A 45-year-old divorced homeless man was admitted to our hospital with abdominal pain. He was a Vietnam veteran. Medical history was significant for MDRTB, chronic hepatitis C, and alcohol use disorder with associated complications including liver cirrhosis with ascites, bleeding from esophageal variceal veins and pancreatits.
Five years previously he presented to an outside hospital with incarcerated inguinal hernia and worsening ascites. He underwent surgery with herniorrhaphy and placement of a Denver shunt catheter from the peritoneal cavity to the superior vena cava for management of ascites presumed secondary to cirrhosis and portal hypertension. Histopathology of the hernia sac revealed caseating granulomas. Cultures of tissue and ascitic fluid grew Mycobacterium tuberculosis (MTb). At this time chest x-ray showed no evidence of pulmonary involvement. A four-drug regimen with isoniazid (INH), rifampin (RMP), pyrazinamide (PZA) and ethambutol (EMB) was begun. Susceptibility testing at Utah State Health Laboratory (USHL) revealed isolates were susceptible to all drugs tested. DOT was managed by Salt Lake County Health Department (SLCHD). DOT log showed perfect compliance with his regimen (Supplement Fig. 1). He received four drugs for the first four months and continuation of INH and RMP for a total of ten months. Monthly visits to the SLCHD TB clinic documented clinical response to treatment. The patient gained weight, had no fever and abdominal pain resolved.
Near completing treatment, he began to have fever, chills, weight loss and cough. He was admitted to an outside hospital where his chest x-ray suggested pulmonary tuberculosis. Sputum smear showed rare acid-fast bacilli (AFB); culture was positive for Mtb. His isolate was resistant to INH and RMP, and to PZA on one sputum sample but susceptible on another (Supplement Figure 2). INH and RMP were discontinued, PZA was continued, and streptomycin, ofloxacin and cycloserine were begun. DOT records again showed excellent compliance with a good clinical response. After 9 months of treatment, he felt well, and his chest x-ray had improved. At this time, he was lost to follow-up.
After a hiatus of almost three years (Supplement Figure 3) he presented to a local emergency room complaining of recurrent abdominal pain. He was referred to our hospital and admitted. He was cachectic with a protuberant abdomen. Vital signs were normal. Denver shunt tubing was visible through a skin defect of the left chest wall with expressible fluid. The abdomen had a doughy consistency. Chest x-ray showed the course of the shunt catheter, which appeared to terminate within the right lung (Fig. 1A). Chest and abdominal CT demonstrated multiple pulmonary cavities including one into which the tip of his shunt catheter protruded (Fig. 1B). There were extensive inflammatory changes of the peritoneal cavity including loculated fluid collections. Sputum, peritoneal fluid and chest wall fluid grew MTb, confirming disseminated infection. All isolates were resistant to INH but susceptible to RMP. A multidrug regimen recommended by the CDC-sponsored TB Hotline was begun.
His hospital course was complicated by recurrent emesis due to small bowel obstructions. Attempts at nutritional replacement were unsuccessful, inanition worsened, and aspiration occurred which was fatal.
At autopsy the Denver shunt catheter was visible within the lung parenchyma (Fig. 1C) but determining the site of entry into the right lung was obscured by caseous inflammation. It was impossible to "run the intestines" due to their incasement within caseous material. His course is summarized in Supplement Figure 3.