Clinical Case Female, 27 years of age 3 rd year Internal Medicine resident at the Mexicali General...
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Transcript of Clinical Case Female, 27 years of age 3 rd year Internal Medicine resident at the Mexicali General...
Clinical Case
• Female, 27 years of age
• 3rd year Internal Medicine resident at the Mexicali General Hospital
• Never smoked; does not ingest alcoholic beverages or use illicit drugs
• Used to run 5 km daily before being ill
• Single, no children; lives with parents
• Previous medical history: non-relevant; no known allergies
• Contact with tuberculosis patients: extremely frequent at her hospital; assisted in bronchoscopy procedures several times during her 1st year of residency
• Has never been diagnosed with TB or received TB treatment before
• Started her symptoms – July 2005; right pleuritic chest pain; self-limited. Chest
x-ray at that time normal– December 2005:
• Headache• Malaise• Hyporexia• Dry cough• Fever• Dyaphoresis
– She received 10 days of gatifloxacin (400 mg OD)
• By the end of January 06 her symptoms persisted
• chest- x-ray Jan 29, 2006 showed two small cavities in the right lower lobe
• She was started on the five available first-line drugs (IRZES), self-administered
• Five days later she underwent bronchoscopy (she could not produce any sputum for AFB exam)
• AFB from bronchoscopy: reported as positive with 354 AFB in 100 fields
• HIV test: non reactive (ELISA)
• She feels better; fever and cough disappeared, gained weight (3 kg)
• Culture results are reported from Imperial Valley Laboratory– Resistant to ISRZ and ethambutol at 2.5; susceptible
to ethambutol at 5– Susceptible to capreomycin, ethionamide and
levofloxacin
• A CT scan (03/29/06) shows persistence of the lung cavitations
• On Dr. Laniado’s advise she stops all treatment on April 01, 2006
• Examined by Dr. Laniado on April 10, 2006; she is asymptomatic and her physical examination is negative; does not expectorate
• Bronchoscopy performed on April 11, 2006 to perform BAL
• AFB from BAL in the State Laboratory in Tijuana and the General Hospital in Mexicali are reported as negative. Culture pending
• PCR analysis of the BAL is reported as positive for Mycobacterium tuberculosis and the mutation for rifampin resistance is detected