A Homeless Alcoholic Patient with
TB
Marcos Burgos M.D.
Medical Director Tuberculosis Program, NM DOH
Department of Medicine, Veteran Affairs Medical Center, The
University of New Mexico School of Medicine, Albuquerque, NM.
October 23, 2012
Durango, Colorado
TB case
 November 2008 paramedics brought to the ER a
52 year old Navajo man that was found on the
streets acutely intoxicated with ETOH.
 In the ER the patient had an alcohol level of 325
 On evaluation, the patient was found to have a
chest X-ray with a large left apical cavity.
 The patient gave a history of homelessness,
history of tuberculosis treatment in the past and
a current cough and weight loss of a couple of
months duration
CXR/CT
TB case
 Multiple sputum samples were found to be 4+ for
AFB and MTB complex probe positive.
 He was admitted to the Medical Intensive Care Unit
for management of alcohol withdrawal, and he was
started on 5 drugs: isoniazid, rifampin, ethambutol,
pyrazinamide and moxifloxacin for presumed
tuberculosis disease and superimposed
pneumonia.
 The tuberculosis programs was notified and the
patient was interviewed and records reviewed
What other information will you want to know?
• What treatment did the patient get in the
past?
TB case - PMH
 The patient is homeless and an alcoholic for
most of his adult life
 February 1992 the patient was diagnosed with
pulmonary tuberculosis in Utah and was started
on IRP
 November 1992 readmitted to McKay-Dee
Hospital in Ogden, Utah
 Patient left against medical advice and lost again
to follow up
TB case - PMH
 April 1993 readmitted in with a febrile illness,
hypoxia and shortness of breath and a chest
X-ray with a miliary pattern
 The patient again lost to follow up and
because of poor compliance the patient is
court ordered to receive treatment under DOT
in Oct. 1993.
 The patient’s tuberculosis isolate from May
5, 1993 was susceptible to all drugs
TB case - PMH
 In addition to Ogden, Utah, the patient
received treatment in Boise, Idaho, and in
Eugene, Oregon where he completed
treatment for pulmonary TB in January 1994
 There are no records of the type of treatment
he received.
 After this episode of tuberculosis, he was
evaluated in California and Colorado for active
tuberculosis in 2001 and 2003.
TB case
 A sputum sample was sent to the California
State Laboratory for rapid susceptibility
testing (molecular beacons).
 Rapid susceptibility results became
available on November 22 and the M.
tuberculosis isolate was found to have
resistant mutations for isoniazid and
rifampin (MDR-TB)
MDR-TB case
 MDR-TB treatment: ethambutol 1200 po QD,
pyrazinamide 1250 po QD, cycloserine 250 mg po BID,
ethionamide 500 mg po BID, moxifloxacin 600 mg po
QD and amikacin 1000 mg IV TIW.
 In addition to MDR-TB disease, the patient was found by
psychiatry to be ETOH dependent with a depressive
disorder.
 The patient refused referral to an alcohol treatment
center.
 Susceptibility results by standard methods were still
pending.
Can we treat this case as an
outpatient?
MDR-TB case
 The patient was deemed a poor candidate for
outpatient treatment
 Potential risk to public health
 History of non-adherence to treatment for TB
disease
 History of homelessness and an alcohol abuse,
both commonly associated with non-adherence.
 The patient remained in the hospital after he was
determined to be non-infectious as the program
struggled to prepare for the next phase of his
treatment
MDR-TB case
 TB program has limited resources to retain
high risk patients and provide a regimen for
MDR TB
 DOH worked together with HIS to come up
with the funds to pay for an inpatient facility
 In the past New Mexico had a similar case for
which IHS and DOH split up the cost for an
inpatient treatment of a MDR-TB case at the
Center for Infectious Diseases (TCID) in San
Antonio, Texas.
TB case
 The results of drug susceptibility testing by
standard methods took more than 8 weeks to
become available
 The drug susceptibility results showed that the
isolate was susceptible to all primary and
secondary drugs
 Due to the discrepancies in results from
standard methods and the rapid method, the
initial culture was sent to the California State
Laboratory for molecular beacons
 The isolate did not have any resistant mutations
TB case
 The patient was no longer infectious
 He was started on isoniazid, rifampin, and
pyrazinamide and the patient was discharged
from the hospital to a motel room arranged
and paid by the TB control program.
 The patient started receiving his treatment
under DOT with close follow up by the TB
program
 The patient completed additional 6 months of
treatment
TB case
 The diagnosis of TB opened the door for the
development of a trusting relationship with
the TB program that eventually allowed him
to stay sober and obtain an apartment
 The cost of his hospitalization: $160,000
Tuberculosis
in an Urban Setting
M. Frances Vasquez, M.S.
Tuberculosis Case Manger
Stanford Public Health Office
Albuquerque, NM
Initial Situation
Phone call, we have a new client
at Lovelace Hospital
 Help him apply for
General Assistance
 Apply for Institutional level care
 He may qualify for D&E Waiver

General History
 First DOT on 11-03-2008.
 Age: 51
History of Alcoholism and
Homelessness
BAC was .325 when admitted.
Client was malnourished and gave a
history of previous injuries and
hospitalizations.
First Visit
 Met client on 12-22-08 wearing my
endearing ensemble of N-95 mask,
gown and gloves
 I am one of 3 or 4 people in the room
talking to him.
 He receives lots of information but
speaks very little.
Homework
 GA is $266 per month
 Needs photo ID for Food Stamps
 Needs Birth Certificate – no record in NM system
 Ageing and Long Term Services stated wait list is
over 2 years; do not think my client would qualify
 If found incompetent, check out guardianship.
 Homeless shelters may be best option for persons
w/o an income.
Surprise!
 On visit to client on 11-12-08, he told Dr.
Burgos that he finished his TB medicine in
1994 in Eugene, OR.
 Stated he started treatment in Ogden, UT.,
then moved to Boise Idaho and then completed
treatment in Oregon.
 Arrived in ABQ two weeks ago from Kingman
AZ and before that he lived in Phoenix.
 BAC was .325 when admitted.
04-23-09
 Phone call received from sister.
 Reported that mother had active TB
in 1950’s and was treated in a
sanatorium in Albuquerque.
a
 Around this time client given neuropsychological
evaluation. Found incompetent. Makes our job
easier.
 Sister calls and complains that the neuropsych
eval needs to be in Navajo, his native language.
 Navajo interpreter difficult to find. Finally I
recruit our WIC clerk from Cuba to come and
interpret. Client refuses to use her!
 Client is more cooperative and responsive during
second evaluation and is found to be competent.
Building Rapport and Trust
 01-07-09 Inquired about ID. Client stated that
he has no documents on his person or in his
wallet.
 Began to stop in when time permitted to spend
time with client and make small talk. I asked
him if there was anything he was craving.
 Began to bring burritos from home or snacks.
One day he told me he had an AZ ID
and a Social Security card!
I felt like . . .
Isolation
 Client was in isolation about 4 months.
 Had lots of time to think about his
situation and his life.
 Decided to quit drinking while in
hospital.
 Requested, and was given,
double portions of food.
 Spent his time watching TV and he
seemed to enjoy the newspaper.
 Revealed he could only read some of
the words in the newspaper.
 Once client was coming to office for
DOT, I began to tutor him in reading.
Meeting with Key Stakeholders
 Question as to how to proceed once found
competent.
 Meeting with hospital staff, DOH attorneys,
Indian Health Service, TB Staff, MD’s
regarding payment for services if client was
sent to Heartland in TX.
 Everyone had their iron in the . . .
Upon Release
 Was set up in hotel to complete DOT.
 Set up with a few utensils for cooking.
 When no long infectious used local services for
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homeless for food, bus passes, clothes, etc.
Eventually received GA
Eventually received Social Security
Found low-income housing for client.
Has been clean and sober since he was
hospitalized at the end of 2008.
Post Treatment
 I became his representative payee
for Social Security.
 He did continue to receive reading
tutoring for several months.
 He lives independently and is still
clean and sober.
 He lives a fairly isolated life but
manages his life well.
Good Outcome!
A homeless alcoholic patient with
TB
Marcos Burgos M.D.
Department of Internal Medicine, Division of
Infectious Diseases, UNM SOM
Medical Director TB Program, DOH NM
Durango, Colorado