The father of the index case was first diagnosed with pulmonary TB at a local clinic in Cape Town when the index case was 9 months old. Microscopy of his sputum showed 3+ acid-fast bacilli (AFB) and cultured M.tuberculosis, however drug susceptibility testing was not performed. He was started on standard 4-drug TB therapy but defaulted.
One month after the index case had died, the father presented to a primary care clinic in Hermanus outside of Cape Town. At that assessment, his sputum showed 3+ AFB and cultured M.tuberculosis. However DST was again not requested even though the South African National TB Programme guidelines require DST in cases of retreatment due to previous non-compliance. Clinic staff empirically started him on regimen 2 (INH, rifampicin, pyrazinamide, ethambutol and streptomycin) because of his previous non-compliance. Clinic records confirmed daily attendance and adherence to TB therapy.
A chest radiograph (CXR) was performed six months after starting regimen 2 because he was still severely symptomatic (productive cough, weight loss and night sweats). His CXR showed multiple cavities in his right upper lobe with bronchiectatic changes, and a right pleural effusion. This occurred despite documented directly observed compliance on regimen 2 for six full months. For the first time, his sputum was sent for TB culture and DST. Unfortunately, multiple sputum specimens did not culture M.tuberculosis, and therefore routine DST could not be done. Since he continued to deteriorate, and since his child had been proven to have had MDR-TB, he was empirically started on an MDR regimen (kanamycin, pyrazinamide, ofloxacin, ethambutol, ethionamide). Unfortunately he experienced significant side-effects and his MDR-TB regimen had to be interrupted. Team discussion regarding the possibility of a right pneumonectomy concluded that he was not a suitable candidate. He remains chronically breathless.