A 21-year-old Hispanic female with a 32-week twin pregnancy presented in preterm labor. She had immigrated to the United States two years prior, and her pregnancy course was uncomplicated except for complaints of an occasional nonproductive cough. She was a nonsmoker, denied any history of TB exposure, and was HBsAg and HIV negative. On general exam, she was tachypneic and anxious but in no apparent respiratory distress. She was found to have a low oxygen saturation of 89% on room air with a respiratory rate of 30/min and her blood pressure was 127/76 mmHg. Lung exam was clear to auscultation. Her uterine fundal height corresponded to 32-week twin pregnancy and she had bilateral pedal edema. She was also noted to have uterine contractions every 1-3 minutes.
She was initially admitted to the labor and delivery unit in our hospital and subsequently transferred to the medical ICU. ABG showed pH of 7.41, PaCO2 of 29, PaO2 of 64, bicarbonate of 18, and the base excess of -6, saturating at 93% on 21% FiO2. CBC showed WBC 9.9 th/mm3, Hb, and Hct 10.8 g/dl and 32.8%, respectively, Platelets 432 th/mm3. The chest X-ray demonstrated a right paratracheal soft tissue opacity measuring approximately  4 x 4 cm with a slight elevation of the right hemidiaphragm with a linear density in the right lower lung consistent with atelectasis (see Figure 1). No prior X-ray was available for comparison. Patient was put in respiratory isolation early on and the pulmonary team was consulted. CT showed a large extensive mediastinal soft tissue mass in the right paratracheal region extending into the hilar and subcarinal region. An associated atelectasis on the right upper and lower lobe with questionable alveolar infiltrate in the right lower lobe was also found. An abdominal ultrasound showed twin-twin transfusion with reversed end-diastolic flow on umbilical artery doppler in twin B and the patient had an emergent low transverse cesarean section the next day with delivery of two male infants. Infant A had Apgars of 7 and 9, and infant B had Apgars of 0, 4, and 5, respectively. Both infants went to the NICU, and the patient returned to the MICU.
A PPD was placed which was positive at 10 mm after 72 hours. Successful samples of sputum could not be obtained but a bronchoscopy with endobronchial biopsy and bronchoalveolar lavage (BAL) was done. Bronchoscopy showed a trachea with diffuse mucosal swelling and the mucosal abnormalities persisted throughout the right bronchial tree. She also had irregular tumor growth from the anterior wall of the proximal bronchus intermedius and the base of the proximal right upper lobe bronchus. These two growths were sampled and the infectious disease team was consulted. There was an abundant growth of Staphylococcus aureus but no acid-fast bacilli (AFB), fungus, or hyphae from the BAL. The patient was started on Vancomycin and Clindamycin to cover Methicillin-resistant Staphylococcus aureus (MRSA) which was later changed to Moxifloxacin based on sensitivities. Transbronchial biopsy of the right bronchus intermedius showed inflammatory and squamous debris with ulceration, reactive squamous epithelium, and colonizing coccal bacteria. Endobronchial biopsy of the proximal bronchus wall showed caseating granulomatous inflammation.
The treatment of this young Hispanic immigrant female with an occasional cough, positive PPD, questionable alveolar infiltrate, caseating granulomatous inflammation and no significant evidence of TB infection posed a definite challenge. Given her high risk for TB, she was empirically started on INH, Rifampin, Ethambutol, and Pyrazinamide. It was only on Day 26 that Mycobacterium tuberculosis was isolated by DNA probe from her right lung tissue which was subsequently confirmed on culture. The infants were started on INH prophylaxis after placental pathology did not demonstrate evidence of TB. Patient was discharged to home in a stable condition to be followed up at the local TB center for direct observation therapy.