AbstractThe global emergence and sp

Abstract
The global emergence and spread of multidrug resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB) has led to the reexamination of surgical therapy as a possible adjunctive therapy for the treatment of drug-resistant TB. We present a case of a 26-year-old HIV-seronegative patient with pulmonary XDR-TB refractory to medical therapy. Surgical resection of the patient’s solitary cavitary lesion was performed as adjunctive treatment and a successful outcome with a combination of surgery and medical therapy was achieved. We review the history of surgical therapy for TB and the literature published on the role of surgical therapy in the treatment of MDR- and XDR-TB. A total of 26 case series and cohort studies were reviewed demonstrating surgical resection is beneficial in the treatment of drug-resistant TB; however, the results may not be applicable to all settings as all studies were observational, tended to select “healthier” TB patients, and all surgeries were performed at specialized thoracic surgery centers. Additional well-designed studies are needed to determine the efficacy of surgery in the treatment of drug-resistant TB.

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Introduction
Thoracic surgery was a common treatment for pulmonary tuberculosis (TB) in the pre-chemotherapy era after the discovery of Mycobacterium tuberculosis in 1882 by Robert Koch.1,2 Early surgical therapies consisted of a variety of collapse therapies including thoracoplasty, ball plombage, and induced pneumothorax.3 The first report of pulmonary resection was in 1891 and during the early twentieth century, surgery played a prominent role in TB management.2,4 However, after the advent of effective anti-TB medications in the mid-twentieth century, the use of surgical resection became limited in most countries. The global emergence of drug-resistant TB including multidrug resistant (MDR) and extensively drug-resistant (XDR) disease5 has led to the re-examination of surgery as an adjunctive treatment for highly drug-resistant TB. We present a case of XDR-TB treated with a combination of medical therapy and surgical resection and review the literature on the role of surgery in the treatment of MDR- and XDR-TB.

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Case Report
A 26-year-old HIV-seronegative male from the country of Georgia presented to the Georgian National Center for Tuberculosis and Lung Diseases (NCTBLD) in Tbilisi on April 1, 2009, with 2 weeks of fever, productive cough, and a 10-pound weight loss. The patient had been diagnosed with “community-acquired pneumonia” in December 2008 and received an empiric course of 7 days of an unknown antibiotic. The patient reported alcohol intake of 1–4 drinks weekly and smoking one half pack of cigarettes per day. He had received BCG vaccination as an infant. He had no other significant past medical history and was not taking any medications at the time of presentation. The patient was employed as a security guard at the NCTBLD for the three years prior to onset of symptoms. He reported not wearing a mask or respirator while patrolling the inpatient tuberculosis wards. The patient reported there was a new infection control policy that included wearing appropriate masks on patient floors; however, he stated he did not wear one because there were limited masks available and most hospital personnel were not wearing masks [at that time]. A chest radiograph revealed a left lower lobe infiltrate (Figure 1a). Sputum examination with Ziehl-Neelsen staining was positive for 3+ acid fast bacilli (AFB). Based on the above results, the patient was clinically diagnosed with pulmonary TB. He was admitted to the hospital, placed in respiratory isolation, and started on first-line anti-TB therapy with rifampin, isoniazid, pyrazinamide, ethambutol; he also received vitamin B6 (pyridoxine).

Figure 1
Figure 1
Chest radiography
The initial sputum culture, performed on Löwenstein-Jensen medium, grew M. tuberculosis (MTB). The patient initially noted some symptomatic improvement after one month of anti-TB treatment but did not have complete resolution of symptoms. Drug susceptibility testing (DST) to first-line anti-TB drugs, utilizing the agar proportion method6 was performed by the Republic of Georgia National TB Reference Laboratory; it demonstrated resistance to all first-line drugs including rifampin, isoniazid, pyrazinamide, ethambutol, and streptomycin. The patient’s medications were subsequently changed to a second-line regimen that included capreomycin, levofloxacin, cycloserine, PAS, prothionamide, and pyrazinamide. Approximately one month later in August 2009, second-line DST results were available and identified further resistance to ethionamide, kanamycin, capreomycin, ofloxacin, and susceptibility to PAS. Based on the resistance pattern (resistance to isoniazid, rifampin, ofloxacin, capreomycin and kanamycin) which was further confirmed by subsequent positive cultures and DST, the patient was diagnosed with XDR-TB. Anti-TB medicat

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AbstractThe global emergence and spread of multidrug resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB) has led to the reexamination of surgical therapy as a possible adjunctive therapy for the treatment of drug-resistant TB. We present a case of a 26-year-old HIV-seronegative patient with pulmonary XDR-TB refractory to medical therapy. Surgical resection of the patient’s solitary cavitary lesion was performed as adjunctive treatment and a successful outcome with a combination of surgery and medical therapy was achieved. We review the history of surgical therapy for TB and the literature published on the role of surgical therapy in the treatment of MDR- and XDR-TB. A total of 26 case series and cohort studies were reviewed demonstrating surgical resection is beneficial in the treatment of drug-resistant TB; however, the results may not be applicable to all settings as all studies were observational, tended to select “healthier” TB patients, and all surgeries were performed at specialized thoracic surgery centers. Additional well-designed studies are needed to determine the efficacy of surgery in the treatment of drug-resistant TB.Go to:IntroductionPhẫu thuật lồng ngực là một điều trị phổ biến cho phổi bệnh lao (TB) trong thời kỳ tiền hóa trị sau khi phát hiện ra Mycobacterium tuberculosis năm 1882 bởi Robert Koch.1,2 đầu phương pháp điều trị phẫu thuật bao gồm một loạt các liệu pháp sụp đổ, bao gồm cả thoracoplasty, ball plombage và gây ra pneumothorax.3 báo sự giải phẩu phổi, đầu tiên là vào năm 1891 và trong thời gian đầu thế kỷ XX, phẫu thuật đóng một vai trò nổi bật trong TB management.2 , 4 Tuy nhiên, sau sự ra đời của hiệu quả chống-TB thuốc ở giữa hai mươi thế kỷ, việc sử dụng phẫu thuật cắt bỏ đã trở thành bị giới hạn ở hầu hết các nước. Sự nổi lên toàn cầu của bệnh lao kháng thuốc bao gồm kháng dòng (MDR) và rộng rãi kháng thuốc disease5 (XDR) đã dẫn đến tái khám phẫu thuật như là một điều trị adjunctive cho TB cao kháng thuốc. Chúng tôi trình bày một trường hợp của XDR-TB được điều trị với sự kết hợp điều trị y tế và phẫu thuật cắt bỏ và xem xét các tài liệu về vai trò của phẫu thuật trong điều trị của MDR - và XDR-TB.Đi tới:Trường hợp báo cáoA 26-year-old HIV-seronegative male from the country of Georgia presented to the Georgian National Center for Tuberculosis and Lung Diseases (NCTBLD) in Tbilisi on April 1, 2009, with 2 weeks of fever, productive cough, and a 10-pound weight loss. The patient had been diagnosed with “community-acquired pneumonia” in December 2008 and received an empiric course of 7 days of an unknown antibiotic. The patient reported alcohol intake of 1–4 drinks weekly and smoking one half pack of cigarettes per day. He had received BCG vaccination as an infant. He had no other significant past medical history and was not taking any medications at the time of presentation. The patient was employed as a security guard at the NCTBLD for the three years prior to onset of symptoms. He reported not wearing a mask or respirator while patrolling the inpatient tuberculosis wards. The patient reported there was a new infection control policy that included wearing appropriate masks on patient floors; however, he stated he did not wear one because there were limited masks available and most hospital personnel were not wearing masks [at that time]. A chest radiograph revealed a left lower lobe infiltrate (Figure 1a). Sputum examination with Ziehl-Neelsen staining was positive for 3+ acid fast bacilli (AFB). Based on the above results, the patient was clinically diagnosed with pulmonary TB. He was admitted to the hospital, placed in respiratory isolation, and started on first-line anti-TB therapy with rifampin, isoniazid, pyrazinamide, ethambutol; he also received vitamin B6 (pyridoxine).Figure 1Figure 1Chest radiographyThe initial sputum culture, performed on Löwenstein-Jensen medium, grew M. tuberculosis (MTB). The patient initially noted some symptomatic improvement after one month of anti-TB treatment but did not have complete resolution of symptoms. Drug susceptibility testing (DST) to first-line anti-TB drugs, utilizing the agar proportion method6 was performed by the Republic of Georgia National TB Reference Laboratory; it demonstrated resistance to all first-line drugs including rifampin, isoniazid, pyrazinamide, ethambutol, and streptomycin. The patient’s medications were subsequently changed to a second-line regimen that included capreomycin, levofloxacin, cycloserine, PAS, prothionamide, and pyrazinamide. Approximately one month later in August 2009, second-line DST results were available and identified further resistance to ethionamide, kanamycin, capreomycin, ofloxacin, and susceptibility to PAS. Based on the resistance pattern (resistance to isoniazid, rifampin, ofloxacin, capreomycin and kanamycin) which was further confirmed by subsequent positive cultures and DST, the patient was diagnosed with XDR-TB. Anti-TB medicat