‘This medical student just gets sicker’

Abstract

A 26-year old female medical student presented to hospital with a 2-week history of abdominal pain, fevers and vomiting. There was no history of smoking, alcohol, foreign travel or animal contact. Examination revealed hepatomegaly and temperature of 38°C. Initial blood results were haemoglobin 9.1 g/dl, white cell count 2.7×109/litre, platelets 130×109/litre, alanine aminotransferase 199 IU/litre, aspartate aminotransferase 62 IU/litre, alkaline phosphatase 247 IU/ litre, international normalized ratio 1.4, sodium 133 mmol/litre. Admission chest radiograph was normal (Figure 1a). Hepatitis screen showed prior infection with hepatitis A and cytomegalovirus. Human immunodeficiency virus and autoimmune profile serology were negative. On day 4 the patient developed a dry cough and hypoxia. Chest radiograph revealed basal pulmonary infiltrates (Figure 1b). The patient was treated for ‘atypical’ pneumonia with co-amoxiclav, clarithromycin and continuous positive airway pressure on the intensive care unit. Over the next 48 hours she deteriorated, requiring intubation and ventilation; teicoplanin was added. Computed tomography scanning showed patchy pulmonary air space shadowing, pleural effusions, ascites and normal pelvic images. Pleural fluid aspiration and drainage revealed transudate effusions and a bronchoscopy and bronchoalveolar lavage was performed. Exhaustive microbiology investigations of blood (including multiple serological studies for bacteria and viruses), CSF (<1 white blood cell, glucose 3.8 mmol/litre, protein 460 mg/litre), urine, stool, sputum, nasopharyngeal aspirate, pleural and bronchoalveolar lavage fluid failed to identify an infectious cause for the patient's illness. She was extubated after 36 hours with complete resolution of chest radiological infiltrates. Lack of clinical improvement, persisting pyrexia, deteriorating pancytopenia and liver function tests prompted further investigation with liver and bone marrow biopsies. Ziehl–Neelsen staining of a liver biopsy (Figure 2) and bone marrow demonstrated the presence of granulomatous inflammation and acid-fast bacilli. Acid-fast bacilli were abundantly seen in under 5 minutes of starting histological inspection of tissue sections. Mycobacterium tuberculosis was confirmed by tissue culture, and found to be sensitive to rifampicin by the reference laboratory using rapid reverse hybridization. A good clinical response was seen with non-hepatotoxic anti-tuberculous therapy, including amikacin, ofloxacin and ethambutol, since standard therapy resulted in marked hepatitis. First-line antituberculous drugs were then gradually introduced. The patient made a full recovery with resolution of liver function tests and blood counts.