A Holistic Approach to Treating Multi-Drug Resistant Tuberculosis in an Urban Health Department in Virginia

Introduction: Multi-drug resistant Tuberculosis (MDR-TB) has an estimated global mortality rate of 40% and poses a threat to the patients, their families, and communities. In the United States, 90 cases of MDR-TB were treated in 2019 at an estimated cost of at least $134,000 per patient. Treatment for drug-resistant cases requires skilled medical management and immense resources for patient support. Description: This case report describes how an urban health department in Virginia marshalled expertise and external resources to manage a pre-extensively drug resistant TB case. In November of 2018, the case was referred to the health department from a community-based clinic. The patient's chest x-ray and symptoms were consistent with TB disease despite being treated twice for TB in her home country. Upon drug-susceptibility testing, the patient was found to be resistant to all first line drugs (rifampin, isoniazid, pyrazinamide, and ethambutol). Subsequently, upon further molecular testing in partnership with The Centers for Disease Control and Prevention and National Jewish Health, the patient was found to have additional resistance to critical second-line drugs (streptomycin, ciprofloxacin, ethionamide, and ofloxacin). A team of experts treated the patient medically and psychosocially for a period of 20 months. Vital to the holistic treatment of this patient was the development of a substantial network of support that considered not only the patient, but her family, and community. Discussion: Managing this case not only required treating the patient medically, but also supporting and engaging family members and protecting them and the community at large from infection. Such extensive public health care required a widespread network of partners: state and local government agencies, a community-based clinic, state and university-based clinicians, pharmaceutical companies, laboratories, and national experts. Together, these partners addressed concerns ranging from language interpretation, to meeting psychosocial needs, and securing basic necessities. Successful treatment required consistent communication among providers and gaining the full trust and respect of both the patient and family. Conclusion: Treating MDR-TB involves more than providing medical care to the patient; it requires a holistic approach. In addition to establishing a solid, trusting relationship, an extensive network of medical and community partners supplied the necessary support to manage and treat the patient. Community collaboration, empathy, teamwork, and the enduring support to the patient's family are key components to managing MDR-TB cases and protecting the public's health.