Intended for healthcare professionals

Endgames Case Report

Persistent Baltic cough

BMJ 2010; 341 doi: (Published 01 September 2010) Cite this as: BMJ 2010;341:c3756
  1. E Moran, clinical lecturer, specialist registrar in infectious disease1,
  2. A McGown, consultant in respiratory medicine2,
  3. C Conlon, consultant in infectious disease1
  1. 1Department of Microbiology and Infectious Disease, John Radcliffe Hospital, Oxford
  2. 2Department of Respiratory Medicine, Royal Berkshire Hospital, Reading
  1. Correspondence to: E Moran ed.moran{at}

    A 22 year old female Lithuanian student studying in the United Kingdom presented to her university’s health centre on several occasions over a three month period starting in May 2008. She had moved to the UK in 2004 and had received the BCG vaccination some years previously. She described cough productive of sputum and night sweats, and she was given three courses of antibiotics that had little effect.

    By August 2008, the patient had lost 4 kg in weight and was referred to her local hospital. On examination the only findings were a temperature of 37.6°C and a mild expiratory wheeze. Chest radiography showed a small patch of left upper lobe consolidation. Sputum was collected for examination, and she was treated empirically with doxycyline and co-amoxiclav. She was HIV negative.

    The patient was seen in the chest clinic the following week and informed that sputum microscopy had shown acid fast bacilli. She was started on rifampicin, isoniazid, pyrazinamide, ethambutol, and pyridoxine. Sputum culture confirmed Mycobacterium tuberculosis shortly afterwards.

    Review two weeks later suggested that the patient was improving. One month after starting therapy for tuberculosis, the clinic was contacted by the National Mycobacterium Reference Laboratory and informed that the patient’s isolate was resistant to all tested first line drugs. All four anti-tuberculous agents were stopped pending further sensitivity data. Three weeks later, the National Mycobacterium Reference Laboratory issued a further report confirming resistance to all fluoroquinolones and kanamycin sulphate.


    • 1 How is drug resistant tuberculosis defined and how would you classify this case?

    • 2 How would you manage this patient?

    • 3 What measures should be taken in the interests of public health?

    • 4 What is the prognosis for patients with drug resistant tuberculosis?

    • 5 What are the risk factors for multidrug resistant tuberculosis in the UK?

    • 6 How might the …

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