inflammatory reaction where the mycobacteria are being affected by treatment, it then follows that there probably were mycobacteria there. Alfred Elizabeth Talbot: The primary problem was impaired drainage from the few mycobacteria, but something happened. It's just too coincidental ten days in the treatment. Before … Alfred we begin a – sorry. Go ahead. Elizabeth Talbot: … well, no, I'm very curious to hear what others think about that. Alfred I think that the – because it happened very early on, it’s probably more TB-related than … Elizabeth Talbot: Yes. Alfred Lardizabal: … the constitution-related – as you had in one of your slides, these upgrading reactions occur more than a month after treatment is started. So … Elizabeth Talbot: Yes. Alfred Lardizabal: … it could be related to the TB infection itself since we waited a little while. Elizabeth Talbot: Yes. Alfred other questions or comments? Dana Kissner: I have a question, this is Dana Kissner. Alfred go Dana Kissner: Do you have time for another question? Alfred … Dana Kissner: Did you do sputum cultures for TB?
Slide 45 So, this is the patient who was referred to the Washington D.C. Department of Health Chest Clinic. And she is a 40 year-old woman who won a green card lottery, and immigrated from on October of 2010. She had previously worked as a lawyer she was in , and she – her husband unfortunately passed away two years prior, and she came here to the with her five year-old son. She had no significant past medical history, or any bad habits like alcohol, or tobacco, or drug use. About one month after arriving in the , she was admitted to the hospital over complaints of malaise, abdominal discomfort, shortness of breath and cough, with a reported 18-kilogram weight loss. Although I'm not sure what timeframe that was over. And unfortunately, she was diagnosed with a new diagnosis of HIV infection with AIDS with a CD4 count of 10. And she had a chest x-ray which I'll show you on the – on the next slide. Incidentally, we have no record of her having a PPD or an IGRA done, and we also don't have any information about her immigration work-up prior to arrival. Slide 46 So, this is the CAT scan she had. As you see, I don't really need a pointer, but there’s a large right pleural effusion here. And then over here, in the abdominal slices, you can see, in the spleen, there is a low density lesion as well as some ascites, and some necrotic nodes. So, the radiologist read – formally read her CT scan as consistent with lymphoma. And so, she’s carried around this diagnosis. And as the primary physician who saw her was initially very concerned about malignancy, and sent of numerous tumor markers. Slide 47 So, because of this worry about malignancy, she underwent a retroperitoneal lymph node biopsy, and the pathology showed that there were intracellular acid-fast bacilli, but no caseous necrosis. And the pathologist read this as suggestive of mycobacterium avium-intracellulare.
about 48 hours to get our nucleic acid amplification test done, and that was positive for MTB. And yesterday, I found out that the cultures were positive. He had a QFT that’s just a hair above the cut point for a TB infection and that was on February 23rd. 79 So, I don't have a discussion about extra-pulmonary TB and a previously gouty foot, but I think there are issues that have been raised by this case. One of them is that TB is not mentioned by our pathologist at all, even when caseating granuloma are noted. And these cases are not referred to Epidemiology. The clinicians were not called by the pathologist. I have no idea what Podiatry saw in this biopsy, or didn’t see in the biopsy, or didn’t recognize the significance. There is not a single note on the chart from them regarding pathology. And I also think that no other clinician found out about this because these reports were now buried in a tremendous morass of clinical data that is piling up in our electronic systems, and I think as time goes by, none of us is going to have any of our information readily available. Multiple clinicians fail to find or note the report. And then finally, even in a center where we see a lot of TB, spinal fluid was obtained and pleural fluid was obtained but not sent for mycobacterial cultures. So, I'll open this up to questions or comments. Slide 80 Alfred thanks Dana. Any comments or questions from the audience before we open it up to the whole panel? Would you conjecture to tell us how you think the organism got to the toe? Dana Kissner: We were talking that before, because I felt that was an hour-long talk. You know, my suspicion is that he had gout all along. But I'm not really sure about that. It’s really hard to say. And then somehow or other, he had an open wound, and I suspected he could have caught this as a wound infection, which is really unusual, or he really did have a source, you know, a focus of extra-pulmonary TB that flared up his gout.