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First report of multi-drug resistant tuberculosis in a systemic lupus erythematosus patient.

Dorjee K, Dierberg KL, Sadutshang TD, Reingold AL - BMC Res Notes (2015)

Bottom Line: Imaging studies revealed avascular necrosis of right femoral head.She was then treated with intravenous methyl-prednisolone, followed by maintenance corticosteroid.She is currently scheduled for a total hip replacement surgery.

View Article: PubMed Central - PubMed

Affiliation: Division of Epidemiology, School of Public Health, University of California, Berkeley, 113 Haviland Hall #7358, Berkeley, CA, 94720-7358, USA. kunchok@berkeley.edu.

ABSTRACT

Background: Treatment of a multi-drug resistant tuberculosis (MDR-TB) patient is clinically challenging, requiring a minimum of 18 months of therapy. Its occurrence in a systemic lupus erythromatosus (SLE) patient may complicate management of both MDR-TB and SLE. This is the first descriptive report of MDR-TB in an SLE patient.

Case presentation: A 19-year old female receiving long-term prednisolone for SLE was diagnosed with MDR-TB. She was started on MDR-TB treatment regimen and prednisolone was replaced with azathioprine. After an initial response to therapy, patient experienced a flare of lupus symptoms. Imaging studies revealed avascular necrosis of right femoral head. She was then treated with intravenous methyl-prednisolone, followed by maintenance corticosteroid. Azathioprine was discontinued due to hematological toxicity and failure to control SLE. Her symptoms of lupus regressed and did not re-occur for the duration of her MDR-TB treatment. Patient was declared cured of MDR-TB after 18 months of ATT. She is currently scheduled for a total hip replacement surgery.

Conclusions: This case highlights the challenges of simultaneously managing MDR-TB and SLE in a patient due to their over-lapping signs and symptoms, drug-drug interactions, and the need for use of immunomodulatory agents in the absence of standard guidelines and documented previous experiences. Our experience underscores the importance of appropriate selection of treatment regimens for both MDR-TB and SLE.

No MeSH data available.


Related in: MedlinePlus

Radiograph showing elevated right hemipelvis and irregular contour of right hip-joint with lytic and sclerotic lesions in the femoral head in an SLE patient diagnosed with MDR-TB.
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Fig2: Radiograph showing elevated right hemipelvis and irregular contour of right hip-joint with lytic and sclerotic lesions in the femoral head in an SLE patient diagnosed with MDR-TB.

Mentions: On November 24, 2010, we started MDR-TB treatment with kanamycin 600 mg, levofloxacin 750 mg, para-aminosalicylic acid 8 g, cycloserine 750 mg, pyrazinamide 1,250 mg, and clofazimine 100 mg. Her weight was 42 kg. A dose reduction of methyl prednisolone was initiated and azathioprine 50 mg was introduced, with a plan to gradually increase the dose to 100–125 mg. After gradual taper, methyl prednisolone was stopped after 30 days. Her symptoms initially improved with resolution of fever and subsidence of cough. Sputum-smear became negative. However, after 2 months of MDR-TB therapy, she complained of difficulty walking with right hip pain radiating to the knee, worse with movement, and had developed a limp. On examination, there was notable shortening of right lower extremity with muscle wasting in the thighs and legs. In a week’s time, she developed butterfly rash on her cheeks, alopecia, and increased difficulty in walking. Radiograph of the hip-joints showed lytic and sclerotic lesions of the right femoral head with irregular contour (Fig. 2). MRI of the hip-joints showed avascular necrosis of bilateral femoral heads, right greater than left, with minimal effusion of right hip-joint. Her hemoglobin had dropped from 12 to 7.9 gm% and platelet count had dropped from 260,000 to 68,000/µl. She was referred for multi-disciplinary consultation, which revealed no evidence of central nervous system involvement or lupus nephritis. Methyl prednisolone IV pulse therapy was started, followed by an oral prednisolone taper. Azathioprine was stopped in view of possible myelosuppression resulting in anemia and thrombocytopenia. The patient clinically improved, with resolution of the skin rash and arthralgias. She was put on maintenance prednisolone dose of 7.5 mg, HCQ 200 mg twice daily, calcium supplements and once-weekly alendronate with vitamin D3. MDR-TB treatment was continued. Two months after stopping Azathioprine, her hemoglobin level and platelet count had increased to 10.1 gm% and 139,000/µl respectively. During follow up orthopedic consultations, no progression of osteonecrosis of hip joint was observed, and total hip joint replacement was recommended after completion of MDR-TB treatment. Injection kanamycin was stopped after 9 months of ATT and pyrazinamide was stopped after 1 year of ATT. Consecutive sputum smears were negative. She had seven negative cultures for TB since the start of MDR-TB treatment. After 18 months of ATT, she was declared cured and TB treatment was stopped. She is currently being planned for a hip replacement surgery.Fig. 2


First report of multi-drug resistant tuberculosis in a systemic lupus erythematosus patient.

Dorjee K, Dierberg KL, Sadutshang TD, Reingold AL - BMC Res Notes (2015)

Radiograph showing elevated right hemipelvis and irregular contour of right hip-joint with lytic and sclerotic lesions in the femoral head in an SLE patient diagnosed with MDR-TB.
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4527098&req=5

Fig2: Radiograph showing elevated right hemipelvis and irregular contour of right hip-joint with lytic and sclerotic lesions in the femoral head in an SLE patient diagnosed with MDR-TB.
Mentions: On November 24, 2010, we started MDR-TB treatment with kanamycin 600 mg, levofloxacin 750 mg, para-aminosalicylic acid 8 g, cycloserine 750 mg, pyrazinamide 1,250 mg, and clofazimine 100 mg. Her weight was 42 kg. A dose reduction of methyl prednisolone was initiated and azathioprine 50 mg was introduced, with a plan to gradually increase the dose to 100–125 mg. After gradual taper, methyl prednisolone was stopped after 30 days. Her symptoms initially improved with resolution of fever and subsidence of cough. Sputum-smear became negative. However, after 2 months of MDR-TB therapy, she complained of difficulty walking with right hip pain radiating to the knee, worse with movement, and had developed a limp. On examination, there was notable shortening of right lower extremity with muscle wasting in the thighs and legs. In a week’s time, she developed butterfly rash on her cheeks, alopecia, and increased difficulty in walking. Radiograph of the hip-joints showed lytic and sclerotic lesions of the right femoral head with irregular contour (Fig. 2). MRI of the hip-joints showed avascular necrosis of bilateral femoral heads, right greater than left, with minimal effusion of right hip-joint. Her hemoglobin had dropped from 12 to 7.9 gm% and platelet count had dropped from 260,000 to 68,000/µl. She was referred for multi-disciplinary consultation, which revealed no evidence of central nervous system involvement or lupus nephritis. Methyl prednisolone IV pulse therapy was started, followed by an oral prednisolone taper. Azathioprine was stopped in view of possible myelosuppression resulting in anemia and thrombocytopenia. The patient clinically improved, with resolution of the skin rash and arthralgias. She was put on maintenance prednisolone dose of 7.5 mg, HCQ 200 mg twice daily, calcium supplements and once-weekly alendronate with vitamin D3. MDR-TB treatment was continued. Two months after stopping Azathioprine, her hemoglobin level and platelet count had increased to 10.1 gm% and 139,000/µl respectively. During follow up orthopedic consultations, no progression of osteonecrosis of hip joint was observed, and total hip joint replacement was recommended after completion of MDR-TB treatment. Injection kanamycin was stopped after 9 months of ATT and pyrazinamide was stopped after 1 year of ATT. Consecutive sputum smears were negative. She had seven negative cultures for TB since the start of MDR-TB treatment. After 18 months of ATT, she was declared cured and TB treatment was stopped. She is currently being planned for a hip replacement surgery.Fig. 2

Bottom Line: Imaging studies revealed avascular necrosis of right femoral head.She was then treated with intravenous methyl-prednisolone, followed by maintenance corticosteroid.She is currently scheduled for a total hip replacement surgery.

View Article: PubMed Central - PubMed

Affiliation: Division of Epidemiology, School of Public Health, University of California, Berkeley, 113 Haviland Hall #7358, Berkeley, CA, 94720-7358, USA. kunchok@berkeley.edu.

ABSTRACT

Background: Treatment of a multi-drug resistant tuberculosis (MDR-TB) patient is clinically challenging, requiring a minimum of 18 months of therapy. Its occurrence in a systemic lupus erythromatosus (SLE) patient may complicate management of both MDR-TB and SLE. This is the first descriptive report of MDR-TB in an SLE patient.

Case presentation: A 19-year old female receiving long-term prednisolone for SLE was diagnosed with MDR-TB. She was started on MDR-TB treatment regimen and prednisolone was replaced with azathioprine. After an initial response to therapy, patient experienced a flare of lupus symptoms. Imaging studies revealed avascular necrosis of right femoral head. She was then treated with intravenous methyl-prednisolone, followed by maintenance corticosteroid. Azathioprine was discontinued due to hematological toxicity and failure to control SLE. Her symptoms of lupus regressed and did not re-occur for the duration of her MDR-TB treatment. Patient was declared cured of MDR-TB after 18 months of ATT. She is currently scheduled for a total hip replacement surgery.

Conclusions: This case highlights the challenges of simultaneously managing MDR-TB and SLE in a patient due to their over-lapping signs and symptoms, drug-drug interactions, and the need for use of immunomodulatory agents in the absence of standard guidelines and documented previous experiences. Our experience underscores the importance of appropriate selection of treatment regimens for both MDR-TB and SLE.

No MeSH data available.


Related in: MedlinePlus