A 35-year-old African American woman presented with a three-week history of intermittent low-grade fever, progressive dyspnea, and hemoptysis (approximately 30-40 ml/day). She reported no weight loss or sick contacts. She had two negative TB skin tests in the last two years prior to presentation, as an employee of the corrections department. She had been working in a business office setting for the year prior to the hospital visit. A chest x-ray two years prior to the presentation for pre-operative evaluation for a fibroid surgery was essentially normal. There were mild hilar calcifications which were thought to be associated with old histoplasmosis. (Fig. 1a) Chest x-ray during the current admission revealed bilateral upper lobe opacities (Fig. 1b). Her Human-Immunodeficiency Virus (HIV) test was negative and quantitative immunoglobulin levels were normal. She denied using intravenous drugs. The amount of hemoptysis was concerning and thus she had a flexible bronchoscopy (FB) which identified blood trickling from the left upper lobe into the left main-stem bronchus. Computed tomographic angiography (CTA) was done which showed biapical cavitary lesions with infiltrates and pulmonary artery aneurysms (Fig. 2 a, b and c). Her hemoptysis rapidly worsened, and she was emergently intubated and taken to the interventional radiology where a pulmonary angiogram confirmed three left upper lobe aneurysms, two of which were actively bleeding (Fig. 3a and b demonstrate one of the aneurysms). She underwent emergent glue embolization of all three aneurysms (Fig. 4). She remained stable post-procedure without further hemoptysis. Sputum and bronchoalveolar lavage (BAL) specimens were smear positive for Acid-Fast Bacilli (AFB) and grew Mycobacterium tuberculosis complex that was sensitive to all first line anti tuberculosis drugs. Patient was treated for tuberculosis and has now completed her course of ATT with no further episodes of hemoptysis.
After the diagnosis, the contact investigations by the health department, found 8 more patients with active infection at her office, which was the business office of a dance club.