Search for the Complication

Abstract

A 58-year-old woman was hospitalized for the evaluation of prolonged fever and hemoptysis. She reported an eight-month history of intermittent fevers, a productive cough, shortness of breath, and hemoptysis, which had been evaluated at another hospital. Computed tomographic (CT) scans of the chest revealed peripheral infiltrates in the upper lobe of the left lung and the lingula and a calcified left hilar opacity with additional, small mediastinal lymph nodes. Bronchoscopy demonstrated hyperemic bronchi. A transbronchial biopsy showed fibrinous material in some alveolar spaces, with a few scattered neutrophils, and capillary congestion in portions of the septa. Culture of a bronchial-lavage specimen was positive for a nontuberculous, slow-growing mycobacterium. Staining and culturing were negative for Mycobacterium tuberculosis. A course of amoxicillin–clavulanic acid and a subsequent course of cefuroxime resulted in no apparent benefit. A tuberculin skin test with purified protein derivative (5 TU) was positive, with an induration of 30 mm. The combination of prolonged fever, unilateral pulmonary infiltrates, hemoptysis, calcified hilar lymph nodes, and a positive tuberculin skin test is highly suggestive of active tuberculosis. Although staining and culturing of a bronchoalveolar-lavage specimen were reportedly negative for M. tuberculosis, such results do not effectively rule out this diagnosis; smears of bronchoalveolar fluid are reportedly negative in almost half the cases, and cultures are negative in a quarter of the cases. It would be prudent to have three sputum specimens reexamined for M. tuberculosis despite the negative bronchoscopic findings. Respiratory precautions are needed until active tuberculosis is ruled out. In the absence of underlying immunosuppression or appreciable prior chronic lung disease, the slow-growing mycobacterium on a single culture may represent a clinically insignificant contaminant, but further evaluation is needed. Ten days before the current admission, the patient consulted another pulmonologist, who prescribed methylprednisolone (40 mg per day) and isoniazid (300 mg per day). At presentation to our medical center, she reported increased cough, hemoptysis, pleuritic chest pain, and fever. The patient had a history of hypertension, chronic atrial fibrillation, inflammatory bowel disease, and hypothyroidism that was attributed to the use of amiodarone. She had undergone ablation therapy for atrial fibrillation one year earlier, after which the amiodarone had been stopped. She did not smoke or drink. Her medications on admission were 5-aminosalicylic acid, pravastatin, and levothyroxine.