COMING OUT AFTER A DECADE OF HIDING: A 35-YEAR-OLD FEMALE WITH CHRONIC COUGH AND UNINTENTIONAL WEIGHT LOSS

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Tuberculosis is one of the oldest infectious causes of death in adults, with archeological evidence of Potts disease in bones 9,000 years old. Incidence of tuberculosis in the United States continues to decline even though the pace of decline has slowed in the recent years. Most infections are diagnosed with exposures in the highly endemic, homeless, or prison population. Here we present a case of tuberculosis after a decade of possible exposure CASE PRESENTATION: A 35-year-old female with no prior medical history presented with one-year history of chronic productive cough with brown sputum associated with generalized weakness, dizziness, and shortness of breath. At an outside hospital, she was treated for bacterial pneumonia with continued worsening of symptoms. She also endorsed about 80 pounds of unintentional weight loss in the past year. She denied fever, chills, night sweat, chest pain, palpitations, heartburn, sick contacts, or hemoptysis. She denied any prior or current alcohol or illicit drug and was employed at a convenience store. She denied international traveling but admitted that she was incarcerated in 2010 for six months. She was born at term in the United States without any significant childhood illness. She denied family history of lung disease, tuberculosis, or malignancy. Work up showed extensive cavitary lesions in the left upper lobe and left lower lobe and some bronchiectasis. Sputum acid fact bacilli culture was positive. Human immunodeficiency was negative. Patient was diagnosed with pulmonary tuberculosis and started on appropriate treatment. DISCUSSION: Mycobacterium tuberculosis is most commonly transmitted by droplet nuclei from an infected person. The intimacy, duration of contact, the degree of infectiousness, and the shared environment in which contact takes place are all important determinants of the likelihood of transmission. The majority of active tuberculosis cases manifest soon after infection, rarely occurring more than two years of infection. Reactivation of latent tuberculosis is thought to occur later in life, when immunity wanes from natural aging or immunocompromised states. In our patient, the distinction between primary and reactivation tuberculosis is challenging as she has no recent risk of acquiring tuberculosis and reactivation in relatively young patient with no significant underlying medical problems is uncommon. CONCLUSIONS: In low transmission countries such as the United States, we usually see tuberculosis disease in elderly or in immigrants from high transmission area. Detecting and treating all tuberculosis patients is important to prevent outbreaks and untreated tuberculosis is often fatal. This case illustrates the importance of a wide differential during patient assessment. REFERENCE #1: Behr MA, Edelstein PH, Ramakrishnan L. Revisiting the timetable of tuberculosis. BMJ 2018; 362:k2738. REFERENCE #2: Cain KP, Haley CA, Armstrong LR, et al. Tuberculosis among foreign-born persons in the United States: achieving tuberculosis elimination. Am J Respir Crit Care Med 2007; 175:75. REFERENCE #3: Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L. 1., Jameson, J. L., & Loscalzo, J. (2015). Harrison's principles of internal medicine (19th edition.). New York: McGraw Hill Education. DISCLOSURES: No relevant relationships by Samapon Duangkham, source=Web Response No relevant relationships by Megan Hughes, source=Web Response No relevant relationships by Kenneth Iwuji, source=Web Response No relevant relationships by Cristina Morataya, source=Web Response No relevant relationships by Upama Sharma, source=Web Response No relevant relationships by Divya Vangipuram, source=Web Response No relevant relationships by Alexandra Wichmann, source=Web Response