Multi-drug resistant tuberculosis in pregnancy: need for more intensive treatment.

An approved treatment regimen for multi-drug resistant tuberculosis (MDR-TB) patients during pregnancy does not exist to this day. The main reason for the lack of information in this area is the small number of patients and insufficient studies regarding the safety of the second-line drugs during pregnancy on the mother and the fetus [1]. This case report highlights the difficulties associated with MDR-TB. In December 2003, an 18-year-old Afghan woman was admitted to our center on complaints of cough, sputum, and dyspnea. The patient had a history of two periods of anti-TB treatments (Cat I and Cat II) in the past two years. Despite two years of anti-TB treatment the patient’s mother died secondary to TB. The patient’s chest X-ray demonstrated opacity accompanied by a cavity in the middle-upper lobe of the right lung, and alveolar infiltration together with nodular densities in the lower lobe of the left lung. Sputum smear was positive for Koch’s Bacillus (BK). An empirical regimen for MDR-TB was commenced because of a positive smear of sputum for BK (Ofloxacin, high-dose Isoniazid, Amikacin, Clofazimin, Pyrazinamid, and B6). After completion of five months of therapy, sputum smear and culture results were negative again. The performed chest X-ray at this stage demonstrated a decrease in the size of the right cavitary lesion. Considering the results of the patient’s drug susceptibility test, which demonstrated resistance to the four drugs Isoniazid, Rifampin, Ethambutol, and Streptomycin, and sensitivity to Pyrazinamid, the treatment regimen was continued. Earlier in the treatment the patient was advised to refrain from becoming pregnant and educated regarding the potential teratogenic side effects of anti-TB medications on the fetus and the need for up to 18 months of further treatment. In January 2005 despite this recommendation the patient was pregnant in the eighth week. Termination of the pregnancy was discussed and declined by the patient and her partner. The patient and her partner decided to proceed with the pregnancy accompanied by treatment of the patient’s MDR-TB. In March 2005, at 20 weeks gestation, cough, sputum, and dyspnea appeared once again. Sputum smear resulted positive for BK. The treating physicians decided to add three new drugs including Co-Amoxiclave, Amikacin and Prothionamide to the regimen. After the addition of the drugs, the smear and culture became negative once again. The culture and smear sensitivities demonstrated results similar to the prior one. Anomaly scans performed twice at 14 and 30 weeks gestation were normal. Maternal serum screenings were not performed. The patient at 38 weeks gestation had a successful vaginal delivery of a healthy 3 kg baby with apgars of 9 and 10. Pediatric review of the new born baby was normal. Three gastric-washes resulted negative and a chest X-ray appeared normal. The infant was treated with Ethambutol and Pyrazinamid for two months postnatally. Following this course of treatment a PPD test was performed which was negative. In accordance with national guidelines the infant was vaccinated with BCG. The mother was prescribed Pyrazinamid, Ofloxacin, Amikacin, Cycloserin, Prothionamide, Co-Amoxiclave and B6. Anti-MDR-TB treatment for the mother was continued for 18 months after the negative culture. Following general improvement in health and partial improvement of the chest X-ray, treatment stopped and the patient was pronounced cured. The infant, who is now 15 months old, is completely healthy and demonstrates normal growth. Treatment of TB during pregnancy has been implemented in accordance to various treatment guidelines [2, 3]. Treatment in this case is a complicated one. Some studies recommend the use of the second-line drugs after pregnancy [4]. This is due to the fact that the side-effects of the second-line drugs are not entirely known or characterized. This has impeded the prescription of some drugs by physicians. Considering the high mortality and morbidity of infant TB and the complicated treatment of MDR-TB in infants, treatment of pregnant MDR-TB patients could be used as an important measure to prevent congenital TB [5, 6]. On the other hand, it is worth considering that in addition to the potential outcomes of congenital MDR-TB, delayed treatment of pregnant