SESSION TYPE: Infectious Disease Global Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Tuberculosis (TB) still remains a major public health problem in most of the Asia and African countries. Recently it has been reported that some genotypes of the causative agent Mycobacterium tuberculosis are more virulent and carry high rate of drug resistance. Beijing lineage is one such genotypes. Approximately 109 strains of Beijing genotype have been reported from India, so far. Here we report a rare and first case of disseminated tuberculosis caused by a rare “Beijing” genotype of M. tuberculosis from India.
CASE PRESENTATION: A 27 year old married male presented to us with back pain and swelling on right knee joint. The swelling was soft and tender. He also gave past history of confirmed tubercular pleural effusion two years back. For which he had received 6 months anti-tubercular treatment. At the time of presentation he had no chest complaints and his chest x-ray was clear. His CECT chest and abdomen showed normal lung parenchyma , D7-D10 vertebral bodies showed areas of sclerosis and lyric destructions with reduced intervertebral disc spaces and a large pre and para-vertebral abscess extending from D7-D11. MRI showed evidence of circumscribed geographic areas of T1/T2 prolongation involving the upper end of tibia and moderately large fluid collection anterior to tibia. Mild synovial collections tracking to supra-patellar bursa along with distended medial gastrocnemius-soleus bursa were also seen. The rest investigations were within normal ranges except raised ESR. He was HIV negative. Synovial fluid from right knee abscess was aspirated. Gram stain was non-contributory but Zeihl-Neelsen staining showed acid fast bacilli. The pus was cultured in the BACTEC MGIT 960. The culture isolate was identified as M. tuberculosis and was subjected to drug susceptibility in BACTEC MGIT 960 for streptomycin, isoniazid, rifampin and ethambutol. DNA was isolated from the culture to identify the mycobacterial lineage by Spoligotyping. Results of Drug susceptibility testing showed the isolate was resistant to all four primary drugs. Spoligotyping results showed the isolated M. tuberculosis strain belonged to the Beijing lineage with the spoligo-pattern of 0000000000000000000000000000000000111011111 (Octal number: 000000000003571). At the time of the comparison, SIT632 represented a total of 4 strains in the SITVIT2 database. The worldwide distribution of SIT632 strains was essentially limited to Georgia, Thailand, and Taiwan but none from India. The final diagnosis of disseminated multidrug resistant tuberculosis with Pott’s spine-D 7 to D 11 with paravertebral psoas abscess and tubercular osteomyelitis of right tibia was made. The patient was administered with second line anti-tubercular treatment, which included injection Kanamycin, Ofloxacin , Ethionamide, Cycloserine, Pyrazinamide, PAS and Pantoperazole. The patient was followed up every three months. After 3 months his knee swelling further increased and repeat pus aspirate was again culture positive with same drug susceptibility pattern. However, his symptoms normalized after adding the steroids to the standard second line anti-tubercular therapy. His last follow up was 12 months on ATT with complete resolution of his swelling and no residual disability.
DISCUSSION: Drug resistant strains are known to have substantially better transmissibility. He was resident of Bihar adjacent to Nepal where large scale drug smuggling from other countries is common. Hence it is likely that this strain entered Indian through these drug smugglers. Beijing genotype which is a predominant endemic strain in China, Japan and Russia, today constitutes an emerging pathogen in several other areas of the world.
CONCLUSIONS: Routine screening of all MDR stains in Indian subcontinent to identify the proportion of Beijing genotype will be helpful in understanding the transmission and rising frequency of MDR-TB cases.
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DISCLOSURE: The following authors have nothing to disclose: Sarman Singh, Manimuthu Sanakar, Manoj Kumar, S. Sharma
No Product/Research Disclosure InformationAll India Institute of Medical Sciences, New Delhi, India