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A.G. Holley Hospital 

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Case 1

LP is a 53 yo African American female who presented to Mt. Sinai Hospital in New York in December of 1992 with a two week history of fevers, chills and productive cough.  CXR revealed RUL infiltrate and cavity. Sputums were AFB (+).   The patient was started on five first line drugs.  The patient had a PMH of insulin dependent diabetes for ten years.  The patient was born in the U.S., never traveled.  She worked as a nurse assistant. Sensitivities returned resistant to INH, RIF, PZA.  Her meds were adjusted and she was placed on DOT however she was non compliant.  The patient complained of various "allergies" to the meds and developed elevated hepatic transaminases with ETA and PAS.  The patient remained culture positive and in Sept ‘93 was found to be resistant to every first and second line drug but ETA, KM and OFL. The patient was offered surgery but refused.

The patient stopped taking her meds because she was "tired of TB". She was rehospitalized at Columbia in 2/96 and again sent to DOT, still smear and culture positive. She again stopped taking her meds and went to Jacksonville, Florida in 7/96 "hoping the weather would help" (though NY DOH claims they were about to take legal action).  The patient became weak and went to the health department in 7/97 in Jax and was admitted to AGH in 9/23/97.

Physical exam was significant for significant hearing loss.  The patient was placed on imipenim, amikacin (750mg BIW IV), CS, and ETA. (Subsequently Fla DOH lab showed Sensitivities to above) .  The patient developed hepatitis to ETA which was d/c’d.  She became smear and culture negative on 2/3/98.  PFT’s showed an FEV1 1.69 (56%), FVC 2.78 (73%) and FEV1/FVC 61% without significant change with BDs. Quantitative Perfusion Scan was less than 20% to the right lung. (Calculated left residual FEV1 1.35).  A right pneumonectomy was performed on 7/21/98 and patient had an uneventful post op course.  athology revealed a necrotic cavity, with aspergillosis organisms, but AFB culture negative.  Patient was returned to A.G. Holley on post op day 8.

Patient has done well on imipenim, amikacin and CS and has remained culture negative. Asymptomatic.   FEV1 1.35. Audiometry and renal status stable.  No ventilation to right on Ventilation scan.  Patient will complete medical therapy on 8/3/99 after 18 mths of culture negative therapy.