RAPID RECOVERY FROM MYCOBACTERIUM TB EPIGLOTTITIS REQUIRING ENDOTRACHEAL INTUBATION

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Laryngeal Tuberculosis (LTb) currently accounts for <1% of all Tb cases. Patients most often present with dysphonia, weight loss, and typically respond well to targeted antimicrobial regimens [1]. To our knowledge, there is minimal data regarding time to liberation from mechanical ventilation and the efficacy of corticosteroids in LTb. We present a case of LTb in a 37-year-old immunocompetent female requiring endotracheal intubation with a subsequent rapid recovery. CASE PRESENTATION: A 37-year-old female presented to the Emergency Department for a 2-week history of dyspnea, and 3 months of intermittent fevers, weight loss, and dysphonia. She had no known past medical history. The patient was febrile, tachycardic, and hypoxic requiring 100% oxygen via non-rebreather mask. Physical exam was remarkable for respiratory distress and mild stridor. Laboratory studies found a leukocytosis of 18.3 K/μL with a neutrophilic predominance to 84%. HIV screening was negative. A CXR revealed bilateral interstitial opacities. Chest CT angiography found diffuse, bilateral centrilobular nodules, tree-in-bud opacities, and bilateral upper lobe cavitary lesions measuring up to 3.9cm (Image 1). Contrast-enhanced Neck CT demonstrated marked swelling of the epiglottis and moderate narrowing of the airway (Image 2). Nebulized racemic epinephrine, albuterol, ipratropium, and IV dexamethasone resulted in mild improvement of her stridor. Transnasal flexible fiberoptic laryngoscopy revealed an enlarged epiglottis with >50% obstruction of the supraglottic airway. She underwent endotracheal intubation for airway protection, and a flexible bronchoscopy was performed. Bronchoalveolar lavage fluid analysis revealed 95% neutrophils, cultures grew Mycobacterium tuberculosis, and cytology was negative for malignant cells. Rifampin, isoniazid, pyrazinamide, ethambutol (RIPE), and pyridoxine were initiated. She also received dexamethasone 6mg IV daily for seven days. Twelve days after intubation, the patient was extubated without signs of stridor. DISCUSSION: LTb has two categories: primary, in which bacteria seed the larynx directly, and secondary, via invasion by advanced pulmonary Tb [1]. Diagnosis is often a combination of visualization of laryngeal lesions via laryngoscopy, tissue culture, and laryngeal histopathology [1]. A review of the literature identified 13 cases of LTb requiring mechanical ventilation, all via tracheostomy. Time to decannulation ranged from 2-6 months, with one case reporting 2 weeks [2]. Data regarding the efficacy of corticosteroids in LTb with airway compromise is limited. However, a recent retrospective study found steroid use in pulmonary Tb with acute respiratory failure to be beneficial [3]. CONCLUSIONS: When treated with appropriate antimicrobials along with consideration to adjunct corticosteroid use, LTb patients may demonstrate a rapid recovery obviating the need for tracheostomy. REFERENCE #1: Benwill JL, Sarria JC. Laryngeal tuberculosis in the United States of America: a forgotten disease. Scand J Infect Dis. 2014;46(4):241-249. doi:10.3109/00365548.2013.877157 REFERENCE #2: Gupta R, Fotedar S, Sansanwal P, et al. Obstructing mass lesion of epiglottis: it can be tubercular. Indian J Tuberc. 2008;55(2):100-103. REFERENCE #3: Yang JY, Han M, Koh Y, et al. Effects of Corticosteroids on Critically Ill Pulmonary Tuberculosis Patients With Acute Respiratory Failure: A Propensity Analysis of Mortality. Clin Infect Dis. 2016;63(11):1449-1455. doi:10.1093/cid/ciw616 DISCLOSURES: No relevant relationships by Nathaniel Allison, source=Web Response No relevant relationships by Christopher Lee, source=Web Response No relevant relationships by John Prudenti, source=Web Response No relevant relationships by Lourdes Sanso, source=Web Response