We present the case of a 59-year-old male patient with past medical history of Diabetes Mellitus type 2 who developed progressive fatigue, shortness of breath and dry cough by the end of 2012. Within the next 7 months patient had worsening of symptoms with rapid weight loss of 55kg (121bs) associated fever, chills, night sweat, loss of appetite and relentless weakness. Patient had traveled only to Ecuador for vacation with his family in 2010. During this travel he denied exposure to sick contacts or crowded household conditions. A chest x-ray and PPD skin test was performed by his primary care physician for the initial evaluation of symptoms. The PPD revealed no skin induration. Chest x-ray showed multiple pulmonary nodules with no obvious cavitary lesion. Patient was referred to a pulmonary specialist for further evaluation. He underwent bronchoscopy that resulted inconclusive and the patient has lost to follow-up.
In mid-2013, because of worsening of his symptoms as described above he returned to the pulmonary disease specialist who repeated the bronchoscopy due to suspected malignancy vs. infectious process. Samples from the bronchoalveolar lavage had positive AFB smear, with positive culture growth for M. tuberculosis. Initial culture resulted pansensitive for TB. Other studies were remarkable for an indeterminate Quantiferon-TB Gold test (see Table 1), chest x-ray with right upper lung opacity and chest CT scan showing right upper lobe consolidate with central cavitation (see Fig. 1, Fig. 2). He was placed on airborne isolation and started in 4 anti-tuberculous drugs regimen including isoniazid, pyrazinamide, ethambutol, and rifampin. After 36 days of treatment and 3 negative sputum samples for AFB smear the patient was removed from negative pressure room, airborne precaution and discharged home.
The patient was followed by the Department of Health (TB office) as outpatient with Direct Observed Therapy (DOT). Two months after been discharged form hospital and while still on TB treatment symptoms reappeared. For this reason patient was readmitted and repeated sputum cultures for M. tuberculosis were done on January 2014. Samples sent to the Centers of Disease Control (CDC) found to have multidrug resistant tuberculosis with resistance to isoniazid, rifampin, ethambutol and streptomycin. Genotype G24767 revealed the first of its kind genomic sequence not classified in the known cluster of Puerto Rico nor in the United States Population. The patient was hospitalized and started on second line anti-tuberculous drugs which included linezolid, levofloxacin, amikacin and cycloserine. The patient remained in hospital isolated for 46 days until 3 negative sputum for AFB smear were reported, but had to continue on at least three effective drugs and one injectable after culture conversion. The patient has at this point completed the 18 months after culture conversion, is symptom free and has gained all his lost weight.