This document presents the case of a 25-year-old woman who was previously treated for multidrug-resistant tuberculosis (MDR-TB) but has now developed recurrent symptoms including fever, cough, and chest pain. After completing MDR-TB treatment, her current symptoms and a sensitive gene expert test result indicate a possible relapse or reinfection with drug-sensitive TB. Key factors that can lead to TB recurrence include incomplete treatment, host vulnerabilities like malnutrition or HIV, and reexposure to the bacteria through environmental transmission. Surgery may help cure cases of localized drug-resistant pulmonary TB when combined with appropriate chemotherapy. The causes, management, and literature on TB recurrence are discussed.

1. Central Case
Presentation

2. A Long Journey
towards Healing

3. Dr Tanveer Kamal Fahim
Phase B Resident , Pulmonology
Medicine Unit IV
NIDCH

4. Particulars of the
patient
Happy Akter
25 years
Home Maker
Jatrabari , Dhaka
Admitted on 20/8/19
Examined on 22/8/19

5. Chief Complaints
Low grade fever for 1 month
Cough with occasional
expectoration for 1 month
Chest pain for 1 month

6. H/O of Present Illness
Reasonably well 1 & ½ years back
Then she developed-
Low grade fever with evening rise of
temperature for 2 month
Cough with occasional expectoration of
sputum for 1 month
Loss of weight about 15 kg
Loss of appetite

7. Diagnosed as a case of Smear +ve
PTB on the basis of sputum smear
report and Chest x ray
Started Cat-1 ATT from 26/2/18 and
completed in august , 2018

8. 22/2/18

10. Improved clinically- gained weight
Improved
appetite
◦ Subsidence of
fever ,cough
◦Follow up X ray chest and
Sputum Smear was done

11. 30/8/18

12. 30/8/18

13. 11/10/18

14. 16/10/18

15. In October , 2018 she was diagnosed as a case
of MDR-TB on the basis of Sputum Gene-expert
Admitted into NIDCH
Shorter Treatment Regimen (STR) started on
15/10/18 for 9 months

20. 14/2/19

21. Completed STR-TB regimen in july ,
2019

22. Now
Fever for 1 month
◦low grade
◦Intermittent
◦Night sweat
◦Not associated with chills and rigors
◦Highest recorded temperature was 100 degree
Fahrenheit
◦Subsided with sweating after taking antipyretics

23. Cough for 1 month
◦Persistent throughout the day and night
◦Occasional expectoration of mucoid
sputum
2 -3 spoons in each episode
◦Not foul smelling & purulent
◦No orthopnea
◦No paroxysmal nocturnal dyspnea

24. •Chest pain for 1 month –
• Mild to moderate
•Lancinating
•mid chest
•Gradual onset
•localized
•associated with movement, breathing

25. Rash
Itching
Joint pain
Gait abnormality
Limb weakness
Bowel bladder abnormality
H/O contact with TB patient
( father , 9 years back)
No H/O –
Headache
Visual impairment
Breathlessness
Coughing out of blood
Palpitation

26. Normotensive
Non - Diabetic

27. History of Past Illness:
Nothing significant

28. Family History :
Her Father developed Tuberculosis 9
years back , took CAT-1 ATT , died in
the same year due to unknown
complications
2 daughters
All are in good health

29. Socio-economic History :
Low-middle class family
Immunization History :
Immunized according to EPI schedule

30. Menstrual & Obstetrical H/O
Menstrual Cycle regular with average
blood flow and duration
Para 2
Gravida 2 ( before getting ATT)
No H/O miscarriage
Not OCP consumer

31. General Examination

32. Ill-Looking
Anxious
Pulse : 90 beats/min
BP: 100/60 mm of Hg
Temp : 100 degree Fahrenheit
Respiratory rate : 18 breaths per min

33. Systemic Examination

34. Respiratory System
Inspection : Normal
Palpation :
◦Trachea : Central
◦Apex beat: At left 5th
ICS just medial to mid
clavicular line
◦Chest Expansion: Normal
◦Vocal Fremitus: Normal

35. Percussion Note :
Resonant
Auscultation :
◦Breath sound : Vesicular
◦Added sound : Absent
◦Vocal resonance : normal

36. Neurological System : No
abnormality detected
Cardiovascular system : No
abnormality detected
Gastro-Intestinal System : No
abnormality detected
Locomotor System : No abnormality
detected

37. Provisional Diagnosis
Relapse After
Completion of MDR
Treatment ( Pre-XDR /
XDR/MDR)

38. Differential Diagnosis
Infective Exacerbation of
Bronchiectasis
Pneuomonia in Immune
compromised host

39. Investigations

40. CBC – 22/8/19
◦HB-12.2 g/dl
◦ESR 35 mm in 1st hr
◦TcWBC 6000 cu.mm
◦Neutrophil 55%
◦Lymphopcyte 40 %
◦Platelet 2,50,000 cu.mm
SGPT – 25 u/l
SGOT 40 u/l
S. Creatinine 0.8 mg/dl
S. Bilirubin 0.9 mg/dl
TSH 0.97 mU/L
RBS 95 mg/dl
S.Cortisol 25.68 mcg/dl

42. 9/7/19

43. 1/8/19

46. Cold Abcess

47. 28/7/19

48. 19/8/19

49. 20/8/1
9

50. Final Diagnosis
Relapse/Re-infection
(Gene Xpert Sensitive)
after Completion of MDR
Treatment

51. Questions toward the audience
What regimen should be used when there is
recurrence after completion of MDR treatment(when
Gene Expert shows Rif sensitive ) ??
In case of Cold Abcess- what should be the ideal
management ?
What may be the causes of recurrence in this case
??

52. Literature Review

53. Surgery increased the chance of cure in multi-
drug resistant pulmonary tuberculosis
European Journal of Cardio-Thoracic Surgery, Volume 16, Issue 2,
August 1999, Pages 187–193,
https://doi.org/10.1016/S1010-7940(99)00158-X

54. For patients with MDR pulmonary
tuberculosis which is localized, and
with adequate pulmonary reserve
function, surgical pulmonary
resection combined with appropriate
pre and postoperative anti-
tuberculosis chemotherapy can
achieve high success rate with

55. Bacterial Factors That
Predict Relapse after
Tuberculosis Therapy
N Engl J Med 2018; 379:823-833
DOI: 10.1056/NEJMoa1715849

56. In pretreatment isolates of M.
tuberculosis with decrements of
MIC values of isoniazid or rifampin
below standard resistance
breakpoints, higher MIC values
were associated with a greater risk
of relapse than lower MIC values

57. Relapse Versus Reinfection of
Recurrent Tuberculosis Patients in
a National Tuberculosis Specialized
Hospital in Beijing, China
Front. Microbiol., 14 August 2018 |
https://doi.org/10.3389/fmicb.2018.01858

58. Our data demonstrate that relapse is a major mechanism
leading to TB recurrence in patients under the care of a national
tuberculosis specialized hospital. Moreover, male patients have
a higher risk for reinfection than do female patients. Meanwhile,
emergence of LFX resistance in the second TB episode was most
frequently observed during relapse, while reinfection episodes
more likely exhibited emergence of RIF and EMB resistance.
These results collectively illustrate that greater understanding of
the differences between relapse and reinfection types of
recurrent TB can provide important information for the design of
more effective downstream TB control interventions. Such
interventions are urgently needed to counter extremely high
rates of MDR-TB among reinfection cases that reflects highly
successful MDR-TB transmission, underscoring the immediate
need for better TB control strategies in China

59. Patients at high
risk of tuberculosis
recurrence
DOI: 10.4103/ijmy.ijmy_164_17

60. Recurrent tuberculosis (TB) continues to be a significant problem and is an
important indicator of the effectiveness of TB control. Recurrence can occur
by relapse or exogenous reinfection. Recurrence of TB is still a major
problem in high-burden countries, where there is lack of resources and no
special attention is being given to this issue. The rate of recurrence is highly
variable and has been estimated to range from 4.9% to 47%. This variability
is related to differences in regional epidemiology of recurrence and
differences in the definitions used by the TB control programs. In addition to
treatment failure from noncompliance, there are several key host factors
that are associated with high rates of recurrence. The widely recognized
host factors independent of treatment program that predispose to TB
recurrence include gender differences, malnutrition; comorbidities such as
diabetes, renal failure, and systemic diseases, especially
immunosuppressive states such as human immunodeficiency virus;
substance abuse; and environmental exposures such as silicosis. With
improved understanding of the human genome, proteome, and
metabolome, additional host-specific factors that predispose to recurrence
are being identified. Information on temporal and geographical trends of TB
cases as well as studies with whole-genome sequencing/DNA Fingerprinting

61. Take Home Message
In case of recurrences of TB ,
patient may not only develop Pre-
XDR , XDR or MDR TB , he/she may
also develop Rif sensitive TB

62. Thank you very much