A 21-year-old male presented with fever, cough, anorexia and weight loss of 2 months duration. He was a student, did not smoke and did not report alcohol or substance abuse. He did not have any significant medical history and was immunized appropriately. He reported exposure to pulmonary tuberculosis as a caregiver to a sibling 18 months prior to this episode; his sister recovered completely with 6 months of antituberculosis treatment. Tuberculin testing or isoniazid prophylaxis was not offered to the index patient according to current practice in India. He did not raise pets and had stayed alone in a hostel for the last 4 months. Chest radiographs showed bilateral infiltrates and computed tomography [CT, Figure 1] showed findings suggestive of extensive pulmonary tuberculosis. Tuberculin skin testing was negative (6 mm with 5 TU at 72 h). Sputum smears were strongly positive for acid-fast bacilli by Zeihl-Neelsen's stain and supervised daily four-drug antituberculosis treatment (isoniazid 200 mg, rifampicin 450 mg, pyrazinamide 1000 mg, ethambutol 600 mg, pyridoxine 20 mg; weight 40 kg) was initiated and sputum cultures and drug susceptibility for Mycobacterium tuberculosis by multiple growth indicator technique (MGIT) was requested. Sputum for GeneXpert for M. tuberculosis did not show resistance to rifampicin. Nutrition counseling and four doses of 2-weekly Vitamin D 100,000 I.U were administered as per unit's protocol. He presented with fever, worsening breathlessness, weight loss and chest pain 4 weeks after starting treatment. On examination he was afebrile, normotensive with respiratory rate of 40 breaths/min and pulse rate of 130 beats/min. He was malnourished (body mass inde x 14 kg/m2, normal 19-25 kg/m2). Respiratory examination showed reduced right-sided movements and breath sound intensity with coarse left-sided crackles. Resting SpO2 was 80%. Chest radiography [Figure 1, left] confirmed the diagnosis of right-sided pneumothorax with increased bilateral infiltrates. He was admitted to the Intensive Care Unit (ICU) with appropriate respiratory isolation; intercostal chest drain was inserted on the right side. There was evidence of air-leak (Cerfolio E) from the right lung with minimal subcutaneous emphysema. Noninvasive positive pressure ventilation (NIPPV) was started; no worsening of air-leak was noted. Repeat sputum smears showed downgrading of smears with scanty acid-fast bacilli by Zeihl-Neelsen's stain. Sputum cultures requested at treatment onset confirmed pan-sensitive M. tuberculosis. Repeat CT-chest [Figure 2] showed increase in cavitation, consolidation and ground-glass opacities bilaterally. Further investigations are summarized in Table 1. Fasting blood glucose was 87 mg/dL and human immunodeficiency virus ELISA was negative and there was no CD4 lymphocytopenia. Sputum smears for Pneumocystis jirovecii were negative. Urine microscopy was normal and negative for albuminuria. Arterial blood gas analysis showed corrected hypoxemia and respiratory alkalosis (pH 7.42, PO2 78 mm Hg on FiO20.4, PCO228 mm Hg, HCO322 mEq/L). Quantiferon-TB GOLD in-tube assay was strongly positive. He was continued on four-drug antituberculosis treatment; further doses of Vitamin D were not administered. He developed contralateral pneumothorax on the 2nd day of admission and worsened hypoxemia needing mechanical ventilation. Urgent left intercostal tube drainage was performed and air-leak (Cerfolio I) was noticed on the left side also. Repeat MGIT tuberculosis cultures were reported negative by day 10 of ICU admission.
High-resolution computed tomography of the chest at diagnosis showing a large right upper lobe cavity. and extensive random nodules in bilateral lower lobes.