Destroyed left lung due to multidrug-resistant Mycobacterium tuberculosis

Abstract

A 40-year-old man who was a Syrian refugee presented to the emergency department with a 2-month history of a productive cough and progressive nocturnal dyspnoea after arriving in the Netherlands 6 days before seeking treatment. Physical examination was notable for tachypnoea of 25 breaths/min, hypotension of 100/70 mmHg, and decreased breath sounds on auscultation of the left lung. Laboratory studies showed a C-reactive protein concentration of 51 mg/L (normal <5 mg/L), erythrocyte sedimentation rate of 81 mm/h (normal <15 mm/h), haemoglobin concentration of 11·4 g/dL (normal 13·7–17·7 g/dL), and mean corpuscular volume of 76·7 fL (normal 80–100 fL). One year before this presentation, the patient was admitted in Greece for an acute myocardial infarction. Chest radiography during the admission in Greece showed signs of tuberculosis, which sputum cultures confirmed to be multidrug-resistant Mycobacterium tuberculosis. The patient was treated for 6 months with tuberculostatic drugs and discharged following three consecutively negative sputum cultures. Monthly follow-ups were advised. However, before his first follow-up, the patient was lost to health services for 5 months as he migrated westward without antibiotic maintenance therapy. After presenting to the emergency department in the Netherlands, chest radiography showed opacification of the left hemithorax and right-sided hyperinflation, a chest CT, which included three-dimensional modelling, demonstrated unilateral atelectasis and leftward mediastinal shift (figure and video). Microbiological assessment confirmed relapsed multidrug-resistant tuberculosis, for which the patient received oral, directly observed therapy with 4 months of moxifloxacin (600 mg once a day), 7 months of cycloserine (750 mg once a day), 8 months of amikacin (400 mg once a day), 13 months of co-trimoxazole (960 mg once a day) and rifampicin (900 mg once a day), and 14 months of clofazimine (100 mg 5 times per week), linezolid (300 mg once a day), protionamide (750 mg once a day), and rifabutin (300 mg once a day). Within 3 months of treatment, the patient's sputum cultures became negative for M tuberculosis; and 6 months later, the patient underwent a pneumectomy of the destroyed left lung. During the past 5 years of follow-up, there has been no tuberculosis recurrence. Considering tuberculosis disproportionately impacts the global migrant population, clinicians should consider proactively screening the lungs of people who are migrants upon entry to the country to avert the debilitating sequelae of multidrug-resistant tuberculosis.