Missed Opportunities

December 2006

Medical History

A 52 year old Hispanic female presented in January 2006 with left upper quadrant (LUQ) pain. An abdominal x-ray series revealed a density in the left upper lung; there was no hilar, mediastinal or axillary adenopathy. She denied cough, fever or night sweats. She had no prior history of tuberculosis. She immigrated to the US from Mexico 20 years ago and occasionally returns there to visit family. She is a diabetic and a non-smoker. She was referred to the local public health department where a tuberculin skin test (TST) was done and had an induration of 25 mm. Three sputums were negative for M. tuberculosis by direct staining and culture. A CT scan revealed a 2.4 cm slightly irregular cavitary mass in the left upper lobe. After the negative cultures, she was started on a 9 month course of isoniazid (INH) and vitamin B6.

Six months later in August of 2006, a CT showed a thick-walled cavitary lesion. She was referred for thoracotomy and surgical removal of the mass. A left upper lobectomy was performed which showed a thick walled cavitary lesion (4.5 x 3.5 x 3 cm in size) with no evidence of malignancy. The cavitary lesion had focal extension into the surrounding bronchiole. A direct smear was 2+ positive for Acid Fast Bacilli (AFB) on the tissue specimen; Mycobacteria tuberculosis was isolated by culture and confirmed by mycolic acid analysis within 9 days. The patient's physician made a diagnosis of old granulomatous disease (tuberculosis). The patient had an unremarkable surgical recovery; she was discharged with diabetic medication and continued on her INH and vitamin B6. Three repeat sputums were obtained by the local public health department after her release from the hospital; they were all AFB smear and culture negative. The state TB public health department initiated a 4 drug regimen; INH, rifampin (RIF), pyrazinamide (PZA) and ethambutol (EMB); also referred to as RIPE. Subsequently, drug susceptibility studies showed her isolate resistant to INH.

Cavitary Lesion

Three CT scans of cavitary lesion; from left to right: January 26, 2006; February 1, 2006; August 3, 2006

Teaching Points

References

Center for Disease Control and Prevention. Core Curriculum on Tuberculosis: What the Clinician Should Know. Fourth edition, 2000; p. 39-46.

Center for Disease Control and Prevention and New Jersey Medical School National Tuberculosis Center. Guide for Primary Health Care Providers: Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection, 2005.

Dutt, A. K. "Epidemiology and Host Factors" in Tuberculosis & Nontuberculous Mycobacterial Infections, 5th ed. New York: McGraw Hill, Medical Publishing Division, 2006.

Khan, A. E. and Kimerling, M.E. "Chemotherapy of Tuberculosis" in Tuberculosis & Nontuberculous Mycobacterial Infections, 5th ed. New York: McGraw Hill, Medical Publishing Division, 2006.

MMWR. Guidelines for the Treatment of Tuberculosis. June 20, 2003, Volume 52(11): p. 3-10.

Heartland National TB Center
2303 SE Military Drive
San Antonio, Texas 78223
Phone: 1 (800) TEX-LUNG
Fax: (210) 531-4590
http://www.heartlandntbc.org/