Estrategia Sanitaria Nacional de Prevención y Control de la Tuberculosis
First case of XDR -TB cured after 10 years of illness with regimen based on Group 5 drugs and bedaquiline in a programmatic approach in Peru DANTE VARGAS, 1 ALBERTO MENDOZA,2 JOSE CABRERA, 2 AND VALENTINA ALARCON 2 1 Hospital Nacional Hipólito Unanue, 2 Estrategia Sanitaria Nacional de Prevención y Control de la Tuberculosis – Ministerio de Salud de Perú
BACKGROUND: Peru has implemented the programmatic management of XDR-TB patients SINCE 2012 based on WHO-Group 5 drugs, surgery and central venous catheters (Type Port).
OBJECTIVE: To report the first case of XDR-TB to be discharged as cured with a regimen based on Group 5 drugs and bedaquiline by the Ministry of Health of Peru.
METHODS:
Figure 1. DST profiles between 2002 - 2008
Case report Droga Isoniacida
RESULTS: A 41 y/o physician female from Lima, was diagnosed with pulmonary TB in April 2002 while she was a medical student. Her first DST in this episode corresponded to XDR-TB, only susceptible to cycloserine and p-amino salicylic acid (PAS). (Figure 1) She underwent surgery twice: right lobectomy (2003) and left segmentectomy (2004). In 2010 the patient was discharged as having failed to respond to five antituberculosis regimens (Figure 1), and was reported as an “incurable” case with culture (+++). In April 2012, she began a regimen showed in Table using a catheter central subcutaneous type Port. She developed an episode of pulmonary embolism, severe nausea and vomiting associated to PAS and bedaquilina, anemia (linezolid), fainting by dysautonomia, hypokalemia, hypomagnesemia and bilateral mild hearing loss. The adverse reactions required the cessation of only PAS. Her weight had increased only 3 kg during treatment, but the clinical and bacteriological courses were favorable, resulting in a negative sputum culture after the second month and remaining that way throughout the treatment, despite having until the 11th month an intermittent smear that was scanty or (+). After that, the monthly smear and culture were negative. Radiographically has not shown changes, with bilateral sequelae images. In April 2014 was discharged as cured with more than 10 negative cultures.
Rifampicina Etambutol Pirazinamida Estreptomicina Ciprofloxacina Moxifloxacina Kanamicina
2002
4 4 8 8 1 4 1 4
Capreomicina Etionamida PAS Cicloserina Amx-clav Clofazimina Claritromicina
4 1 1 1 1 1
2003
2004
2005
2006
2007
1 1 7 1 1 6
1 12
2008
12
12
12
2009
2010
12
2
12
2
6
12
2
4 6
12
2
12
11
12
12
12
12
12 12 12 3 12
12 12 12
12 12 12
12 12 12
12 12 12
12
12
12
12
5 5 29 9 3 24 61 24 59 4 65 81 61 4 61
Numbers are months of treatment
X-Ray in 2011
Figure 2. X-Ray and anti-TB drug taken before treatment
Table. Regimen based on Group 5 and bedaquiline Drug
Dosis and duration Adverse reactions and observations
Linezolid
600 qd x 24 months
Transitory periferical neurophaty Moderade anemia
Imipenem/AMXClavulanic Thioridazine
None, administred through catheter Port
Bedaquiline
1 g bid / 1g bid x 12 months 200 mg qd x 24 months 6 months
PAS
3 gr bid 2 months
Suspended by gastric intolerance
Moxifloxacin
400 mg x 24 months
Changed for levofloxacin while bedaquiline was given (QT)
Capreomicyn
1gr qd x 12 months
Cicloserine
750 mg qd x 24 months 1500 mg qd x 24 months
Mild hearing loss, moderade hipokalemia, hipomagnesemia, Cath Port None
Pirazinamide
(suspended while bedaquiline was given) (QT) Administred between 3 and 9 months Severe nausea and vomiting
None
CONCLUSION: With a regimen based on the WHO G-5, thioridazine and bedaquiline has been possible to cure a XDR-TB patient with a 10 year long history of the disease with mild to moderate adverse reactions. This encourages the programmatic management of XDR -TB and advocacy to reduce the cost of drugs used.
Additional informatio: Until October 2014, 96 XDR patients are being treated with this regimen, four have been discharged as cured, and 100% converted their culture at 6 months. Contact:
[email protected]
Total
