Determining Treatment Options with Limited Documentation

 

 

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Case History

A 62 year old woman from Mexico was referred to the local health department in November 2009 with a positive Tuberculin Skin Test (TST) (22 mm), and an abnormal chest x-ray. Radiography indicated pulmonary parenchymal scarring with no pleural effusion and multiple calcified granulomata. Three sputa samples obtained in August, December, and January, were all smear and culture negative. The patient was asymptomatic, but revealed during intake that she was diagnosed with tuberculosis (TB) thirty-two years before and was treated for one year. Also noted was a partial lung resection in Mexico 7 years earlier, reason unknown.

Many concerns were raised in regards to the adequacy and completeness of the patient’s previous TB treatment given the lack of medical documentation and incomplete history.

Background

With a positive TST, once active tuberculosis is ruled out, the patient should be assumed to have latent tuberculosis infection (LTBI). The patient did have three separate sputum smears and cultures over a 5 month period and denied any symptoms of TB. However she was noted to have an abnormal chest radiograph so to complete the evaluation in order to exclude an active process, a repeat chest x-ray was requested. Comparison chest x-rays revealed no changes, the stable radiograph was consistent with LTBI.

When a patient has a history of active TB in the past and currently has an abnormal chest radiograph even without evidence of active disease, it is important to identify whether treatment was adequate. The 2003 Centers for Disease Control and Prevention (CDC), American Thoracic Society (ATS), Infectious Disease Society of America (IDSA) guidelines, Treatment of Tuberculosis, notes "Persons with a positive TST who have radiographic findings consistent with prior pulmonary tuberculosis (ATS/CDC Class 4) and who have not been treated are at increased risk for the subsequent development of active tuberculosis. Case rates among such persons in one study were about 2.5 times those of persons infected with M. tuberculosis who did not have chest radiographic abnormalities. Once active tuberculosis has been excluded by sputum culture, these persons are high-priority candidates for treatment of LTBI."

This patient was treated for tuberculosis in Mexico 32 years ago (around 1979) at a time when it was very possible that rifampin was not included in the regimen, or if included was not utilized for the entire duration of treatment. This concern regarding rifampin is supported by the reported treatment duration of one year. The introduction of rifampin into treatment schedules was coupled with a “short course” treatment. The FDA approval for clinical use in the US only dates back to 1971 and in the summer of 1980 a nine month course of isoniazid and rifampin was recommended for use in the US. During this time frame, many programs globally only used rifampin in the initial two months of treatment and then completed therapy with another six months of isoniazid and ethambutol or did not use rifampin at all. Rifampin use was limited by its expense and the desire to hold it in reserve. Directly observed therapy (DOT) has only been implemented widely in Mexico during the past decade. DOT was introduced into treatment in the US in the late 1980s. Therefore, the strength of the regimen as well as adherence and adequacy, may be questioned.

Her provider was encouraged to ask questions designed to elicit a better sense of the treatment received in Mexico thirty-two years ago and to identify the reason for pulmonary resection 7 years earlier. During the follow up interview, the patient reported that she was treated with 60 doses of an injectable, and noted that the TB medications made her urine turn red. This report is consistent with a TB regimen that included rifampin. It is possible that she may have been treated for TB more recently than was initially reported. She noted the reason for partial lung resection was hemoptysis.

Health Department staff counseled the patient regarding her increased risk for recurrent tuberculosis as well as for signs and symptoms of active disease. Before a recommendation for treatment of LTBI could be made, the patient returned to Mexico.

Teaching Points

  • Patients with a positive TST or Interferon gamma release assay (IGRA) with symptoms of tuberculosis should be evaluated promptly
  • When obtaining sputa samples for Acid Fast Bacilli (AFB) testing, follow cultures until final (usually 6 weeks)
  • Multiple client interviews may be necessary to obtain full past medical history
  • Comparison chest x-rays can determine stability or evolution of disease; they along with response of symptoms to treatment may be the key to a diagnosis of culture negative TB
  • Patients giving history of treatment for TB should be asked if medications cause their urine to appear orange or red to aid in the assessment as to whether rifampin was used
  • Always counsel patients about the signs and symptoms of TB and give instructions as what to do if they are experiencing symptoms
  • If the patient was treated outside the US, research regarding availability of anti-TB meds in that country should be done
  • Questions should be tailored to the patient’s age, education level, cultural background, and responses to previous questions
  • Obtaining accurate information of prior TB treatment is critical for making a correct diagnosis and recommending proper management

Key Concepts

Soliciting history of previous TB treatment requires a great deal of patience and attention to detail. In a culturally sensitive and confidential setting, allow plenty of time, utilize an accurate and unbiased medical interpreter (if necessary), and be willing to repeat or rephrase a question to obtain information. Give the patient encouragement to reveal accurate information by asking and responding in a nonjudgmental manner.

Ask the patient if he/she has any written in formation regarding his or her treatment, including any old radiographs.

  • Have you been told you had TB before?
  • Have you been treated for TB?
  • Have you received injections for a lung problem?
  • Have you purchased and used medicated cough syrups in a foreign country?
  • Were you ever diagnosed as a “cougher?”

If your patient answers "yes" to any of the following questions he or she may have been previously treated for TB:

  • Where were you treated?
  • What drugs did you receive?
  • How many different drugs? How many pills each day? What size and colors were the pills/capsules?
  • Did you receive injections, if so for how long?
  • How long were you on treatment?
  • When did you start?
  • When did you stop? Why did you stop (completed treatment, adverse reaction)?
  • It’s hard to remember to take medicine every day. How often did you remember your medications?
  • TB medicine is expensive. Were you ever without medication?
  • Did you miss medication sometimes? How often?
  • Did healthcare workers observe you taking your medications?
  • Did your urine turn orange?
  • Did you feel better?
  • Did you ever have sputum examined? What was the result?
  • If positive, did your subsequent sputa test negative?
  • Did your doctor ever tell you that you had to be treated for TB for a longer period? That you had a return of TB? That you had drug resistance?
  • Did your TB symptoms return after completing treatment?

If your patient answers "yes" to the following questions, their treatment may have been for LTBI:

  • Have you been exposed to or had contact with anyone with TB?
  • If yes, when was that?
  • Did you have a skin test? Do you know the results?
  • Did you have a chest x-ray? Do you know the results?
  • Did you receive medications to prevent TB? If so, what drugs did you take and for how long?

f the patient was previously treated for TB in the United States or Mexico, records detailing his or her treatment should be obtained from the local jurisdiction or through CureTB: Binational TB Referral Program (www.curetb.org or 619-542-4013). If the patient was treated by a public health agency or by a private provider in another country, records may be available and should be sought. The World Health Organization website provides links and contact information for TB programs located throughout the world: http://www.who.int/topics/tuberculosis/en/.

Obtain records when possible regarding treatment of a presumed source case.

References

Centers for Disease Control and Prevention (CDC). Treatment of Tuberculosis. American Thoracic Society, CDC, and Infectious Diseases Society of America. MMWR 2003;52 (No. TT-11): pp. 39-40.

Francis J. Curry National Tuberculosis Center and California Department of Public Health. 2008. Drug Resistant Tuberculosis: A Survival Guide for Clinicians. Second Edition: pp. 20-21.

Sensi, P. "History of the Development of Rifampin." Reviews of Infectious Diseases. Volume 5.3 (1983): pp. 402-6.

TBeat :: Vol 5 :: Issue 1