Case Studies

August 2012 ■ Pediatric TB: What to Expect and When to Expect it

Case History 12/18/2010—A 34 year old Hispanic male was diagnosed with pulmonary tuberculosis based on clinical findings, positive AFB sputum smears and a Nucleic Acid Amplification test (NAAT) positive for M. tuberculosis. During the course of the subsequent contact investigation three pediatric contacts were identified aged 11 months, 4 years old and 15 years old. The contacts were the case's children and had been co-habitating with him.

Full printer-friendly version
(PDF  ▣  943 KB)
HTML version »

November 2011 ■ Case History

On 9/8/2010 a 27 year old Hispanic man was admitted to a psychiatric facility for treatment of undifferentiated schizophrenia. The patient received treatment with risperidone 3 mg daily. The patient’s psychiatric issues were well controlled and he tolerated the medication well.

Full printer-friendly version
(PDF  ▣  481 KB)
HTML version »

August 2011 ■ Case History

A 40 year old Native American male with a 1 year history of untreated HIV infection presented with shortness of breath, productive cough and fever of 6 weeks duration. He was noted to have cervical and axillary lymphadenopathy on exam. The chest radiograph showed densities compatible with interstitial pneumonitis and his sputum was acid fast bacilli (AFB) smear and culture positive for M. tuberculosis which was susceptible in vitro to all first line antituberculosis medications. An axillary lymph node biopsy showed caseating granulomas with numerous acid fast bacilli consistent with TB lymphadenitis. The CD4 count was 131 cells/ul. Following initiation of treatment with standard antituberculosis therapy, INH, rifampin, ethambutol, and PZA daily, his symptoms progressively improved. Two weeks after starting TB medications, Atripla (combination tablet consisting of efavirenz, emtricitabine, and tenofovir) was added.

Full printer-friendly version
(PDF  ▣  302 KB)
HTML version »

November 2010 ■ Tuberculosis Pleural Effusions and a Case of Empyema Necessitatis

A 15 year old pregnant female presented to the emergency department of a local hospital with respiratory distress at 32 weeks gestation. She had failed to gain weight appropriately during her pregnancy and throughout her thrid trimester of pregnancy had cough, shortness of breath and night sweats.

Full printer-friendly version
(PDF  ▣  263 KB)
HTML version »

June 2010 ■ Determining Treatment Options with Limited Documentation

Case History: A 62 year old woman from Mexico was referred to the local health department in November 2009 with a positive Tuberculin Skin Test (TST) (22 mm), and an abnormal chest x-ray. Radiography indicated pulmonary parenchymal scarring with no pleural effusion and multiple calcified granulomata. Three sputa samples obtained in August, December, and January, were all smear and culture negative. The patient was asymptomatic, but revealed during intake that she was diagnosed with tuberculosis (TB) thirty-two years before and was treated for one year. Also noted was a partial lung resection in Mexico 7 years earlier, reason unknown.

Many concerns were raised in regards to the adequacy and completeness of the patient’s previous TB treatment given the lack of medical documentation and incomplete history.

Full printer-friendly version
(PDF  ▣  39 KB)
HTML version »

December 2009 ■ Using Genotyping to Confirm a Suspected Case of Tuberculosis Cross Contamination

Case History: Patient A was a 45-year old US-born white female with a six month history of illness characterized by a twenty pound weight loss, dry cough, shortness of breath (SOB), and chest pain. She was seen by a physician on December 12, 2003 to evaluate a spontaneous pneumothorax and rule out lung cancer. A Computed Tomography (CT) of her chest revealed large bilateral cavitary lesions. She underwent a bronchoscopy exam on December 19, 2003. An acid-fast bacillus (AFB) smear-positive specimen was obtained using bronchial-alveolar lavage (BAL). The sputum was culture-positive for Mycobacterium tuberculosis, and on February 20, 2004 Mycobacterium tuberculosis was isolated from her BAL and sputum. The isolated organism was pansensitive. She was started on isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and ethambutol (EMB) at the time of her TB diagnosis and received nine months of treatment due to her large cavitary lesions and advanced TB disease.

Full printer-friendly version
(PDF  ▣  172 KB)
HTML version »

March 2009 ■ Utilizing Mental Health Assessments to Improve TB Outcomes

Case History: A 48 year old Caucasian male was diagnosed with pulmonary tuberculosis in May 2006. The patient's initial isolate was resistant to isoniazid, ethionamide, levofloxacin, ofloxacin, and moxifloxacin. The patient had a history of head injuries and a seizure disorder with reports of personality changes present since 1999. Patient was HIV and Hepatitis C positive. Previous history also included cocaine and alcohol dependence with IV drug use.

Full printer-friendly version
(PDF  ▣  260 KB)
HTML version »

December 2008 ■ *UPDATED 11/2013* The Use of Interferon-Gamma Release Assays in a Contact Investigation

Case History:
A 23 year old university student from Africa was diagnosed with active TB disease in April 2008. The patient presented with an infrequent productive cough and no other symptoms. His tuberculin skin test (TST) was 15mm and chest radiographs were abnormal. His sputum was acid-fast bacillus (AFB) smear negative but culture positive for Mycobacterium tuberculosis. His specimen was pansensitive and he was started on four drug therapy May 2, 2008. A contact investigation was started with his closest contact being a US-born roommate who was TST negative on initial testing. As a precaution, further close contacts were tested including 11 friends, 15 classmates and 5 professors. Initial and follow up testing found that 20/31 (64.5%) were TST positive.

Full printer-friendly version
(PDF  ▣  230 KB)
HTML version »

December 2008 ■ The Impact of Nutrition on TB Treatment Outcomes

Case History:
A 49 year old male was diagnosed with recurrent pulmonary tuberculosis after presenting to an emergency room with a 3 month history of malaise, chills, subjective fevers, shortness of breath, productive cough; and weight loss over the past year. A sputum specimen was positive for AFB and grew M. tuberculosis susceptible to all first line drugs. The chest radiograph was abnormal with bilateral patchy alveolar opacifications in the upper lobes and a CT scan of the chest noted tree-in-bud parenchymal opacifications and consolidation bilaterally, cavitation in the right apex and right lower lobe, and diffuse centrilobular nodules in both lungs. The patient was coughing and appeared malnourished and chronically ill. His height was 5'7 ½" and weight at diagnosis was 114 lbs. His BMI was 18 (underweight). Labs indicated anemia, with a borderline low serum folate level (3.6, normal > 5.4), and iron deficiency (iron 28, normal range 50-160).

Full printer-friendly version
(PDF  ▣  263 KB)
HTML version »

October 2008 ■ Hookah Smoking: A Rising Tuberculosis Health Risk Behavior

Case History: A 20 year old Russian university student, who had entered the United States 2½ years earlier, was diagnosed with extremely drug resistant tuberculosis (XDR TB).

Full printer-friendly version
(PDF  ▣  291 KB)
HTML version »

June 2008 ■ Adherence Difficulties in a Child with Tuberculosis

Case History: A 15 month old child with active pulmonary tuberculosis became a significant management challenge to his public health nursing providers because of his consistent refusal to take medications.

Full printer-friendly version
(PDF  ▣  132 KB)
HTML version »

December 2007 ■ Tuberculosis in an Adoptee

Case History:
A 6-year-old girl presented to her pediatrician with decreased hearing acuity found by routine elementary-age screening. She had been adopted from a Korean orphanage at 9 months of age and had a history of poor growth there. She had scarlet fever and pneumonia prior to the age of 4, but no other recent significant illnesses since adoption. Adoption records did not indicate vaccination with BCG and she had no vaccination scar. She had four documented Tine tests (multi-puncture test for TB infection) during the adoption process, all of which were negative. She had a Tine test at a community hospital prior to presenting to her physician, results of which are unknown.

Full printer-friendly version
(PDF  ▣  111 KB)
HTML version »

November 2007 ■ Primary Tuberculosis Following Exposure

Case History:
A twenty year old woman was evaluated as a contact of a patient who had extensive smear positive pulmonary tuberculosis (drug susceptible isolate). She denied any symptoms of cough, weight loss, fatigue, night sweats or fever. She weighed 86 pounds. A TST was positive with a 20 mm induration. A chest x-ray (CXR) showed opacification of the lower half of the left hemithorax reflective of a moderate size left pleural effusion and/or atelectasis. She had normal laboratory values. She was not able to provide a sputum specimen.

Full printer-friendly version
(PDF  ▣  106 KB)
HTML version »

September 2007 ■ Delayed Culture Conversion, Low Serum Drug Levels

Case History: Our patient is a 54 year-old male who presented to his physician for follow up of a right upper lobe carcinoma which was ressected in 1979. He complained of shortness of breath, weight loss, fatigue, chest pain and a productive cough but no hemoptysis. A chest x-ray on June 20, 2006 revealed new bilateral alveolar infiltrates. He was referred to a pulmonologist and admitted to his hometown hospital on June 20, 2006. Smears were positive for acid fast bacilli and a CT scan June 22nd showed cavitation in the left upper lobe, bilateral infiltrates and mediastinal adenopathy. He was placed on anti-tuberculosis therapy—isoniazid (INH) 300 mgs, rifampin (RIF) 600 mgs, pyrazinamide (PZA) 1500 mgs and ethambutol (EMB) 1600 mgs daily with vitamin B6 50 mgs. Directly Observed Therapy (DOT) was started on July 7, 2006; given Monday through Friday with self-administration on the weekends. His culture grew Mycobacterium tuberculosis and was susceptible to INH, RIF and EMB.

Full printer-friendly version
(PDF  ▣  130 KB)
HTML version »

March 2007 ■ Failure to Convert: Non Adherence to Treatment

Case History: A 67 year old Hispanic male was diagnosed with drug susceptible pulmonary tuberculosis in September 2005. He presented with a three week history of night sweats, weight loss, nausea, shortness of breath and a productive cough. A chest x-ray (CXR) showed extensive bilateral cavitary disease. He was Hepatitis C positive with elevated baseline liver enzymes; HIV testing was negative. Sputum smears were AFB positive with greater than 10 organisms per high powered field. The patient's weight at diagnosis was 96 lbs.

Full printer-friendly version
(PDF  ▣  123 KB)
HTML version »

December 2006 ■ Missed Opportunities

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.

Full printer-friendly version
(PDF  ▣  240 KB)
HTML version »

September 2006 ■ Evaluation and Management of Childhood Contacts to Infectious Pulmonary Tuberculosis

(REVISED Nov. 22, 2006)
Patient History:
A 31 year old male was admitted to the hospital after experiencing gross hemoptysis. He had a 2 month history of productive cough, a 25 pound weight loss, night sweats, and fatigue. A chest x-ray (CXR) revealed bilateral cavitary infiltrates. The initial sputum specimen was 4+ positive for acid fast bacilli (AFB) and a genetic probe assay confirmed Mycobacterium tuberculosis. A culture was positive for M. tuberculosis which was later reported to be resistant to INH and streptomycin. The patient has a history of heavy alcohol and drug use, is HIV negative but Hepatitis B and C positive. He has a long history of cigarette use and a chronic smoker's cough. The patient resides with his wife and 3 children (2 are step-children). [Original case presentation] :: [Original newsletter]

Full printer-friendly version
(PDF  ▣  67 KB)
HTML version »

June 2006 ■ Abdominal Tuberculosis

Patient History: A 27-year old Hispanic female presented to hospital on January 27, 2005 with a fever of 104°, a two week history of abdominal swelling, decreased appetite and body aches. She was admitted for diagnostic testing and follow-up.

Full printer-friendly version
(PDF  ▣  551 KB)
HTML version »

March 2006 ■ TB in a Patient Receiving Immunosuppression Including a TNF Alpha Blocker

Patient History: A 55-year old female emigrated from El Salvador in the mid 1980s. She had been employed by a poultry processing plant for 15 years (high risk environment associated with TB transmission). Medical history included a diagnosis of rheumatoid arthritis which was treated with prednisone 20 mgs twice daily, methotrexate and Humira (adalimumab-a tumor necrosis factor alpha blocking agent (TNFa)).

Full printer-friendly version
(PDF  ▣  44 KB)
HTML version »

Request an archived case study