Case Study

Diagnosis and Treatment of Mycobacterium tuberculosis

Patient Background

Patient A is a 30-year-old male who was admitted to the hospital from home after 1 week of
cough, profuse nocturnal sweating, loss of appetite and hyposomnia. He was seen by an
emergency room physician who noted signs of depression. The patient has a history of
intravenous drug abuse and hepatitis B.

Vitals
Temperature: 38.0oC
Heart rate: 110 beats per minute
Blood pressure: 130/76
Respiratory rate: 20 breaths per minute
Oxygen saturation of 98% on room air

Physical exam
 General: young male, looks older then stated age
 HEENT: depressed, pupils equally round and reactive to light and accommodation
 Neck: supple
 Respiratory system: unilateral (left side) crepitation
 Cardiac system: regular rate and rhythm, no murmurs, rubs, or gallops
 Abdominal system: slightly distended
 Extremities: no edema
 Skin: excoriated, otherwise normal
 Neurological system: slightly altered, but baseline

Labs
Na: 133
Creatinine: 1.8
K: 4.1
WBC: 9.48 x 109/L
Cl: 96
Hgb: 11.4 g/dL (114 g/L)
Platelets: 149 109/L
HIV test: Negative

Radiology
Chest X-ray showed infiltrate in the middle of left lung with diameter of 1.7 cm with signs of
cavitation.
Microbiology
 General Blood Culture: No growth at 5 days
 Sputum Smear Gram Stain: 4+ squamous epithelial cells, 1+segmented neutrophils, no
organisms
 AFS (acid fast stain): No organisms
 Sputum Culture: No growth at 48 hrs
 MGIT (mycobacteria growth indicator tube): Negative

Diagnosis
Infiltrative TB of left lung with cavitation without MTB shedding.

Treatment
Patient A was originally administered isoniazid, rifampin, pyrazinamide, and ethambutol for 7
days per week for 8 weeks, followed by isoniazid and rifampin 7 days per week for 24 weeks.
After two months he returned to the hospital, concerned that he had been “coughing up blood”
over the previous 3 days. In addition to hemoptysis, he revealed that, since his previous visit, he
had continued to feel malaise, was continuing to lose weight, and had been experiencing night
sweats. The emergency room physician immediately transferred the patient for isolation in a
local hospital. A repeat chest radiograph revealed progressive bilateral fibronodular disease
with a “miliary” pattern. The patient was given a 20-month regimen of levofloxacin, kanamycin,
cycloserine, pyrazinamide and prothionamide. Following completion of therapy, closure of the
destruction cavity was found with local pneumofibrosis.