A 77-year-old Vietnamese male presented with a one-week history of hemoptysis. He had had a progressive cough for 6 months for which he was seen by his primary care physician 5 months prior to admission. Chest X-ray (CXR) done at the time revealed right middle lobe infiltrate. He was treated with antibiotics without improvement. Two months prior to admission, he started experiencing night sweats, low grade intermittent fever, fatigue, loss of appetite and 4 pound weight loss.
The patient was a chronic hepatitis B carrier but was not on treatment. There was no history of chronic pulmonary disease, pulmonary tuberculosis (PTB) or contact with PTB, HIV test was negative. He was a Vietnamese prisoner of war who migrated to United States of America 21 years previously. He lived with his son and two grandchildren. There was no history of cigarette smoking.
On examination, he was cachectic with a temperature 98.7  F, heart rate 81/minute and regular, respiratory rate 21/minute, blood pressure 120/82 mmHg, oxygen saturation, 95% in room air. Chest examination was remarkable for right upper lung bronchial breath sounds.
The leukocyte count was 8400/muL (normal range 4800-10800/muL) with normal differentials, and hemoglobin concentration was 11.8g/dl (normal range 14-18g/dl). A comprehensive metabolic profile was within normal limits.
A chest readiograph revealed extensive right upper lobe destruction and fibrotic atelectasis (Fig. 1) while a CT scan of the chest with intravenous contrast showed pulmonary parenchymal fibrosis and chronic cystic bronchiectasis of the right upper lobe with consequent superior migration of the right horizontal fissure and rightward mediastinal shift (Fig. 2). Acid fast bacilli (AFB) were detected in the expectorated sputum. The patient was treated with RIPE (Rifampicin, isoniazid, pyrazinamide and ethambutol). Although the initial amplified mycobacterium tuberculosis direct (MTD) test was negative, RIPE therapy was continued because of high clinical suspicion for PTB. Despite RIPE therapy, sputum AFB smear continued to be positive with all broth medium mycobacteria growth indicator tube (MGIT) cultures growing in 7-10 days. Subsequently, DNA PCR detected M. abscessus but did not detect Mycobacterium avium-intracellulare (MAI).
RIPE therapy and airborne isolation were discontinued on day 14; and treatment with amikacin, cefoxitin and meropenem was started. MTD test was repeated and positive on day 19. RIPE therapy was restarted and airborne isolation was reinstated while continuing the treatment for M. abscessus. Five weeks later, sputum culture from day 19 grew MTB in addition to M. abscessus.
Expectorated sputum samples became negative for AFB in the 5 week of admission and patient was subsequently discharged home to continue treatment for both MTB and M. abscessus. The patient's son and grandchildren were diagnosed with latent TB infection and were currently being treated.