Contributed by Ryan A. Collins, MD and A. William Pasculle, ScD
The patient is a 22 year old Saudi Arabian male, who has been living in the United States for three years. He initially presented 2 days prior to admission to the emergency department of an outside hospital with cough, night sweats, anorexia, severe fatigue, and an unintentional 90 lbs weight loss over the 6 months prior to presentation. He is a previous smoker (1 pack/day for 8 years), but quit several months ago due to his chronic cough.
He denies any sick contacts, fever, or chills. A purified protein derivative (PPD) skin test recently performed at an outside institution was negative.
The patient had lived in Tennessee when he initially arrived in the US, and has lived in Pennsylvania for the last year. Since his move to Pennsylvania, he has travelled to the Middle East twice to visit family. Most recently, he has not left his apartment in two months due to his incapacitating fatigue.
Chest radiography was significant for bilateral reticular infiltrates and bilateral apical cavitary lesions (Figure 1).
Chest computed tomography demonstrates prominent apical cavitary lesions bilaterally (Figures 2 and 3).
Biopsies taken from the right middle lung lobe demonstrate a necrotizing pneumonia (Figure 4), with foci of epithelioid granulomas (Figures 5 and 6). An acid fast stain performed on the biopsy highlights one acid fast bacillus (Figure 7).
An acid fast stain performed on a smear from bronchoalveolar lavage fluid was positive for bacilli, and culture grew organisms identified as Mycobacterium tuberculosis complex by DNA probe. A Quantiferon TB Gold test was positive. Urine antigen testing for Histoplasma was negative.
The patient was initially placed on a RIPE (Rifampin, Isoniazid, Ethambutol, Pyrazinamide) regimen for treatment as an inpatient. Upon further consideration, the patient and his family decided that he should return home to the Middle East to complete treatment. To allow for sooner travel, rapid sequence-based molecular drug sensitivity testing was requested at CDC. Prior to discharge, however, the patient's liver enzymes increased dramatically (ALT: 429 IU/L, AST: 534 IU/L), and all anti-tubercular therapy was stopped pending the sensitivity results, which were not yet available. He was discharged to home without any medication, as he was living alone at the time.