Marcos Burgos M.D. Medical Director Tuberculosis Program, NM DOH Department of Medicine, Veteran Affairs Medical Center, The University of New Mexico School.

Marcos Burgos M.D.Medical Director Tuberculosis Program, NM DOH

Department of Medicine, Veteran Affairs Medical Center, The University of New Mexico School of Medicine, Albuquerque, NM.

A Homeless Alcoholic Patient with TB

October 23, 2012Durango, Colorado

TB case November 2008 paramedics brought to the ER a

52 year old Navajo man that was found on the streets acutely intoxicated with ETOH.

In the ER the patient had an alcohol level of 325 On evaluation, the patient was found to have a

chest X-ray with a large left apical cavity. The patient gave a history of homelessness,

history of tuberculosis treatment in the past and a current cough and weight loss of a couple of months duration

CXR/CT

TB case Multiple sputum samples were found to be 4+ for

AFB and MTB complex probe positive. He was admitted to the Medical Intensive Care Unit

for management of alcohol withdrawal, and he was started on 5 drugs: isoniazid, rifampin, ethambutol, pyrazinamide and moxifloxacin for presumed tuberculosis disease and superimposed pneumonia.

The tuberculosis programs was notified and the patient was interviewed and records reviewed

What other information will you want to know?

• What treatment did the patient get in the past?

TB case - PMH The patient is homeless and an alcoholic for most

of his adult life February 1992 the patient was diagnosed with

pulmonary tuberculosis in Utah and was started on IRP

November 1992 readmitted to McKay-Dee Hospital in Ogden, Utah

Patient left against medical advice and lost again to follow up

TB case - PMH

April 1993 readmitted in with a febrile illness, hypoxia and shortness of breath and a chest X-ray with a miliary pattern

The patient again lost to follow up and because of poor compliance the patient is court ordered to receive treatment under DOT in Oct. 1993.

The patient’s tuberculosis isolate from May 5, 1993 was susceptible to all drugs

TB case - PMH In addition to Ogden, Utah, the patient

received treatment in Boise, Idaho, and in Eugene, Oregon where he completed treatment for pulmonary TB in January 1994

There are no records of the type of treatment he received.

After this episode of tuberculosis, he was evaluated in California and Colorado for active tuberculosis in 2001 and 2003.

TB case

A sputum sample was sent to the California State Laboratory for rapid susceptibility testing (molecular beacons).

Rapid susceptibility results became available on November 22 and the M. tuberculosis isolate was found to have resistant mutations for isoniazid and rifampin (MDR-TB)

MDR-TB case MDR-TB treatment: ethambutol 1200 po QD,

pyrazinamide 1250 po QD, cycloserine 250 mg po BID, ethionamide 500 mg po BID, moxifloxacin 600 mg po QD and amikacin 1000 mg IV TIW.

In addition to MDR-TB disease, the patient was found by psychiatry to be ETOH dependent with a depressive disorder.

The patient refused referral to an alcohol treatment center.

Susceptibility results by standard methods were still pending.

Can we treat this case as an outpatient?

MDR-TB case The patient was deemed a poor candidate for

outpatient treatment Potential risk to public health History of non-adherence to treatment for TB

disease History of homelessness and an alcohol abuse,

both commonly associated with non-adherence. The patient remained in the hospital after he was

determined to be non-infectious as the program struggled to prepare for the next phase of his treatment

MDR-TB case TB program has limited resources to retain

high risk patients and provide a regimen for MDR TB

DOH worked together with HIS to come up with the funds to pay for an inpatient facility In the past New Mexico had a similar case for

which IHS and DOH split up the cost for an inpatient treatment of a MDR-TB case at the Center for Infectious Diseases (TCID) in San Antonio, Texas.

TB case The results of drug susceptibility testing by

standard methods took more than 8 weeks to become available

The drug susceptibility results showed that the isolate was susceptible to all primary and secondary drugs

Due to the discrepancies in results from standard methods and the rapid method, the initial culture was sent to the California State Laboratory for molecular beacons

The isolate did not have any resistant mutations

TB case The patient was no longer infectious He was started on isoniazid, rifampin, and

pyrazinamide and the patient was discharged from the hospital to a motel room arranged and paid by the TB control program.

The patient started receiving his treatment under DOT with close follow up by the TB program

The patient completed additional 6 months of treatment

TB case The diagnosis of TB opened the door for the

development of a trusting relationship with the TB program that eventually allowed him to stay sober and obtain an apartment

The cost of his hospitalization: $160,000

Tuberculosis in an Urban Setting

M. Frances Vasquez, M.S.Tuberculosis Case Manger

Stanford Public Health OfficeAlbuquerque, NM

Initial Situation Phone call, we have a new client

at Lovelace Hospital Help him apply for General Assistance Apply for Institutional level care

He may qualify for D&E Waiver

General History First DOT on 11-03-2008. Age: 51History of Alcoholism and Homelessness

BAC was .325 when admitted.Client was malnourished and gave a history of previous injuries and hospitalizations.

First VisitMet client on 12-22-08 wearing my

endearing ensemble of N-95 mask, gown and gloves

I am one of 3 or 4 people in the room talking to him.

He receives lots of information but speaks very little.

HomeworkHomework

GA is $266 per month Needs photo ID for Food Stamps Needs Birth Certificate – no record in NM system Ageing and Long Term Services stated wait list is

over 2 years; do not think my client would qualify If found incompetent, check out guardianship. Homeless shelters may be best option for persons

w/o an income.

GA is $266 per month Needs photo ID for Food Stamps Needs Birth Certificate – no record in NM system Ageing and Long Term Services stated wait list is

over 2 years; do not think my client would qualify If found incompetent, check out guardianship. Homeless shelters may be best option for persons

w/o an income.

Surprise! On visit to client on 11-12-08, he told Dr.

Burgos that he finished his TB medicine in 1994 in Eugene, OR.

Stated he started treatment in Ogden, UT., then moved to Boise Idaho and then completed treatment in Oregon.

Arrived in ABQ two weeks ago from Kingman AZ and before that he lived in Phoenix.

BAC was .325 when admitted.

On visit to client on 11-12-08, he told Dr. Burgos that he finished his TB medicine in 1994 in Eugene, OR.

Stated he started treatment in Ogden, UT., then moved to Boise Idaho and then completed treatment in Oregon.

Arrived in ABQ two weeks ago from Kingman AZ and before that he lived in Phoenix.

BAC was .325 when admitted.

04-23-09 Phone call received from sister.

Reported that mother had active TB in 1950’s and was treated in a sanatorium in Albuquerque.

a Around this time client given

neuropsychological evaluation. Found incompetent. Makes our job easier.

Sister calls and complains that the neuropsych eval needs to be in Navajo, his native language.

Navajo interpreter difficult to find. Finally I recruit our WIC clerk from Cuba to come and interpret. Client refuses to use her!

Client is more cooperative and responsive during second evaluation and is found to be competent.

Building Rapport and TrustBuilding Rapport and Trust01-07-09 Inquired about ID. Client stated that he has no documents on his person or in his wallet.

Began to stop in when time permitted to spend time with client and make small talk. I asked him if there was anything he was craving.

Began to bring burritos from home or snacks.

One day he told me he had an AZ ID and a Social Security card!

01-07-09 Inquired about ID. Client stated that he has no documents on his person or in his wallet.

Began to stop in when time permitted to spend time with client and make small talk. I asked him if there was anything he was craving.

Began to bring burritos from home or snacks.

One day he told me he had an AZ ID and a Social Security card!

I felt like . . .

Isolation

Client was in isolation about 4 months.

Had lots of time to think about his situation and his life.

Decided to quit drinking while in hospital.

Requested, and was given, double portions of food.

Spent his time watching TV and he seemed to enjoy the newspaper.

Revealed he could only read some of the words in the newspaper.

Once client was coming to office for DOT, I began to tutor him in reading.

Meeting with Key Stakeholders Question as to how to proceed once found competent.

Meeting with hospital staff, DOH attorneys, Indian Health Service, TB Staff, MD’s regarding payment for services if client was sent to Heartland in TX.

Everyone had their iron in the . . .

Upon ReleaseUpon Release Was set up in hotel to complete DOT. Set up with a few utensils for cooking. When no long infectious used local services

for homeless for food, bus passes, clothes, etc.

Eventually received GA Eventually received Social Security Found low-income housing for client. Has been clean and sober since he was

hospitalized at the end of 2008.

Post Treatment I became his representative payee

for Social Security. He did continue to receive reading

tutoring for several months. He lives independently and is still

clean and sober. He lives a fairly isolated life but

manages his life well.

Good Outcome!

Marcos Burgos M.D.Department of Internal Medicine, Division of

Infectious Diseases, UNM SOMMedical Director TB Program, DOH NM

A homeless alcoholic patient with TB

Durango, Colorado