A 23-year-old man with a medical history of treated TB presented to the emergency department with hemoptysis for one week. His symptoms started with a dry cough that progressed from blood-tinged sputum to frank blood over three weeks. He had associated fever, chills, night sweats and subjective weight loss. His previous symptoms had completely resolved and he moved to the United States from Nepal one year prior to the hospital admission.
On physical examination, the patient was afebrile, hemodynamically stable with a generalized cachectic appearance and diffuse rhonchi bilaterally on pulmonary auscultation. His labs were notable for a normal leukocyte count, a hemoglobin of 11.7 g/dL, and normal chemistries. The chest x-ray, Fig. 1, had a lucency in the left suprahilar region and bilateral peribronchial thickening of the upper lobes. A follow up CT scan, Fig. 2, showed multiple cavitary lesions at the superior segment of the left lower lobe.
On hospitalization day 2, a microscopic smear of his sputum showed many acid-fast bacilli that was later identify in cultures as Mycobacterium tuberculosis complex. He was started on a 5-drug regimen with rifampin, isoniazid, pyrazinamide, ethambutol and moxifloxacin due to his prior history of possible resistant TB. He continued to have persistent hemoptysis and worsening anemia requiring a transfusion due tachycardia and dyspnea, suggesting massive hemoptysis. Four days after the anti-tuberculosis medication was initiated, he developed respiratory distress and was transferred to the medical intensive care unit and was placed on non-invasive positive pressure ventilation but did not improve. Thus, he underwent an urgent bronchoscopy, revealing a significant burden of blood clots in the left main bronchus that did not allow for a complete survey of the airway. As a result, an endobronchial blocker was placed and the patient was evaluated by interventional radiology. He underwent urgent left bronchial artery angiography with embolization of two abnormally hypertrophied left bronchial arteries.
The following day, he underwent repeat bronchoscopy that showed persistent clot burden in the left main bronchus. Given his active tuberculosis, difficulty with oxygenation, and multiple cavitary lesions, the decision was made to proceed with left lower lobectomy. On gross examination, the lobe of lung was severely congested weighing 645 g (normal weight of a complete left lung: 395 g). There was widespread consolidation with nodules containing caseous material, Fig. 3A. It corresponded to necrotizing nonsuppurative granulomas with a peribronchial and subpleural distribution in a miliary pattern, Fig. 3B. The granulomatous inflammation extended around medium sized vessels causing destruction of the vasa vasorum and secondary obliterative endarteritis, Fig. 3C. Numerous cavities developed in relation to necrotizing granulomas with suppuration and hemorrhage, Fig. 3D. Round foreign particles were deposited in the arterial lumina, consistent with a prior embolization procedure. Intra-alveolar hemorrhage emerged after bleeding into the cavitating granulomas due to destruction of vessel walls, Fig. 3E and F. Few acid-fast organisms consistent with L-shaped mycobacteria were identified on FITE stain, Fig. 3G-I. Other special stains including Kinyoun cold procedure, auramine-rhodamine staining, and mycobacterium immunostaining, were negative for acid fast bacilli.
On hospitalization day 6 the patient's family, who was previously unable to contacted, arrived at the hospital and the team was able to provide additional history regarding his previous TB therapy. He was diagnosed with multidrug resistant (MDR) TB seven years prior to admission and treated for 18 months with rifampin, isoniazid, pyrazinamide, ethambutol, moxifloxacin and an injectable medication, the name of which they could not recall. The following day, the Health Department confirmed fluoroquinolone-resistant tuberculosis by nucleic acid amplification testing (NAAT). Rifampin, isoniazid, and moxifloxacin were discontinued and the patient was started on amikacin, linezolid, meropenem, clavulanate, para-aminosalicylic acid and ethionamide. Bedaquiline was requested from the Centers for Disease Prevention and Control (CDC). After his lobectomy, he required persistent intensive care unit monitoring because he would not tolerate extubation trials along with multiple episodes of mucous plugging, which required multiple bronchoalveolar lavages. He was successfully extubated on hospitalization day 14. The patient was transferred to the regional TB center of Florida on hospitalization day 21.
After an additional two months of being monitored and treated at the regional tuberculosis center, the patient was discharged to the community and continued his treatment under directly observed treatment through the department of health.