lung bases *Sputum was NOT collected at this time due to a negative BAL from Hospital #1 on 4/21/16*

  22. Case Study #3 • FWACDOH suggested patient be moved immediately to airborne precautions and instructed the hospital to collect 3 sputum samples • Patient was started on RIPE • Symptom Review (6/15/16): fever, night sweats, chills, SOB, hoarseness, decreased appetite, weight loss • 3 sputum were collected: • 6/15/16: smear <1/field, PCR (+), culture (+) • 6/16/16: smear 1-10/field, PCR (+), culture (+) • 6/16/16: smear 1-10/field, PCR (+), culture (+)

  23. Case Study #3 • Contact Investigation • Historical records showed case had a positive PPD in 1980 • Historical urology records dated urinary problems back to 2007 • Pulmonary symptoms started in 4/2016, so infectious period began in 1/2016 • Over 400 healthcare workers, 39 rehab contacts and 6 close family members or friends were tested

  24. Case Study #3

  25. Case Study #3 • From 6/15 - 8/1/16 patient received routine TB treatment while living at an extended care hospital • Patient released from isolation on 7/26/16, remained in extended care hospital • 8/1/16: patient had a seizure • 8/2/16: patient developed horizontal nystagmus and fever and was admitted to Hospital #2

  26. Case Study #3 • 8/2/16: MRI • Multiple foci throughout entire brain with vasogenic edema • Physician stated a lumbar puncture would be too dangerous for patient • Suspicion of TB meningitis per ID doctor and Neurologist • Patient was receiving meds through a PEG tube and it was suspected that the medication was not being absorbed, but drug levels were checked all were found to be within therapeutic range.

  27. Case Study #3 • Patient stabilized at hospital and moved to a long-term care facility. • Patient was placed on hospice and died on 11/5/16.

  28. Questions?

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