A 38-year-old Korean woman who immigrated to California 6 monthsago complains of weight loss, fever, cough, arthralgia,and frequentbouts of hemoptysis for the past 4 months. She has had no perceptible fever. Chest roentgenograms show a 4.0-cm cavity in the right upper lobe with associated infiltrate. There is a BCG scar on her left arm associated with vaccination at age 16 years. The PPD skin test shows 18-mm induration at 48 hours. Five sputum samples have been examined for mycobacteria and fungi, and all are negative on smear. Cultures are pending. Bronchoscopy shows no endobronchial lesions, and bronchial brushings are negative on smear for mycobacteria and fungi.
At this point in the diagnostic workup, which of the following statements is NOT correct?
a. Negative smears for mycobacteria do not exclude tuberculosis, but the diagnosis is less likely
b. The sputum should be examined for other etiologies as TB has definitively been excluded
c. The patient should be started on isoniazid, rifampin, ethambutol and pyrazinamide while awaiting culture results.
d. If the cultures return negative, but the patient clinically responds to anti-tuberculous therapy, the patient should be considered to have culture negative
(or clinical TB) and be treated with therapy for four months
What is the definition of MDR TB? XDR TB?
She also tells you she was recently diagnosed with rheumatoid arthritis and her rheumatologist is considering DMARD therapy. What do you advise?
Iseman MD. Treatment of multi-drug resistant tuberculosis. NEng JMed. 1993; 329(11): 784
Mitnick CD et al. Comprehensive treatment of extensively drug resistant tuberculosis.NEng JMed. 2008; 359(6): 563
cdc.gov/tb
Singh, Jasvinder. Et. Al. “2012 Update of the 2008 American College of Rheumatology Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the Treatment of Rheumatoid Arthritis.” Arthritis Care & Research. Vol. 64, No. 5, May 2012, pp 625–639