Case Studies
October 2008 ■ Hookah Smoking: A Rising Tuberculosis Health Risk Behavior
Case History: A 20 year old Russian university student, who had entered the United States 2½ years earlier, was diagnosed with extremely drug resistant tuberculosis (XDR TB).
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June 2008 ■ Adherence Difficulties in a Child with Tuberculosis
Case History: A 15 month old child with active pulmonary tuberculosis became a significant management challenge to his public health nursing providers because of his consistent refusal to take medications.
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December 2007 ■ Tuberculosis in an Adoptee
Case History:
A 6-year-old girl presented to her pediatrician with decreased hearing acuity found by routine elementary-age screening. She had been adopted from a Korean orphanage at 9 months of
age and had a history of poor growth there. She had scarlet fever and pneumonia prior to the age of 4, but no other recent significant illnesses since adoption. Adoption records did not
indicate vaccination with BCG and she had no vaccination scar. She had four documented Tine tests (multi-puncture test for TB infection) during the adoption process, all of which were negative. She had a Tine test at a community hospital prior to presenting to her physician, results of which are unknown.
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November 2007 ■ Primary Tuberculosis Following Exposure
Case History:
A twenty year old woman was evaluated as a contact of a patient who had extensive smear positive pulmonary tuberculosis (drug susceptible isolate). She denied any symptoms of cough, weight loss, fatigue, night sweats or fever. She weighed 86 pounds. A TST was positive with a 20 mm induration. A chest x-ray (CXR) showed opacification of the lower half of the left hemithorax reflective of a moderate size left pleural effusion and/or atelectasis. She had normal laboratory values. She was not able to provide a sputum specimen.
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September 2007 ■ Delayed Culture Conversion, Low Serum Drug Levels
Case History: Our patient is a 54 year-old male who presented to his physician for follow up of a right upper lobe carcinoma which was ressected in 1979. He complained of shortness of breath, weight loss, fatigue, chest pain and a productive cough but no hemoptysis. A chest x-ray on June 20, 2006 revealed new bilateral alveolar infiltrates. He was referred to a pulmonologist and admitted to his hometown hospital on June 20, 2006. Smears were positive for acid fast bacilli and a CT scan June 22nd showed cavitation in the left upper lobe, bilateral infiltrates and mediastinal adenopathy. He was placed on anti-tuberculosis therapy—isoniazid (INH) 300 mgs, rifampin (RIF) 600 mgs, pyrazinamide (PZA) 1500 mgs and ethambutol (EMB) 1600 mgs daily with vitamin B6 50 mgs. Directly Observed Therapy (DOT) was started on July 7, 2006; given Monday through Friday with self-administration on the weekends. His culture grew Mycobacterium tuberculosis and was susceptible to INH, RIF and EMB.
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March 2007 ■ Failure to Convert: Non Adherence to Treatment
Case History: A 67 year old Hispanic male was diagnosed with drug susceptible pulmonary tuberculosis in September 2005. He presented with a three week history of night sweats, weight loss, nausea, shortness of breath and a productive cough. A chest x-ray (CXR) showed extensive bilateral cavitary disease. He was Hepatitis C positive with elevated baseline liver enzymes; HIV testing was negative. Sputum smears were AFB positive with greater than 10 organisms per high powered field. The patient's weight at diagnosis was 96 lbs.
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December 2006 ■ Missed Opportunities
Medical History A 52 year old Hispanic female presented in January 2006 with left upper quadrant (LUQ) pain. An abdominal x-ray series revealed a density in the left upper lung; there was no hilar, mediastinal or axillary adenopathy. She denied cough, fever or night sweats. She had no prior history of tuberculosis. She immigrated to the US from Mexico 20 years ago and occasionally returns there to visit family. She is a diabetic and a non-smoker. She was referred to the local public health department where a tuberculin skin test (TST) was done and had an induration of 25 mm. Three sputums were negative for M. tuberculosis by direct staining and culture. A CT scan revealed a 2.4 cm slightly irregular cavitary mass in the left upper lobe. After the negative cultures, she was started on a 9 month course of isoniazid (INH) and vitamin B6.
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(REVISED Nov. 22, 2006)
Patient History: A 31 year old male was admitted to the hospital after experiencing gross hemoptysis. He had a 2 month history of productive cough, a 25 pound weight loss, night sweats, and fatigue. A chest x-ray (CXR) revealed bilateral cavitary infiltrates. The initial sputum specimen was 4+ positive for acid fast bacilli (AFB) and a genetic probe assay confirmed Mycobacterium tuberculosis. A culture was positive for M. tuberculosis which was later reported to be resistant to INH and streptomycin. The patient has a history of heavy alcohol and drug use, is HIV negative but Hepatitis B and C positive. He has a long history of cigarette use and a chronic smoker's cough. The patient resides with his wife and 3 children (2 are step-children). [Original case presentation] :: [Original newsletter]
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June 2006 ■ Abdominal Tuberculosis
Patient History: A 27-year old Hispanic female presented to hospital on January 27, 2005 with a fever of 104°, a two week history of abdominal swelling, decreased appetite and body aches. She was admitted for diagnostic testing and follow-up.
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March 2006 ■ TB in a Patient Receiving Immunosuppression Including a TNF Alpha Blocker
Patient History: A 55-year old female emigrated from El Salvador in the mid 1980s. She had been employed by a poultry processing plant for 15 years (high risk environment associated with TB transmission). Medical history included a diagnosis of rheumatoid arthritis which was treated with prednisone 20 mgs twice daily, methotrexate and Humira (adalimumab-a tumor necrosis factor alpha blocking agent (TNFa)).
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(PDF ▣ 44 KB ▣ 1066 downloads)