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Unsolved Mysteries: The Continuing Saga of our XDR-TB case

XDR-TB and all other emerging, infectious diseases have had my attention for a while. For some background information, read:

One of my colleagues here at Healthline is a microbiologist, and she was kind enough to help me track down some information to try to answer some of the unanswered questions in the case of our runaway bridegroom. I asked her about the process for identifying the strain of TB a patient has. She said, " In the old day, multiple drug resistance was rare, so TB susceptibility testing was not routinely done. The steps in the process are
  • Obtain the specimen [sputum] from the patient
  • Identify the bug (microorganism causing the infection)
  • Subculture the bug to grow a pure culture: this is where the process can get bogged down, just growing enough inoculum to test
  • Use the pure culture of the bug to test for drug resistance"
She went on to say "Patients with TB are treated empirically." This means patients are given the usual medications used to treat the causative organism, in this case the bacterium Mycobacterium tuberculosis(M. tuberculosis) ." Susceptibility tests are done only after patients fail to respond to empirical treatment and typically, the most common drugs would be tested. If the patient's sputum sample was resistant to all common medications, then additional medications would be tested. The National Jewish Hospital is/was way ahead of the Public Health Department in developing new drug susceptibility tests."

National Jewish Medical and Research Center, Global Leader in Lung, Allergic and Immune Diseases, is on the international radar because that is where our most famous TB patient since Mimi in Puccini's operaLa Boheme is being treated. Would it take 4 months to test the sputum sample? No. Focus Diagnostics Reference Laboratory indicates the studies would be done in 14 to 21 days from the time they received the pure isolate of the microorganism culture. My microbiologist colleague reports that the culture can be grown from a liquid sample within a week, and if you have just "...a single colony on a solid culture, it can take up to 6 weeks..."

I am no math whiz, but I'm pretty sure that is a little over 2 months. OK. So the scenario I imagine is that he falls, has a chest X-ray, TB is diagnosed and reported to the county public health office and he is treated empirically. He proceeds with his wedding plans. His TB doesn't respond to treatment and the lesion in his lung gets bigger. The only part of this that still doesn't add up to me is Dr. Cooksey, his father-in-law, TB investigator for the CDC. Would not he have discussed his case with him?
  • According to the Atlanta Journal-Constitution, Dr. Cooksey "...prepared his son-in-law's specimen for DNA testing as part of his regular duties."
  • The CDC's own website reports that Drug Susceptibility testing takes one month. The HPLC genotyping is most likely the aspect of testing Dr. Cooksey is involved in.
  • AJC reports that Mr. Speaker feels the Fulton County public health officials and the CDC are casting aspersions on his character to "deflect questions about their own actions"
    • What actions would those be? Working hard to try to solve some of the most challenging problems of humanity? Dedicating their lives to helping others?
Another source of my information is the CDC itself. I receive their Clinician Updates via email, and am on the Terrorism Listserve. Yesterday, I received CDC Clinician Communication: Information from Clinician Outreach and Communication Activity (COCA). The June 7, 2007 communique is a particularly robust "...summary of clinical guidance...of persons potentially exposed to XDR-TB on two transatlantic flights." Per this communique to Health Professionals who may be involved in evaluation and treatment directly impacted by this case, the CDC states:

The case has triggered international investigations in Greece, Canada, the US and Italy. The DHS border guard who allowed the patient back into the US without detaining him has been suspended. Georgia State law does not allow health officials to restrict a patient's movement unless h/she violates a written directive. Mr. Speaker eluded being served a written directive when his fiancee (daughter of CDC TB expert) advised him to leave the country early so that he could rest and relax. Dr. Katkowsky, Director of the Fulton County Department of Health and Wellness, stated the patient changed his flight plan after he was advised not to travel during a May 10, 2007 family care conference. Health officials knew at this time he had MDR-TB.
  • May 11, 2007 Fulton County Health officials wrote up a medical directive advising Speaker against traveling. A county disease investigator attempted to hand deliver the directive to Speaker at his home and business.
  • May 12, 2007 A county disease investigator attempted to hand deliver the directive to Speaker at his home an business, but learned he had already left the country. He had informed health officials that his departure date was May 14, 2007. Sources confirmed that Mr. Speaker called Air France and asked to leave on an earlier flight.
  • May 17, 2007: Health officials learned that Mr. Speaker has XDR-TB. Sources say he was instructed to go into voluntary isolation in a hospital in Italy. Speaker already knew enough about his diagnosis to have pre-arranged to be treated at National Jewish Hospital with medications and surgery. He had been told he had " chance to get the treatment right."
  • Mr. Speaker was "...appalled..." that the CDC and the government was not going to help him out by footing the $140,000 bill for the private air ambulance.

Thank you alexanderljung for use of photo Partial microscope bacteria view.

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