Culture studies from the biopsy were performed and grew Mycobacterium tuberculosis. Sequencing identification of the pathogen by the CDC matched that of patient zero, a transient adult male that lived in the same city and was the source of multiple exposures. In the case of our patient, epidemiological studies showed that he was likely exposed to TB on an ED visit when he was 6 years old and was being seen for chronic lung disease exacerbation.
The patient was started on isoniazid, rifampin, pyrazinamide, and ethambutol. However, during the first two weeks of treatment, he began to have feeding difficulties and developed jaundice. Alanine transaminase (ALT) and aspartate aminotransferase (AST) were five times the normal range. All TB medications were stopped until ALT and AST returned to normal. Rifampin was restarted, but the patient again developed jaundice and elevated liver enzymes. We determined that he could not tolerate rifampin and placed him on double therapy of isoniazid and ethambutol for 24 months. The patient performed well with therapy whereby there were resolution of granulation tissue and no AFB found on post-treatment biopsy.
Three months after the completion of treatment, the patient underwent a VPS revision without complications during the procedure. However, six months later, he developed a new erythematous, non-pruritic rash with oozing at the site of incision of the shunt revision on the scalp. A new biopsy was obtained which showed multiple AFB, thereby resulting in his diagnosis of recurrent cutaneous TB. Due to the hepatotoxicity of the first treatment plan, the patient was placed on intravenous amikacin, oral cycloserine, and oral ethionamide for three months and subsequently, amikacin was replaced with levaquin. The triple therapy was maintained for 18 months with resolution of the lesion. Given the recurrent nature of the patient's TB, he was placed on prophylaxis isoniazid and ethambutol with no documented recurrence TB throughout the remainder of his life. He succumbed from unrelated complications of his chronic disease.