Drug Resistant Tuberculosis: A Case Study

by Kathy Shield, Health Network Intern

[Editor’s note: This case study demonstrates how our Health Network team works diligently to assure each patient’s treatment completion. Health Network is MCN's bridge case management program, which assists mobile patients in continuing their care as they move. TBNet is a program of Health Network focused on patients with tuberculosis. Thank you to MCN’s intern, Kathy Shield, for the thoughtful write-up. Watch short introductory videos on Health Network and learn how to enroll patients on our Health Network page.]

In the summer of 2013, Nicholas* was enrolled with Health Network’s TBNet in preparation for his return to Mexico. Nicholas’s medical records included with the enrollment showed that Nicholas had a positive chest x-ray due to large pleural effusions and nodules on the the lungs. In addition, Nicholas was found to have a positive sputum smear and a positive Polymerase Chain Reaction (PCR) test for Mycobacterium tuberculosis bacteria. Nicholas showed physical symptoms of a persistent cough with phlegm. In addition to these signs and symptoms of tuberculosis, he was a methamphetamine user. 

Leslie, one of Health Network’s associates, called Nicholas for an interview on the day of his enrollment. She also called Nicholas’s father in Mexico to verify the address to where he intended to move. Before leaving the US, Nicholas started treatment for TB. Health Network received notification of the dosage amount for Nicholas's RIPE (Rifampin, Isoniazide, Pyrazinamide, Ethambutol) treatment, after which Leslie sent an International Tuberculosis Notification (INF) to the health department in his district in Mexico. 

In Mexico

On the same day the INF was sent, Leslie called Nicholas’s father, who confirmed that Nicholas was back in Mexico. The father was concerned because he was very sick. Leslie provided some reassurance and updated him on Nicholas’s treatment plan. Over the next few months, Leslie was in regular contact with Nicholas to ensure that he was receiving treatment. During this time, Nicholas had to undergo surgery on his lungs but continued his TB treatment. 

While Nicholas continued treatment in Mexico, the department of health (DOH) from the US state that initially enrolled Nicholas sent a susceptibility report for Nicholas showing a resistance to ETH and INH, from the cultures collected before Nicholas’s enrollment in Health Network the year before. 

From Mexico, to the US, and back 

At this juncture, we received a new enrollment form for Nicholas from a new southern state where he was being treated. Sometime around February, 2014, Nicholas returned to the US but Health Network lost contact with Nicholas.

In September, Nicholas's father contacted Health Network and informed us that Nicholas had at some point abandoned his treatment but now had restarted and was seeing a doctor in Mexico. Health Network explained to him the importance of his son continuing his treatment and the implications of now having confirmed drug-resistant TB. An updated INF was sent to the Instituto de Servicios de Salud Pública in his region in Mexico to inform them of the susceptibility report and the changes in treatment. Health Network also called and informed the new enrolling DOH that continuity of care had been established for Nicholas in Mexico and Nicholas was now responsive to the treatment.

A few days after speaking to the Nicholas's father, Health Network spoke to the doctor who was in charge of the Nicholas's care. Leslie also spoke directly with Nicholas. Throughout the winter of 2014 Nicholas was undergoing treatment and Nicholas's father told Health Network that their family was taking the situation very seriously. In December, 2014, Nicholas informed us that he was no longer taking injectables since he did not like them and had instead switched to pills three times a week and was not sure when he would be done. Health Network called and checked on Nicholas multiple times throughout the following months to ensure the continuity of treatment with the family as well as with the doctor. 

Trouble finishing treatment

In June, 2015, Health Network was informed that Nicholas should finish treatment later that month. Health Network stayed in contact with Nicholas's physician and requested multiple updates on Nicholas's treatment. In July, the Instituto de Servicios de Salud Pública in his region in Mexico informed Health Network that Nicholas's treatment end date had been extended due to the resistance of Nicholas's TB.

After not having contact with the Nicholas for a couple months due to no answer, Health Network finally was able to get into contact with Nicholas's father in August, who was unsure whether or not his son was still on treatment. He informed us that his son was a drug addict. Health Network reminded Nicholas's father again of the severity of the son’s condition and advised him to be tested for TB. Later that month, Nicholas's family was contacted again and Health Network spoke to Nicholas's mother who was unaware of the severity of the condition and did not know that the son was contagious.  We advised her to be tested as well. Recently, Nicholas completed nine months of treatment for TB after which the Instituto de Servicios de Salud Pública informed Health Network that Nicholas's latest culture results were negative for TB and he no longer required treatment.  His Health Network case was then closed.  

This case is an example of how important it is for clinics and Health Network to be in constant contact on the status of active TB cases. The case also demonstrates the need for multiple contacts with not only the patient but the patient’s family as well, to ensure that the patient is getting the care they need. This case required eight clinic contacts to clinics in the US and Mexico. Also Health Network contacted Nicholas 26 times and have spoken to Nicholas, Nicholas's father, mother, and other family members on multiple occasions. 

Health Network is provided free of charge to health centers and their mobile patients. Learn more on our Health Network page. Support MCN programs like Health Network before December 31st and your donation will be doubled, dollar-for-dollar!

*All names, dates, and locations have been changed to protect the patient’s identity.

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