An 87-year-old Chinese man with a history of diabetes and ischemic cardiomyopathy presented with one week of productive cough of green sputum and dyspnea. He denied any fevers, chills, night sweats, or weight loss. He did not have any recent travel or exposure to sick contacts. His last travel to China or outside the United States was 40 years ago. On presentation, he was afebrile and hemodynamically stable with a blood pressure of 123/74, a heart rate of 71, and an oxygen saturation of 97% on room air. Physical examination was otherwise notable for nonlabored breathing at rest with scattered bilateral crackles throughout both lung fields.
Infectious labs were initially significant for a white blood cell count of 10.5 x 103/muL, a procalcitonin level of 0.54 ng/mL, and a positive Streptococcus pneumoniae urine antigen. Other labs including respiratory viral panel, Legionella urine antigen, and blood cultures were negative. A chest radiograph on admission was consistent with a multifocal pneumonia (see Figure 1). A computed tomography (CT) scan of the chest without contrast confirmed multilobar opacities, including the left apical and upper lobe consolidations with bronchiectasis, as well as a right upper lobe consolidation with ground-glass opacification (see Figure 2). A small calcified granuloma was also noted in the right lower lobe. Testing for TB with an interferon-gamma release assay was considered but not performed given that an etiologic agent was already identified.
The patient was started on ceftriaxone 1 gram every 24 hours for empiric coverage of Streptococcus pneumoniae. On hospital day 4, he became increasingly somnolent and hypoxic, requiring intermittent nasal canula despite four doses of ceftriaxone. Repeat chest X-ray revealed worsening bilateral infiltrates. Ceftriaxone was increased to 2 gram every 24 hours, and vancomycin was added to cover for possible beta-lactam resistance.
On hospital day 6, he developed rigors, tachypnea, and labored breathing. Arterial blood gas analysis revealed a pH, carbon dioxide (CO2), and lactate of 7.36, 18, and 7, respectively. At this point, heart failure with volume overload and acute respiratory distress syndrome were considered. Aggressive diuresis was started, and antibiotics were escalated to piperacillin-tazobactam, azithromycin, and vancomycin. He was also placed on bilevel positive airway pressure for work of breathing. Repeat CT scan of the chest revealed persistent bilateral consolidations with diffuse ground-glass opacities and small pleural effusions (see Figure 3). On hospital day 7, respiratory status deteriorated despite noninvasive positive pressure ventilation, and emergent intubation with bronchoalveolar lavage (BAL) was performed. He died shortly after intubation. Subsequently, BAL studies returned positive for acid-fast bacilli which speciated as Mycobacterium tuberculosis.