Case Study

A 44-year-old man presented to the TB Clinic with symptoms of progressive shortness of breath and cough with greenish sputum production. His sputum test results showed that he had atypical TB (Mycobacterium Avium Complex MAC infection). He was HIV negative at this time. Past history revealed that he was in good health till 1991 when he was diagnosed to have active typical tuberculosis (TB) and treated successfully with the regular TB drugs at that time.

As he showed clinical signs of disease, he was prescribed other antibiotics specific for this infection. It was recommended that he take these medications for at least a year with regular medical follow-up. Due to the cost of the medicines and personal financial constraints, he was not compliant with his medications and took only some of his medications intermittently. He complained of subjective fever, night sweats, weight loss, shortness of breath on exertion and chest pain during his follow-up. Although he periodically sought medical attention due to persistent symptoms, his treatment regimen was unsatisfactory due to compliance and availability issues. The Chest X-ray showed progressive deterioration. (He himself described his condition as “being eaten inside”.) Attempts to obtain medications from various social services sources were temporarily successful and when he took the prescribed medicines for two months at a stretch he showed clinical improvement. Later, once again due to financial constraints and lack of availability of all medicines, he took some of his medications some of the time, and not only deteriorated clinically but subsequently developed resistant and multi drug resistant disease (MDRMAC).

Commentary

This patient's clinical course illustrates the medico-social problem. A correctable problem has turned into a health care nightmare. 
 
It is true that the nature of this infection and the knowledge we have as of today makes us complacent regarding its spread. Since this infection is not known to have human to human transmission, it is not a true public health issue. It is not a reportable disease and hence the true incidence is unknown. However, it could be a silent killer and affects both groups of patients i.e. with chronic respiratory disease who have had previous lung disease and destroyed lung due to old TB and those who have overtly normal lungs and immune status. The cost of the diagnostic tests to reach a decision to treat, or not to treat, notwithstanding, the cost of therapy itself, both in terms of patient tolerance, as well as financial dollar costs is enormous. Public health support of undertaking or sharing this cost is erratic, and almost negligible. Philanthropic support by patient advocate foundations like the Wetmore Foundation is dependent upon availability of funds. The uninsured population cannot tap in to the public health resources that are available for treatment of “typical” tuberculosis. 
 
Efforts are those needed to create a philanthropic supported, pharmaceutical sponsored “single window” MCLNO based program to assist patients with atypical TB who require long term treatment. 
 
We welcome your comments. jali@lsuhsc.edu (Dr. Juzar Ali)