|Year : 2007 | Volume
| Issue : 3 | Page : 97-99
Primary multidrug resistant tuberculosis
Supriya Sarkar1, GN Maity2, KK Mukhopadhyay2, Biplab Acharyya2, AG Ghoshal1
1 Department of Chest Medicine, Nil ratan sircar Medicla College ,Kolkatta 14, West Bengal., India
2 Department of Orthopedic Surgery, Nil Ratan Sircar Medicla College, Kolkatta 14, West Bengal., India
Department of Chest Medicine, Nil ratan sircar Medicla College ,Kolkatta 14, West Bengal.
Source of Support: None, Conflict of Interest: None
| Abstract|| |
A 37-year old man presented at our institution with back pain, low-grade fever and weight-loss. X-ray of chest (postero-anterior view) showed multiple opacities with erosion of right 2nd and left 6th ribs. CT-scan of thorax and CT-guided FNAC confirmed the diagnosis of tuberculosis of ribs. Even after 5-months of treatment with four first line drugs, the patient developed a cold abscess at the back. Mycobacterial culture and drug sensitivity of material aspirated by Radiometric method from the cold abscess showed growth of Mycobacterium tuberculosis, and those bacilli were resistant to both isoniazide and rifampicin. The patient did not have anti-tubercular medication in the past, and that established the diagnosis of primary multidrug resistant tuberculosis of ribs. Patient was treated successfully with 2nd line drugs at the cost of moderate degree of hearing loss. After one and half years of treatment X-ray of chest (PA view) showed complete healing of rib erosions with new bone formation.
|How to cite this article:|
Sarkar S, Maity G N, Mukhopadhyay K K, Acharyya B, Ghoshal A G. Primary multidrug resistant tuberculosis. Lung India 2007;24:97-9
| Introduction|| |
Tuberculosis (TB) of the rib occurs from zero to three percent of all osteoarticular TB  . TB of the rib can be pure tuberculous osteomyelitis of the rib or juxtracostal TB with or without rib destruction. The pathogenesis is either by hematogenous spread or by local spread from intercostal lymph nodes. The presenting symptoms are either chest pain or chest wall swelling  .
Drug resistance develops as a result of spontaneous mutation of bacilli. Spontaneous resistance to isoniazid (H) and rifampicin (R) occurs approximately 1 in 10 6 and 1 in 10 8 bacilli, respectively. Hence the chance of spontaneous resistance to both drugs (H+R) is 1 in 10 14 bacilli, and that is not possible even in bilateral extensive TB. Thus multidrug resistant TB (MDR-TB), defined as bacilli resistant to both H & R with or without other drugs, is essentially a man-made disease  . MDR-TB usually occurs as a result of irregular and interrupted treatment (Acquired drug resistance). Rarely MDR-TB can occur in persons with out history of antitubercular drug (ATD) intake (primary drug resistance) as a result of infection from individuals harboring resistant strains.
In this article, we are reporting a case of primary MDR-TB of ribs.
| Case Report|| |
A 37 years old man presented with chest pain from 2nd week of June'02. Pain was insidious in onset, dull aching, persisting, involving both sides of chest, more in the back, and not responding to analgesics and other treatment. Patient had irregular low-grade fever, loss of appetite, weight loss and weakness. There was no history of cough, expectoration, hemoptysis or respiratory distress. He had a past history of perianal abscess, which was treated successfully with incision and drainage and antibiotics. He denied past history of tuberculosis or ATD intake. He had no addiction or exposure history, or history of contact with known cases of TB.
General survey revealed no abnormality except raised temperature (100 0 F) and mild pallor. Examination of respiratory system displayed only tenderness over back of thorax. Examination of other systems was essentially normal.
Investigation revealed Hb-10.6g %; WBC-11300/mm 3 ; P62 L11 E16 M10 B 1 ; ESR-120mm in 1st hr.; Blood Glucose (PP)-161mg/dl. Mantoux test was positive (13 X 12mm) but induced sputum was negative for acid-fast bacilli (AFB) and malignant cells. He was HIV negative. X-ray of chest PA view [Figure 1] showed opacity in the right upper zone with erosion of posterior end of right 2nd rib, second opacity on left mid zone with erosion of posterior part of left 6th rib and a third opacity at the anterior end of right 4th rib. X-ray of Dorsal spine showed destruction of posterior end of right 2nd rib but there was no involvement of vertebrae or disc spaces. CT scan thorax [Figure 2] showed multi nodular hypo dense opacities in the right upper thorax involving right paravertebral soft tissues with 2nd rib erosion but underlying lung and pleura were completely normal. Lower section of CT-scan of thorax showed a nodular opacity with adjacent left 6th rib erosion. CT-guided FNAC from right upper zone opacity demonstrated mostly necrotic material with epithelioid cells and inflammatory cells, and Ziehl-Neelsen stain showed presence of AFB.
So, the diagnosis of rib TB was established and anti-tubercular chemotherapy with H-300mg, R-450mg, pyrazinamide(Z)-1500mg and ethambutol(E)-800mg daily in the morning was started. Patient took drugs regularly but even after 5 months of treatment patient developed a swelling in the back. The swelling was 12x10x5 cm in size, soft, fluctuating, non-tender, deep to the skin, without any sign of inflammation, and was clinically diagnosed as cold abscess. Necrotic material, aspirated from the cold abscess, was negative for gram stain and ordinary culture but positive for AFB smear and Mycobacterial culture by Radiometric method (BACTEC-450). Drug sensitivity by Radiometric method showed bacilli were resistant to H, R, Z. E and streptomycin (S) but were sensitive to kanamycin, ethionamide, ofloxacilin, cycloserin and para-aminosalicylic acid (PAS).
The diagnosis of primary MDR-TB of ribs was established, as the patient did not received ATD in the past. Patient was put on 2nd line drugs with kanamycin-750mg and Z-1500mg daily in the morning; ethoinamide-250mg and ofloxacillin-400mg twice daily and PAS-3gm four times daily, as par the guideline of World Health Organization (WHO)  . WHO recommended Z to be included in all reserve regimes irrespective of sensitivity result  . After three months of treatment, patient was clinically improved with weight gain and reduction of swelling. The patient developed moderate degree of hearing loss, and kanamycin was stopped after 3 months. Treatment was continued for one and half years with other drugs. At the end of treatment X-ray chest PA view [Figure 3] showed complete healing of lesions with new bone formation that bridged the eroded parts of ribs. More than one year follow up of the patient did not reveal any abnormality or relapse.
| Discussion|| |
Diagnosis of TB rib is frequently delayed in patients with widespread lytic lesions because it occurs rarely and multiple osteolytic lesions are usually regarded as highly suggestive of malignancy. Among the infectious causes, actinomycosis, aspergilosis, nocardiasis, blastomycosis and tuberculosis may cause rib erosion. Radiolographs of TB rib typically reveal lytic lesions with variable degrees of sclerosis and periosteal reaction, and after treatment with ATD, the lesion heals with sclerosis  . In CT-scan lesion appears as well-defined juxtra costal soft tissue masses with central low attenuation and peripheral rim enhancement with frequent evidence of rib destruction, and the most frequent site of involvement is the rib shaft (61%), followed by the costovertebral joint (35%) and the costochondral junction (13%)  .
The prevalence of MDR-TB in India is increasing in number in recent years. Primary MDR-TB was found to be less than or equal to 3.2 % and the level of acquired MDR-TB was less than or equal to 6.0% except in Gujrat where a high level was observed 11.4-18.5%  . However the prevalence of MDR-TB among patients undergoing treatment for varying periods of times in Tamil Nadu was 20.3 %, and majority of those patients had irregular and interrupted treatment  . Treatment of MDR-TB is very difficult and to be done with 2nd line drugs, which are costly, toxic, have weak anti-mycobacteriocidal activity. Surgical resection and addition of fluroquinolone improved the treatment outcome in MDR-TB, the initial favorable response was found to be 85%, long-term success rate 75% and death rate 12%, in comparison to previous results which were 65%, 56% and 22% respectively  .
We are reporting a case of primary MDR-TB of ribs, and that was treated successfully with one and half year of treatment with reserve drugs. This case report is to highlight the diagnostic dilemma and to create an awareness regarding MDR-TB of extra-pulmonary sites.
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[Figure 1], [Figure 2], [Figure 3]