A Nepalese 14 year old adolescent female with history of treated LTBI presented to the emergency department (ED) with two weeks of non-productive cough and acute fever. The patient emigrated from southern Nepal two years prior with PPD induration of 11 mm, positive Interferon gamma release assay (IGRA) (Quantiferon-TB Gold in-tube test) of 9.55 IU/ml and negative chest radiograph. The patient completed a ten month course of INH and was asymptomatic until the start of this acute episode. Chart review documents patient reported compliance with INH during a TB follow-up visit, but there is no mention of directly observed therapy (DOT) or involvement of the local health department. She had no evidence of immunosuppression though was noted to have low vitamin D levels and growth along the fifth percentile. In the ED she was afebrile, tachycardiac, and tachypneic; she received fluid resuscitation and antipyretics. CBC, CMP were unremarkable with negative blood culture. Chest X-ray demonstrated an ovoid lucency in left upper lobe measuring 1.6 cm by 1.7 cm concerning for post-infectious pneumatocele versus cavitary necrosis in a consolidation (Fig. 1). She received IV ceftriaxone and was admitted to the pediatric infectious disease service.
After further review, she was placed in airborne isolation with concern for TB. Physical exam noted a thin, well-appearing teen with decreased air exchange in the upper left lung field. Chest CT revealed a 2.4 cm cavitary lesion in the left upper lobe consistent with post-primary TB (Fig. 2). Repeat IGRA was positive. Sample was obtained from three consecutive daily gastric aspirates which grew Mtb pan-sensitive to Ethambutol, INH, Pyrazinamide, and Rifampin. Four drug therapy was initiated under direct observation of the health department and she was followed by the local pediatric infectious disease specialist. Repeat sputum acid fast smears were negative for mycobacterium and chest X-ray showed significant improvement upon completion of therapy (Fig. 3).