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• W4387265703 abstract "SESSION TITLE: Lung Pathology: Atypical Connections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Empyema necessitans is a rare long-term complication of persistent empyema, consisting of extravasation of exudative fluid (pus) due through the pleural cavity into the chest wall, often presenting as a swelling/lump due to the accumulation of the fluid in the subcutaneous space. (2) In this report, we present the case of a unique presentation of Tuberculous Empyema necessitans in an immunocompetent adult presenting with a left-sided soft tissue mass. CASE PRESENTATION: 38 year old male Ukranian national arrives in the US under the parolee program. As required, he undergoes tuberculosis screening. His QuantiFeron TB test is positive and subsequent chest x-ray is abnormal. As required, he undergoes tuberculosis screening. After obtaining records form Ukraine, his past medical history was found positive for MDR TB. He also report that he was sent to the US with a 3 month supply of bedaquiline, linezolid, moxifloxacin, clofazimine (Cfz). He was initially treated with levofloxacin (Lfx), kanamycin (Km), cycloserine(Cs), pyrazinamide(Z) regimen with right lung lobectomy in 2012. He relapsed in 2021 and was started to bedaquillne (Bdq), Lzd, delamanid (Dlm), Lfx ,Cs. He subsequently underwent a left upper lobectomy in Ukraine for source control. On presentation to the TB clinic, his sputum was smear-negative, but MTB PCR was positive. After the drug susceptibility testing (DST), he was placed on Bdq, Lzd, moxifloxacin (Mfx), pretomanid (Pa) and Cycloserine. After being on this regimen for 3 months, the patient developed a painful lump of left lower ribs with chest CT findings suggestive of empyema necessitans and DST consistent with Bdq resistance. DISCUSSION: The patient discussed in this case demonstrated failed treatment with known multidrug TB regimen despite adjunct de-bulking lung surgery in setting of TB drug resistance. Bdq, Pa and Lzd (BPaL) regimen reported to have 90% efficiency against the drug resistant TB (5). Treatment nonadherence to Bdq may lead to treatment failure, resistance and even relapse of TB. Studies demonstrated that Bdq has a baseline resistance prevalence of 3.8% associated with prior exposure to the agent and there is a 2.3% treatment emergent resistance of patients at 90 days of treatment (3). Early stages of TB ET are managed medically, and surgical intervention takes role in later stages if treatment is not progressing. Although many document case studies report the treatment of EN with medical management, there is not a set of guidelines for surgical management. (3). Bdq is efficacious in MDRTB and has less known side effects compared to Km buy aminoglycosides might be the only option in such tuberculous empyema necessitans cases with extensive resistance profile. CONCLUSIONS: This case study highlights the importance of timely and effective monitoring of MDR TB treatment. Further studies need to be conducted to evaluate the treatment of MDRTB outcomes in settings of Bdq resistance. REFERENCE #1: Pagan AJ, Ramakrishnan L. Immunity and Immunopathology in the Tuberculous Granuloma. Cold Spring Harb Perspect Med. 2014 Nov 6;5(9):a018499. doi: 10.1101/cshperspect.a018499. PMID: 25377142; PMCID: PMC4561401. REFERENCE #2: Ormerod LP. Multidrug-resistant tuberculosis (MDR-TB): epidemiology, prevention and treatment. Br Med Bull. 2005 Jun 14;73-74:17-24. doi: 10.1093/bmb/ldh047. PMID: 15956357. REFERENCE #3: Akgül AG, Örki A, Örki T, Yüksel M, Arman B. Approach to empyema necessitatis. World J Surg. 2011 May;35(5):981-4. doi: 10.1007/s00268-011-1035-5. PMID: 21404081. DISCLOSURES: No relevant relationships by Alfred Lardizabal No relevant relationships by Richa Nahar No relevant relationships by Suilon Ng No relevant relationships by Nikita Tangella" @default.
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• W4387265703 date "2023-10-01" @default.
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• W4387265703 title "MULTI-DRUG-RESISTANT (MDR) TUBERCULOSIS (TB) COMPLICATED WITH EMPYEMA NECESSITANS (EN)" @default.
• W4387265703 doi "https://doi.org/10.1016/j.chest.2023.07.3125" @default.
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