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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 26-29

Disseminated Multidrug-Resistant Tuberculosis in a Young Patient: A Rare Case Report


Department of Chest and TB, Government Medical College, Amritsar, Punjab, India

Date of Submission27-May-2019
Date of Acceptance16-Jul-2019
Date of Web Publication11-Feb-2020

Correspondence Address:
Dr. Ritu Dadra
Department of Chest and TB, Government Medical College, Amritsar, Circular Road, Amritsar, Punjab - 143001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacp.jacp_21_19

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  Abstract 


Drug resistance is a persistent threat to tuberculosis (TB) control program worldwide. Patients infected with multiple drug-resistant strains are less likely to become cured. Management of resistant cases is complex and presents therapeutic limitations. Patients with multidrug-resistant strains are more prone to treatment failure and progress to more chronic forms of the disease and death. According to the Global Tuberculosis Report 2018, about 3.5% of newly diagnosed patients had multidrug-resistant tuberculosis (MDR-TB) and 18% of previously treated TB cases were estimated to have MDR-TB. This case presented a rare occurrence of disseminated MDR-TB in a diabetic patient. A case of a 14-year-old female, who was an old-treated case of abdominal TB, presented with 5 months of history of fever, breathlessness, and pain in the abdomen with diabetes mellitus, in whom disseminated MDR-TB was documented with fine-needle aspiration cytology of abdominal lymph nodes and bronchoalveolar lavage fluid that showed drug-resistant TB. So this case emphasizes the importance of screening all extrapulmonary TB patients for drug resistance especially if the patient also has associated comorbid conditions.

Keywords: Abdominal lymph nodes, bronchoalveolar lavage, fine-needle aspiration cytology, multidrug-resistant tuberculosis


How to cite this article:
Dadra R, Kajal NC, Malhotra B, Pandiyaraj P, Kaur L, kaur G. Disseminated Multidrug-Resistant Tuberculosis in a Young Patient: A Rare Case Report. J Assoc Chest Physicians 2020;8:26-9

How to cite this URL:
Dadra R, Kajal NC, Malhotra B, Pandiyaraj P, Kaur L, kaur G. Disseminated Multidrug-Resistant Tuberculosis in a Young Patient: A Rare Case Report. J Assoc Chest Physicians [serial online] 2020 [cited 2020 May 27];8:26-9. Available from: http://www.jacpjournal.org/text.asp?2020/8/1/26/278118




  Introduction Top


Strains of Mycobacterium tuberculosis resistant to both isoniazid and rifampicin with or without resistance to other drugs have been termed multidrug-resistant tuberculosis (MDR-TB). India has the highest burden of both tuberculosis (TB) and MDR-TB in the world and accounts for one-fourth of the global TB burden. In India, more than 6000 people develop TB disease everyday and more than 600 people die of TB (i.e., two deaths every 5 min).[1] Drug-resistant TB is a persistent threat, with 490,000 cases of MDR-TB emerging in 2016 and an additional 110,000 cases that were susceptible to isoniazid but resistant to rifampicin (RR-TB), the most effective first-line anti-TB drug.[2] WHO-estimated incidence of rifampicin (R) and MDR-TB in India is estimated to be around 147,000. This translates to around 11 patients per 100,000 population annually as per the Global TB Report, 2017.[3] Adequate follow-up of patients during the treatment period is a challenging task under pragmatic conditions. The most important risk factor in the development of MDR-TB is an improper implementation of the guidelines in the management of TB and high risk of defaults on the part of patients. Other risk factors like diabetes, alcoholism, and intravenous drug abuse also play an important role in the development of drug resistance. This case presented a rare occurrence of disseminated MDR-TB and highlights the importance of aggressively searching for MDR-TB in a previously exposed patient.


  Case History Top


A 14-year-old female presented with complaints of low-grade intermittent fever, which was not associated with chills, rigors, and dyspnea on exertion for the previous 5 months. The patient also had complaints of loss of appetite and weight loss. The patient had a significant past medical history of taking antitubercular therapy (DOTS category I) for abdominal tuberculosis which was started clinicoradiologically. She took treatment for 9 months, tolerated well and completed the course. The patient again developed fever after a gap of 1 month and then was investigated further. The patient had no other past medical history. She had never smoked and had not taken any medication in the past. She had no significant environmental and occupational history. On physical examination, the patient appeared to be in good condition, with a respiratory rate of 22 breaths/minute, a temperature of 37.4°C, blood pressure of 110/70 mmHg, and a heart rate of 90 beats/minute. Laboratory investigations showed normocytic normochromic anemia (hemoglobin 8 g/dL), white blood count 6200/mm3 (neutrophils: 62%, lymphocytes: 38%), and erythrocyte sedimentation rate 65 mm/h. The patient had serum electrolytes within normal range and was nonreactive for human immunodeficiency virus (HIV), Hepatitis C virus (HCV), and Hepatitis B Surface Antigen (HBsAg). The patient also had a known case of diabetes mellitus from 2 years. X-ray of the chest showed consolidation in the right upper zone [Figure 1]. Ultrasonography (USG) of the whole abdomen revealed multiple lymph nodes in mesentery mainly in the lower abdomen and were necrotic. Few of them got conglomerated to form larger nodal masses, the largest measuring 20 × 47 mm in size. The impression was necrotic abdominal lymphadenopathy. CECT chest was suggestive of consolidative changes involving the right upper lobe and air bronchogram and few enlarged pretracheal lymph nodes [Figure 2]A–C). CECT abdomen showed multiple enlarged retroperitoneal and mesenteric lymph nodes. Ultrasonography-guided FNA smears from retroperitoneal lymph nodes showed epithelial cell granulomas, reactive lymphoid cells, polymorphs, and degenerated cells in a necrotic background. Features were suggestive of necrotizing granulomatous inflammation [Figure 3]. Ziehl-Nielson staining for acid-fast bacilli was negative. GENEXPERT MTB/RIF (GDF diagnostics) of fine needle aspiration cytology (FNAC) fluid showed mycobacterium TB complex and rifampicin resistance. The patient was not able to expectorate sputum, therefore bronchoalveolar lavage (BAL) sample was taken and sent for line probe assay (LPA) that detected mycobacterial TB complex and resistance to both rifampicin and isoniazid (mutation detected in KAT G gene). The patient was detected to be a multidrug-resistant case involving both pulmonary and abdominal system and was started with shorter MDR regimen of antitubercular chemotherapy (ATT) under revised national tuberculosis control programme (RNTCP) programmatic management of drug-resistant tuberculosis (PMDT).
Figure 1 X-ray of the chest showing consolidation in right upper and middle zone.

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Figure 2 (A) CECT chest (coronal view) suggestive of consolidative changes involving the right upper lobe and air bronchogram and few enlarged pretracheal lymph node. (B) CECT chest (sagittal view) suggestive of consolidative changes involving the right upper lobe and air bronchogram and few enlarged pretracheal lymph node. (C) CECT chest (axial view) suggestive of consolidative changes involving the right upper lobe and air bronchogram and few enlarged pretracheal lymph node.

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Figure 3 FNA smears from retroperitoneal lymph nodes showing epithelial cell granulomas, reactive lymphoid cells, polymorphs, and degenerated cells in a necrotic background.

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  Discussion Top


India is endemic for TB infection.[4] A high index of suspicion and a low threshold for initiation of empirical antituberculous treatment is usually noted among the treating physicians. However, the case highlights the fact that a drug sensitivity testing is imperative for assessing the sensitivity pattern of the Mycobacterium strain, to detect the primary MDR or XDR-TB strains. Failure to do so leads to ineffective treatment and further emergence of drug resistance. The combination of drug resistance in FNAC fluid of retroperitoneal lymph nodes and BAL fluid is seen in our patient that is a rare manifestation. The patient is an old-treated case of abdominal TB and also has maturity-onset diabetes in young (MODY), which can be the risk factors associated with drug resistance in our case. There is growing evidence that diabetes mellitus is an important risk factor for TB and might affect disease presentation and treatment response. Furthermore, TB might induce glucose intolerance and worsen glycemic control in people with diabetes. Two studies have shown that diabetic patients are more likely to develop MDR-TB than those without diabetes.[5],[6] However, four studies in disparate settings showed no significant increased risk.[7],[8],[9],[10] The mechanism by which diabetes mellitus would lead to the preferential acquisition of MDR-TB is unclear. In a study from Saudi Arabia, Alrajhi et al.[11] showed that history of previous anti-TB treatment was the only risk factor associated with drug-resistant tuberculosis with odds ratio 19.9 (P < 0.001). In a study conducted by Elmi et al.[12] found diabetes mellitus in 26.7% of MDR-TB cases and HIV infection in 5.7% of cases. Drug resistance in TB is a matter of great concern for TB control programs. MDR-TB is a man-made phenomenon; poor treatment, poor drugs, and poor adherence lead to the development of MDR-TB. RNTCP is the state-run TB control initiative by the Government of India. The development of PMDT is the RNTCP’s fight against drug-resistant TB, adhering to the WHO guidelines.[13] The regimen for shorter MDR-TB under PMDT includes total duration of 9 to 11 months with intensive phase of 4 to 6 months and continuation phase of 5 months.[3] Drugs given in intensive phase includes kanamycin, high-dose moxifloxacin, pyrazinamide, ethionamide, clofazimine, and high-dose isoniazid ethambutol, and continuation phase includes high-dose moxifloxacin, ethambutol, clofazimine, and pyrazinamide. Treatment success is dependent on several factors such as host immunity, the extent of drug resistance, and disease severity. The successful outcome in the present case can be attributed to strict compliance, directly observed therapy, and guided multidisciplinary team management.


  Conclusions Top


We have presented the case of a disseminated MDR-TB involving both pulmonary and abdominal systems and emphasized the fact that every case of extrapulmonary TB should be screened adequately for MDR and treated accordingly. Therefore, this case highlights the importance of aggressively searching for MDR-TB in all the cases of extrapulmonary TB.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
4773363959TOG. Chapter 1: Introduction [Internet]. Available at https://tbcindia.gov.in/showfile.php?lid=3197. [Accessed August 21, 2018].  Back to cited text no. 1
    
2.
WHO Global tuberculosis report 2017. Chapter 3: TB disease burden. Available at http://www.who.int/tb/publications/global_report/en/. [Accessed on 2 August 2017].  Back to cited text no. 2
    
3.
Guidelines for PMDT in India 2017-1.pdf. https://tbcindia.gov.in/index1.php?lang=1&level=2&sublinkid=4781&lid=3306.  Back to cited text no. 3
    
4.
World Health Organization. Annex Country Profiles for 22 High-Burden Countries. Available at http://www.who.int/tb/publications/global_report/gtbr15_annex02.pdf. [Accessed January 23, 2016].  Back to cited text no. 4
    
5.
Bashar M, Alcabes P, Rom WN, Condos R. Increased incidence of multidrug-resistant tuberculosis in diabetic patients on the Bellevue Chest Service, 1987 to 1997. Chest 2001;120:1514-9.  Back to cited text no. 5
    
6.
Fisher-Hoch SP, Whitney E, McCormick JB, Crespo G, Smith B, Rahbar MH et al. Type 2 diabetes, and multidrug-resistant tuberculosis. Scand J Infect Dis 2008;40:888-93.  Back to cited text no. 6
    
7.
Singla R, Khan N. Does diabetes predispose to the development of multidrug-resistant tuberculosis? Chest 2003;123:308-9.  Back to cited text no. 7
    
8.
Subhash HS, Ashwin I, Mukundan U, Danda D, John G, Cherian AM et al. Drug resistant tuberculosis in diabetes mellitus: a retrospective study from south India. Trop Doct 2003;33:154-6.  Back to cited text no. 8
    
9.
Suárez-García I, Rodríguez-Blanco A, Vidal-Pérez JL, García-Viejo MA, Jaras-Hernández MJ, López O et al. Risk factors for multidrug-resistant tuberculosis in a tuberculosis unit in Madrid, Spain. Eur J Clin Microbiol Infect Dis 2009;28:325-30.  Back to cited text no. 9
    
10.
Tanrikulu AC, Hosoglu S, Ozekinci T, Abakay A, Gurkan F. Risk factors for drug resistant tuberculosis in southeast Turkey. Trop Doct 2008;38:91-3.  Back to cited text no. 10
    
11.
Alrajhi AA, Abdulwahab S, Almodovar E, Al-Abdely HM. Risk factors for drug-resistant Mycobacterium tuberculosis in Saudi Arabia. Saudi Med J 2002;23:305-10.  Back to cited text no. 11
    
12.
Elmi OS, Hasan H, Abdullah S, Jeab MZ, Alwi ZB, Naing NN. Multidrug-resistant tuberculosis and risk factors associated with its development: a retrospective study. J Infect Develop Countries 2015;9:1076-85.  Back to cited text no. 12
    
13.
Chauhan LS, Arora VK, Central TB, Directorate General of Health Services M. Management of pediatric tuberculosis under the Revised National Tuberculosis Control Program (RNTCP). Indian Pediatr 2004;41:901.  Back to cited text no. 13
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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