Management Tactics for Patients with Combined Cavernous Tuberculosis with Multidrug Resistance/Extensive Drug Resistance and Macleod Syndrome (Clinical Case)

Abstract

Our own observation of a case of combined cavernous tuberculosis with multidrug resistance (MDR-TB) and extensively drug resistance (XDR-TB) and MacLeod syndrome is presented. Our aim was to determine the managing tactics of such patients. MDR-TB with a cavity in the upper lobe of the left lung was first diagnosed in the patient 5 years ago and MacLeod syndrome was diagnosed in the right lung (a thin-walled emphysematous bulla measuring 88.5 х 54.2 х 45.2 mm in diameter in the upper third of the subpleural mediastinal pleura). At the end of the intensive phase, after 6 months of treatment, the patient developed massive bacterial excretion and additionally developed resistance to ethambutol. X-rays revealed the formation of fibro-cavernous tuberculosis in the upper lobe of the left lung (several destructions with thickened walls, some of them deformed, with significant fibrous changes around them); bullous dystrophy with several dense foci was detected in the right lung. Considering the negative dynamics, the patient was operated on: left upper lobectomy, atypical resection of S6 of the left lung. The patient completed treatment with residual changes in the form of metatuberculous fibro-focal changes in the lungs and the condition after surgery. No actions were taken regarding MacLeod syndrome. The patient had stable clinical and radiological dynamics for 5 years, which indicated the high effectiveness of surgical intervention in addition to antimycobacterial therapy (AMBT). COVID-19 provoked reactivation of a specific process after 5 years, which turned into XDR-TB due to additional resistance (bacterial excretion was one-time, and foci were identified on the X-ray). At the same time, the patient still had grade II pulmonary insufficiency, as 5 years ago, and the number of emphysematous bullae increased, measuring 7—46.6 mm in diameter on the anterior surface in the right lung. Considering the negative dynamics of MacLeod syndrome, the patient needs to undergo an operation to reduce the volume of the upper third of the right lung. Thus, the management tactics for patients with a combined course of cavernous MDR-TB/XDR-TB and MacLeod syndrome, when AMBT fails, are as follows: in the presence of bacterial excretion after 4—6 months of treatment and a cavernous process, consider the possibility of additional surgical intervention (lobectomy, resection, etc.); in the presence of MacLeod syndrome, consider the possibility of additional surgery to reduce the volume of the affected part of the lung.