Extensively Drug-Resistant Tuberculosis, Lesotho

To the Editor: Reports of extensively drug-resistant tuberculosis (XDR TB) in the Republic of South Africa have generated concern in the medical and public health literature (1,2). Given that XDR TB is spread through the air, it is not surprising that cases have been reported in multiple countries throughout the world (3). We report a documented case of XDR TB in Lesotho. This case is closely tied to transnational work in South Africa, thus raising concern about the spread of this disease across highly porous borders and the need for international attention to migrant worker health. Lesotho is a mountainous nation that is home to 2 million people and completely surrounded by South Afri-ca. It has the third highest rate of HIV in the world; an estimated 24%–30% of the population is infected (4). Le-sotho also has a high prevalence of TB with an estimated 695 cases per 100,000 population (5). Ten percent of patients with smear-positive TB are estimated to have multidrug-resistant TB (6). The US Centers for Disease Control and Prevention is undertaking a national reporting registration survey in Lesotho. In 2007, the Ministry of Health and Social Welfare began working with Partners In Health and the Foundation for Innovative and New Diagnostics, Geneva, Switzerland, to document and treat drug-resistant TB in Lesotho. Hundreds of cases of drug-resistant TB have been reported in the country, and the patient we describe in this letter was reported to have XDR TB. The patient was a 44-year-old man who had been working in the gold mines in South Africa. He had a history of receiving multiple treatments for TB while he was working in one of the mines. His condition was declared a treatment failure in July 2007. The patient was discharged from medical care in South Africa with no follow-up plan or medical records and was told, per his report, to " return home. " He traveled by road and bus to Lesotho and easily crossed the border. He was originally seen at a public TB clinic in Lesotho but, given his reports of prior TB treatment, his sputum was sent for culture and drug susceptibility testing. He was followed up at his home with a daily visit from a village health worker trained in the management of drug-resistant TB. When XDR TB was confi rmed (in vitro resistance to at least isoniazid, rifampin, a fl uo-roquinolone, and an injectable …