Concomitant multidrug-resistant pulmonary tuberculosis and susceptible tuberculous meningitis

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From: Emerging Infectious Diseases(Vol. 20, Issue 3)
Publisher: U.S. National Center for Infectious Diseases
Document Type: Letter to the editor; Report
Length: 1,222 words
Lexile Measure: 1310L

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To the Editor: In 2012, a 34-year-old HIV-seronegative man was hospitalized after several months of cough, fever, night sweats, 10-kg weight loss, and, in the past month, severe headache. The patient was born in Romania and had lived in France for 2 years. He had a history of pulmonary tuberculosis (TB) for which treatment was started in Romania in 2006 and 2008, but he did not complete treatment. The treatment he received in Romania was unknown.

At hospital admission, the patient had a fever of 39 [degrees]C, stiff neck, and swollen cervical and axillary lymph nodes. A chest radiograph showed multiple cavities and nodular opacities in both superior lobes. Sputum auramine staining indicated that acid-fast bacilli was positive, which supported the diagnosis of pulmonary TB. Examination of cerebrospinal fluid (CSF) revealed hypoglycorrachia (0.95 mmol/L, concentration ratio CSF/blood: 0.2 [reference range 0.5-0.75]), hyperproteinorrachia (1.3 g/L [reference range 0.2-0.4 g/L]), erythrocyte count 2,000 [micro]L (reference value <10 [micro]L), and leukocyte count 150 [micro]L (reference value <10 [micro]L). Auramine staining showed no acid-fast bacilli in CSF. Standard antituberculous therapy with rifampin (RIF), isoniazid (INH), pyrazinamide, and ethambutol was started.

Genomic amplification-based assay (Xpert MTB/RIF; Cepheid, Maurens-Scopont, France), performed on sputum, confirmed the presence of the Mycobacterium tuberculosis genome and detected resistance to RIF (Table). The line probe assay Genotype MTBDRplus (Hain Lifescience, Bandol, France) performed on sputum showed a positive signal for all wild-type sequences and for rpoB (S531L associated with RIF resistance) and katG (S315T associated with INH resistance) mutations, suggesting the presence of mixed susceptible and resistant M. tuberculosis. Second-line treatment was started: moxifloxacin, amikacin, ethionamide, paraaminosalicylic acid, cycloserine and linezolid. The presence of mixed M. tuberculosis organisms in lungs was confirmed with culture methods and by phenotypic drug susceptibility testing (DST) that showed 1% resistant mutant to RIF and INH (proportion method) (1). The isolate...

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