TB-INDUCED BRONCHIECTASIS IN A HISPANIC MALE WITH COMMON VARIABLE IMMUNODEFICIENCY AND CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR CARRIER

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Bronchiectasis is a chronic condition characterized by irreversibly dilated bronchi leading to a debilitating respiratory syndrome with excessive sputum production and recurrent infections. The presence of radiologic findings of bronchiectasis should alert clinicians to explore other causes including congenital defects, chronic inflammation, immune deficiencies, opportunistic infections and assess functional lung capacity as multiple etiologies contributed to bronchiectasis in our patient. We present the case of a middle-aged Hispanic male diagnosed with bronchiectasis in the setting of active Mycobacterium tuberculosis (MTB), common variable immunodeficiency (CVID), and cystic fibrosis carrier. CASE PRESENTATION: A 44-year-old Hispanic male with a history of SARS-CoV 2 infection presented with worsening cough and fatigue. He reported subjective fever, night sweats, weight loss, and yellowish sputum production. CT chest showed diffuse bronchial dilatation and thickening, diffuse bronchiectasis, multifocal cavitary lesions in bilateral upper lobes, and tree in bud nodularity. QuantiFERON-TB Gold was indeterminate. However, acid fast bacilli was seen on smear and culture. PCR confirmed MTB complex. He was found to have low IgG and IgM levels 661 and 26 respectively. Genetic testing showed a heterozygous cystic fibrosis transmembrane conductance regulator (CFTR) D508 gene mutation. He was treated with quadruple therapy with rifampin, isoniazid, pyrazinamide, ethambutol and referred to an immunologist for immunoglobulin therapy. DISCUSSION: Bronchiectasis is a cycle of airway damage creating an environment conductive to chronic colonization of bacteria causing an inflammatory response leading to further injury. Our biggest diagnostic challenge was to determine if bronchiectasis was due to an infection or developed due to an underlying predisposition. His clinical symptoms were worrisome for tuberculosis;however, diffuse bronchial dilation was concerning for other concurrent pathologies which warranted further work up. Bronchiectasis may be classified as cystic fibrosis induced bronchiectasis and non-cystic fibrosis bronchiectasis (NCFB). Cystic fibrosis is an autosomal recessive disorder. While bronchiectasis is classically associated in CF patients, it has also been reported in patients having one gene mutation, like our patient. Furthermore, MTB and CVID are also documented causes of bronchiectasis. Pharmacological treatment is challenging and depends on the etiology. However, non-pharmacological treatment, such as chest physiotherapy centered on mobilizing and eliminating mucosal secretion, is used to manage bronchiectasis. CONCLUSIONS: The rise in the incidence of bronchiectasis in the US annually demands the understanding of the disease's etiology and characteristic features as effective treatment is directed towards its cause. REFERENCE #1: Lesan, A., & Lamle, A. E. (2019). Short review on the diagnosis and treatment of bronchiectasis. Medicine and pharmacy reports, 92(2), 111–116. https://doi.org/10.15386/cjmed-1060 REFERENCE #2: Miller, A. C., Comellas, A. P., Hornick, D. B., Stoltz, D. A., Cavanaugh, J. E., Gerke, A. K., Welsh, M. J., Zabner, J., & Polgreen, P. M. (2020). Cystic fibrosis carriers are at increased risk for a wide range of cystic fibrosis-related conditions. Proceedings of the National Academy of Sciences of the United States of America, 117(3), 1621–1627. https://doi.org/10.1073/pnas.1914912117 REFERENCE #3: Pasteur, M. C., Bilton, D., Hill, A. T., & British Thoracic Society Bronchiectasis non-CF Guideline Group (2010). British Thoracic Society guideline for non-CF bronchiectasis. Thorax, 65 Suppl 1, i1–i58. https://doi.org/10.1136/thx.2010.136119 DISCLOSURES: No relevant relationships by Jane Parks, source=Web Response No relevant relationships by Niyanta Patel, source=Web Response No relevant relationships by Nathaniel Rodriguez, source=Web Response No relevant relationships by Joshuam Ruiz Vega, source=W b Response No relevant relationships by Zoheb Sulaiman, source=Web Response