International Journal of Science and Research (IJSR)

ISSN (Online): 2319-7064

Index Copernicus Value (2016): 79.57 | Impact Factor (2015): 6.391

Clinical Case of Multidrug-Resistant in King Khalid

Hospital, Hail
DR. Fahd Z. Eissa1, Fayez Nashi Alshammari2, Abdulrahman Ali Al Anazi3

Abstract: Multidrug-resistant tuberculosis (MDR-TB) in patients with human immunodeficiency virus (HIV) infection poses multiple
challenges for treatment, and has a high mortality. MDR-TB coinfection with HIV has been reported in African. In saudi , we did not
come across any report of HIV and MDR-TB coinfection, though such coinfection has been reported in adults. 34 -year-old HIV-
infected male requiring antiretroviral therapy (ART) developed MDR-TB and responded to second-line antituberculous therapy.

1. Introduction left lower zone consolidation. He was then started on six-

drug ATT consisting of isoniazid (INH), rifampicin,
Multidrug-Resistant Tuberculosis (MDR-TB) is caused by a ethambutol, pyrazinamide, streptomycin and cipro-floxacin.
strain of Mycobacterium tuberculosis that is resistant to at NVP was increased to 400 mg/m2/day. Subsequently, he
least Isoniazid (INH) and Rifampin (RIF), the two most developed NVP-induced maculopapular rash and NVP was
effective of the four first-line TB drugs; the other two drugs replaced with efavirenz. Culture of sputum after 6 weeks
are Ethambutol (EMB) and Pyrazinamide (PZA).1 grew Mycobacterium tuberculosis resistant to streptomycin,
INH, rifampicin and ethambutol. The bacteria were sensitive
The current vaccine for tuberculosis (TB), bacillus Calmette- to pyrazinamide, kanamycin, ethionamide, para-
Guérin, has variable (mostly poor) efficacy in protecting aminosalycylic acid (PAS) and ofloxacin. Treatment under
against pulmonary TB in children and adults [2,3]. TB the directly observed treatment, short-course (DOTS)
control is further threatened by the emergence of multidrug- programme was suggested but the mother wished to
resistant (MDR), extremely drug-resistant and totally drug- continue treatment at our centre.he was started on alternate
resistant strains of M. Tuberculosis. According to the fourth ATT consisting of kanamycin (15 mg/kg/day for 2 months),
WHO report on antituberculosis drug resistance, MDR-TB PAS (150 mg/kg/day in divided doses for 3 months),
has been shown to be almost twice as common in patients ethionamide (15 mg/kg/day for 8 months), pyrazinamide (30
with HIV infection than in those without HIV. In 2010, there mg/kg/day for 2 years) and ofloxacin (16 mg/ kg/day for 2
were an estimated 650,000 prevalent cases of MDR-TB years).
worldwide, and at least 150,000 deaths were due to MDR-
TB. In the same year, 3.4% of all newly diagnosed and
19.8% of all previously treated TB patients were estimated
to have MDR-TB4. We present the case of a 34 year old,
Non Saudi male who developed MDR-TB and responded to
second-line antituberculous therapy (ATT).

2. The Case
A 34-year-old Non Saudi male presented in June 2016 with
fever for 7 months and dry cough for 10 days.. He was on
ATT for the past 10 months, which had been started by her
treating physician for non-resolving pneumonia.

Sputum examination 5 months ago was negative for acid-

fast bacilli (AFB). On examination, he was 175 cm tall and
weighed 65 kg. He had oral thrush and bilateral diffuse
crepitations on respiratory system examination. Other
systems were normal. His haemoglobin was 10.9 g/dl and
white blood cell count was 4800/cmm (64% polymorphs,
35%lymphocytes) with a platelet count of 325 000/cmm. His Chest X-rays were done every 3 months.his sputum smear
X-ray chest showed right-sided calcified primary complex. became negative after one month of therapy. Repeat cultures
Her alanine aminotransferase was 29 IU/L, serum amylase were not done since the he had stopped producing sputum.
19 IU/L and CD4 count was 36 cells/cmm (1.69%). She was In November 2016, her weight had increased to 68 kg.
started on azithromycin and cotrimoxazole prophylaxis. However, on regular screening for adverse effects, he was
ATT was stopped. he was also started on three-drug ART found to have hypothyroidism (T3 1.3 ng/ dl, T4 60 mg/dl,
consisting of zidovudine (AZT), lamivudine (3TC) and TSH 7.5 mIU/ml). He was started on 25 mg of levothyroxine
nevirapine (NVP). once a day. In December 2016, her CD4 count increased to
77 cells/cmm, in June 2007 it increased to 170 cells/ cmm
A month later, he had fever with cough. Sputum smear and in January 2017 it increased to 304 cells/cmm.
examination was positive for AFB and a chest X-ray showed Azithromycin prophylaxis was stopped in December 2016.

Volume 7 Issue 2, February 2018

www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
Paper ID: ART20179871 DOI: 10.21275/ART20179871 1
 International Journal of Science and Research (IJSR)
ISSN (Online): 2319-7064
Index Copernicus Value (2016): 79.57 | Impact Factor (2015): 6.391
his chest X-ray done in February 2017 was normal. As his duration of therapy, in combination with another agent such
thyroid function tests remained normal, thyroxine was as ethambutol (or pyrazinamide in this case) for 18 months
tapered and stopped. he was tolerating ART well. after smear ‘conversion’..Common adverse effects of
Pyrazinamide and ofloxacin were stopped at the end of 2 second-line ATT include gastrointestinal effects, rash,
years. ototoxicty, peripheral neuropathy, psychiatric symptoms and
jaundice. The rate of thyroid toxicity is high,12 and may be
3. Discussion due to ethionamide or PAS, requiring regular monitoring.
Besides, serial CD4 levels, monitoring of liver function
MDR TB is more difficult to treat than drug-susceptible tests, lipid profile and pancreatic enzymes is essential for a
strains of TB. The success of treatment depends upon how child receiving ART.
quickly a case of TB is identified as drug resistant and
whether an effective drug therapy is available. The second- A delay in laboratory diagnosis, limited choice of active
line drugs used in cases of MDR TB are often less effective drugs and increased toxicities and interactions when ATT
and more likely to cause serious side effects such as and ART are simultaneously administered, all contribute to
Nephrotoxicity and or Ototoxicity. Tests to determine the making the treatment of MDR-TB with HIV a challenging
resistance of a particular strain to various drugs usually take task. It calls for individualization of treatment.
several weeks to complete. During the delay, the patient may
be treated with a drug regimen that is ineffective. Once a 4. Conclusion
strain's drug resistance is known, an effective drug regimen
must be identified and implemented As Soon as Possible MDR-TB remains uncommon in Hail, but its challenges are
Treatment for an MDR TB involves drug therapy over many increasingly recognized. Despite delays in commencing an
months or years at least 18 months to 24 month..Treatment effective therapy; fortunately, MDR-TB is usually
of TB and HIV coinfection is complicated by various factors associated with treatment success. Adverse effects of
including drug resistance, drug interactions and drug medications are common, and treatment courses are long
toxicity. He already on three-drug ART, was started on first- and complex. Specialist TB services should continue to be
line ATT when He was sputum AFB-positive. Six weeks involved in provision of treatment, management and
later, TB culture and drug susceptibility results showed the prevention of spreading cases of MDR-TB. (Quarantine
strain to be MDR, i.e. resistant to most of the first-line drugs Measurement).
including INH and rifampicin.
References
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drug resistance in developing countries, has the inherent [1] Global Tuberculosis Control, 2011.
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TB is a useful predictive factor for MDR-TB in a cohort of control report 2011. World Health Organization, Geneva,
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[4] Sahal Al-Hajoj etal (2013) Epidemiology of
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drug susceptibility testing to include at least five drugs likely
to be effective.10 Fluoroquinolones play a key role in
resistant TB and the later generation fluoroquinolones may
be effective despite resistance to ciprofloxacin. Use of an
injectable agent such as capreomycin or an aminoglycoside
(e.g. kanamycin), have been shown to predict culture
conversion and survival.11

However, resistance to more than one aminoglycoside is

becoming increasingly common. The regimens may be
reinforced by pyrazinamide and ethambutol despite prior
exposure to these drugs, as these contribute by increasing the
regimen’s activity or preventing resistance to more active
agents. An oral quinolone is generally continued for the
Volume 7 Issue 2, February 2018
www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
Paper ID: ART20179871 DOI: 10.21275/ART20179871 2