Multiple-drug resistant cavitary pulmonary tuberculosis is the common difficulty and most threaten TB source of infection, which constitutes of the serious threat to TB control plan. Unfortunately, extensive drug-resistant TB was detected not only anti-isoniazid and rifampicin, but also secondary anti-TB drugs (capreomycin, kanamycin, amikacin) and fluoroquinolones, making it to be the “incurable” disease. Since 1997, we have investigated the percutaneous lung puncture protocol and achieved better outcomes in treating each kind of hard-to-treat tuberculosis including chronic cavitary pulmonary TB (1
), MDR-TB (2
) and pulmonary tuberculoma (3
The protocol of percutaneous lung puncture was following: the position, puncture point and depth was determined under the guidance of CT. 2% Lidocaine (5 mL) was used for local anesthesia. 22 G lung puncture needle was selected, and pointed in the cavity after CT determination to inject isoniazid (0.1 g), amikacin (0.2 g). CT scan was performed after needle expelling to exclude pneumothorax. The patient was asked to lie down for two hours after operation. The protocol was repeated once a week, tenth as a course.
The XDR-TB in this case derived from originated multiple drug resistant tuberculosis (MDR-TB), and had no satisfactory results due to drug resistance in spite of regular anti-TB treatment. The characteristic of that disease is fibrosis cavity, where TB amount is about 1×107
, and at their active growth stage (1
). Routine administration could not infiltrate to cavity because of barrier effect of fibrosis cavity and surrounding vessels’ closure. In this way, the minimum inhibitory concentration (MIC) could not be achieved, and septum bacteria test is hard to be negative. However, percutaneous lung puncture could inject the drug directly to the cavity and lesion, letting drug kill the TB and making the local concentration reach tens and hundreds times than aforementioned MIC. The drugs eroded the cavity wall and accelerated the excretion of cheese lesions. Multiple injects might reduce the barrier effect of cavity and the drug could infiltrate to surrounding lesions through needle canal, which would facilitate the granulation tissue rehabilitation and cavity purification.
Isoniazid is the first-line general fungicides, with low molecular weight, high infiltration ability, less side effects, thus is the first-of-choice for TB. Amikacin is a highly-efficient antibacterial drug, and it has similar effect to aminoglycoside antibiotics resistant bacteria with lesser side effects compared to streptomycin and kanamycin. Therefore, the combination of isonizid and amikacin is more ideal.
The cure standard for MDR-TB was defined as continuous septum culture negative results at least for five times during the last 12 months of treatment process, with each interval for 30 days.
The patient not only met above criteria, and septum smear and TB culture results all were negative during 4 years of follow up, which meant totally cure. Presently, it’s still lack of valid chemotherapy to XDR-TB and novel anti-TB drugs, thus making the choice limited for physicians and the chemotherapy schedule could only base on principles of MDR-TB, resulting in therapy course over 24 months. By the mean of lung puncture, only one year is enough. Our case also demonstrates that staffs in hospital are belongs to XDR-TB susceptible population, which needs to be cautioned.
Tang et al
. reported (4
) the prevalence, clinical characteristics and treatment outcomes of XDR-TB and found that 126/1,156 (10.9%) were XDR-TB in a specialist TB hospital in Shanghai and the clinical treatment outcome of XDR-TB is usually very poor. We are devoted to explored XDR-TB therapy for several years and firstly applied percutaneous lung puncture to injected anti-TB drugs directly to the lesion of XDR-TB and more importantly the septum smear and TB culture results all were negative during 4 years of follow up.