A 16-year-old female was admitted to hospital with a one-week history of gradually worsening shortness of breath. For more than two months, she described having a nonproductive cough, nocturnal fever, significant weight loss, joint pains, and fatigue.
The patient had previously sought treatment from her local primary care physician for a cough and fever approximately two months prior to this presentation. At this time, a HIV test was done which was negative. No further follow-up was done until her subsequent deterioration and presentation at our hospital.
On presentation the patient was tachypnoeic and tachycardic, with a respiratory rate of 40 bpm, a heart rate of 148 bpm, and a temperature of 37.8 C. Her oxygen saturation was 100% on facemask oxygen at 6 L/min with a blood pressure of 123/85 mmHg. Crepitations were heard throughout both lung fields. The remainder of the physical exam was normal with the patient noted to be alert and oriented.
An urgent CXR was requested which showed multiple miliary opacities scattered throughout both lung fields (Figure 1). Laboratory results at this time were significant for microcytic anemia, leukocytosis (Hb, 7.6 g/dL, MCV, 76 fL, and WBC, 15.4 x 109/L) and a normal platelet count (332 x 109/L). Serum creatinine and electrolytes were grossly normal. A CT scan of the chest confirmed miliary opacities, with no mediastinal or hilar lymphadenopathy (Figure 1).
Differential diagnoses at this time included pneumocystis pneumonia, viral/fungal pneumonia, miliary tuberculosis, and metastatic disease. Patient was reviewed by the Infectious Disease Unit and transferred to an isolation room on the medical ward.
An HIV rapid test was performed, which was subsequently reported as negative [Determine  and UNI-GOLD ]. Due to the lack of any historical evidence suggesting frequent infections or an immunocompromised state, no immunological tests were requested. An interferon-gamma release assay [QuantiFERON ] was also requested and the patient was empirically started on levofloxacin, fluconazole, and acyclovir.
On day 2 of admission the patient deteriorated (SPO2 70% on Nonrebreather Mask set at 15 L/min), was transferred to the ICU, intubated, and placed on mechanical ventilation. Her P/F ratio at that time was 130 indicating moderate ARDS. After initial stabilization, worsening oxygenation (P/F ratio 113) prompted administration of bolus and infusion of cisatracurium. The patient was ventilated using a lung protective approach with a tidal volume of 330 ml (6 ml/kg), a PEEP of 10 cmH2O, RR of 20, and flow rate of 35 L/min. Sputum, via endotracheal tube suction catheter, was taken for testing at the regional public health lab. On a FiO2 setting ranging from 70 to 100%, the patient's oxygen saturation remained between 85% and 90%.
On further questioning of the patient's parents, it was revealed that she was in contact with a relative who had a nonproductive cough of unknown but prolonged duration. There was no testing or TB confirmation done in the family.
On admission day 3, patient was noted to be hypotensive with MAP's < 60 mmHg and persistently pyretic. Multiple polygeline fluid boluses were given and a noradrenaline infusion was started. As her condition continued to deteriorate, the noradrenaline dose increased to a max of 50 ug/min. Despite this the patient's hypotension persisted and she progressed to a fatal cardiac arrest early on the fourth day.
Shortly after her demise, Nucleic Acid Amplification [Xpert  MTB/RIF] results from her sputum became available and it was positive for Mycobacterium tuberculosis with no rifampin resistance being detected. No smear microscopy or culture was performed in this case. Previously requested QuantiFERON test was marred by postprocessing issues and a retest was suggested.
On the evening before her death, a decision had been made to empirically start antituberculosis therapy; however due to its infrequent presentation in our regional hospital, no drugs were kept in stock and they had to be sourced from our local TB treatment center. Unfortunately, the patient's death preempted this.